Covid-19: Testing and Tracing

We have a quorum and we are now in public session. We have been notified that Deputy Gannon is substituting for Deputy Shortall. There may be other such notifications later.

I welcome our witnesses to our hearing on testing and tracing. We are joined in the Dáil Chamber by Professor Paddy Mallon, professor of microbial diseases in the school of medicine at University College Dublin, and I welcome him. I also welcome in Committee Room 1 from the HSE Mr. Damien McCallion, national director of emergency management and director general of the co-operation and working together partnership; Dr. Colm Henry, chief clinical officer; and Ms Niamh O'Beirne, national lead for contact tracing and testing; from the Department of Health Dr. Cillian De Gascun, consultant virologist and director of the National Virus Reference Laboratory and member of the National Public Health Emergency Team, NPHET; Dr. Alan Smith, deputy chief medical officer; Mr. Muiris O’Connor, assistant secretary of the research and development and health analytics division; and Ms Laura Casey, principal officer.

I wish to 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 the committee. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to so do, 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, persons or entity by name or in such a manner as to make him, her or it identifiable.

We expect witnesses to answer questions asked by the committee clearly and with candour, but witnesses can and should expect to be treated fairly and with respect and consideration at all times in accordance with the witness protocol. If the witnesses have any concerns in this regard I ask them to raise them immediately.

I invite Professor Mallon to make his opening statement and, as is customary at this stage, I ask him to confine it to five minutes as it has been circulated in advance.

Professor Paddy Mallon

I thank the Chair and the committee for inviting me to appear today and for the opportunity to make this opening statement. Ireland is making steady progress in emerging from the first wave of the Covid-19 pandemic that has caused a significant number of deaths and has damaged our economy, the education of our children and the provision of healthcare. Ireland has arrived at this point largely due to the unprecedented support, sacrifices and actions of the Irish people at the request of the Government following the advice of public health officials. The Irish people have chosen this path at considerable personal cost primarily to protect the lives of their families and fellow citizens. As a result, Ireland's now holds the advantage in our war against the SARS-CoV-2 virus, with the potential to maintain infections at an absolute minimum. It is vital that we do this properly.

We are only beginning to understand the impact of this first wave on the health of our citizens. There is no effective pharmaceutical treatment or vaccine to prevent the acquisition or spread of this infection. In addition to the large number of deaths we have witnessed in Ireland, as highlighted earlier this week to the committee, many of those affected - even young and healthy individuals - experience considerable morbidity and prolonged recovery times. Accepting any level of ongoing community transmission puts people's health at risk and will further hold back economic recovery. Ongoing community transmission, such as that seen in the United States, Sweden and parts of the United Kingdom, together with a resurgence of cases in Lisbon and the outbreaks reported in Germany, serve to highlight that Ireland is still within a geographical high risk zone for Covid-19. I and others in the infectious diseases clinical community believe that it is inevitable that we will experience a resurgence of cases as we relax restrictions and permit more travel.

In this context, control of the SARS-CoV-2 virus within our communities through a highly effective programme of rapid testing, contact tracing and community actions becomes a priority in maintaining our national biosecurity. Effective community control permits a more stable and meaningful economic recovery, a recovery of education for our children, a recovery of our health services, including vital screening services, and a restoration of quality of life and improvements in mental and physical well-being. In many ways, this programme becomes the beating pulse of our country. As society reopens, the Irish people are handing back some of the responsibility for controlling SARS-CoV-2 in Ireland to the State. If this programme fails to work effectively, we risk losing the gains provided to us through the sacrifices of the people.

Both infectious diseases physicians and leading figures within the Royal College of Physicians in Ireland, RCPI, have called for a detailed and coherent written plan to deal with the control of the SARS-CoV-2 virus on the island of Ireland. This should include a detailed end-to-end testing and contact tracing plan, embedded with rapid turnaround times and clear key performance indicators, KPIs. Alongside this, greater investment should be made in the coming weeks to rapidly upscale emergency department capacity, and isolation room facilities in hospitals are also required. These actions would be best achieved through the establishment and resourcing of specialist networks operating regionally under a common governance structure. These networks should comprise relevant specialists and be linked to our extensive academic university infrastructure. This will enable rapid and scalable regional responses to both current and future threats as they arrive and evolve as well as enabling the rapid implementation of national guidance and adherence to national KPIs.

Despite the optimism in some quarters in recent weeks, we are still in the midst of a national health emergency and our citizens are no less at risk of severe illness and death if they contract Covid-19 infection now than they were back in March. Lessons learned from the first wave of Covid-19 need to be translated into actions and resources but we have a narrow window of opportunity. At a time the incidence of Covid-19 infections in Ireland is relatively low, we need to avoid complacency and ensure that this time is used wisely to improve our infrastructure. Failure to learn or delays in the planning and resourcing for what is ahead would not only be potentially negligent but would be a travesty to the memories of those who have died from Covid-19, some avoidably, during the first wave.

Dr. Colm Henry

I thank the Chairman and members for the invitation. I am joined by my colleagues: Mr. Damien McCallion, HSE national director; Ms Niamh O'Beirne, national lead for testing and tracing; and Dr. Cillian De Gascun, consultant virologist in UCD and director of the National Virus Reference Laboratory.

As requested by the committee, we submitted a detailed document on testing and tracing for Covid-19. I will, therefore, use this opening statement to make some summary comments.

Since the onset of the Covid-19 pandemic, the HSE has worked tirelessly to build a robust testing and tracing infrastructure with the aim of monitoring and reducing the transmission rate of Covid-19 in order to protect public health. It is important to acknowledge the extent of what has been achieved as part of this response. To date, we have developed a testing system that has enabled us to complete over 400,000 tests. Our World in Data ranks Ireland sixth in the number of tests per head of population within the EU and the UK.

There have been many complexities to the infrastructure that have needed to be considered and overcome. Carrying out polymerase chain reaction, PCR, testing for Covid-19 has proved challenging at times. The process involves more than simply taking swabs; there are multiple layers to the process that impact the end result. In order to take swabs, we had to set up 48 test centres. The first of these opened on 16 March. Within ten days, more than 40 were open. We then had to consider how we would increase laboratory capacity to meet the expected demand. We then had to ensure we could increase our ability to contact-trace to a larger scale than had ever been performed in the country to date. We also built new IT systems to enable us to track and trace individual results through the process. To do all this, we had to redeploy staff from other areas of the HSE and other public sector bodies, set up centres to support our public health departments and build a system from scratch to enable the service to function. This had to be done while responding to the ongoing pandemic, something that has been described in the initial response as equivalent to building the aeroplane while flying it. It has been well publicised that we had issues with testing in the early stages, with delays in testing and the return of test results, much of this connected with global issues with the supply of test kits and reagents, our local lab capacity and a broad initial case definition. The case definition changed as knowledge of the virus and its characteristics increased. This required close work with the primary care community to respond to changes in case definition and referring for testing accordingly.

We have striven to overcome these challenges to build a more robust system capable of meeting demand today with flexibility into the future for any potential surges. Despite early issues, we have strengthened our capability to protect the nation's response to Covid-19. Since 18 May we have the capacity to deliver 100,000 tests per week across our end-to-end testing infrastructure, from referral through to contact tracing. We have reduced our turnaround times significantly, with swabbing appointments being mostly same day or next, laboratories completing testing in one day and contact tracing also completing in one day. In order to meet the need to trace contacts on a large scale, a contact management programme has been in operation since March. It operates a three-call process to efficiently contact-trace a confirmed case and also conducts acts of surveillance for 14 days from contact with a confirmed case. We are one of the few countries to offer automatic testing for contacts of confirmed cases. This has been in place since May. We are ensuring that we remain agile in our approach, driving continuous improvement and striving to be as proactive as possible in our response. Week on week we make changes that increase efficiency. We still face some challenges, however, including anticipating the ongoing number of tests which will be carried out per week.

Referrals from GPs have fallen recently in line with reduced disease prevalence, and positivity rates have fallen from a peak of 25% to 0.5%. As a result of demand, our available capacity has been lower in recent weeks. We must keep in mind, however, that as the country begins to open we may see a demand for increased capacity once again, and we need to be ready.

The current testing and tracing service was put in place in order to meet the immediate requirements of the Covid-19 crisis. The design of a new model that will operate for the next 18 or more months has commenced. This critical project will run over the summer months, with a target implementation date in late August. It will focus on building a fit-for-purpose and sustainable testing service that will deliver short turnaround times, maintain long-term capacity and effective contact tracing and be flexible for any future surges that may come.

I sincerely thank everyone who has played a part in developing the current testing and tracing operational model, which has enabled us to protect public health to date. We are most grateful for the support of the GP community, which has worked with us since the outset in a very collegiate, practical and productive way. Testing and tracing, along with other public measures such as social distancing and good hand hygiene, will play a big part in all our lives until a vaccine for Covid-19 has been developed and delivered. We will be happy to address any questions members may have.

I thank Dr. Henry for his presentation and for all his work over the past three to four months. It has been quite a difficult time for everyone involved, and strong leadership has been provided in the medical advice given and its delivery.

Many of the facilities for testing, etc., are being wound down and some have ceased to operate.

If there was a surge again tomorrow morning, what kind of time period would it take to have everything up and running and in full working order, in terms of being able to provide tests quickly again?

Dr. Colm Henry

I thank the Deputy. The number of testing centres in operation at one stage was at 48 and we built up a capability for 100,000 tests per week but with falling community transmission the demand for testing has fallen week on week to 18,000 tests in the past week. We have capacity for 100,000 tests per week.

We set up a contact tracing exercise to support our public health departments in ten departments around the country. These consist mostly of both medical and non-medical staff who do the more routine contract tracing exercises. Again, demand for this has fallen considerably with reduced community transmission and reduced numbers of contacts per case from a peak of 20 in mid-April to about three or so now. We have centralised the contact management programme to a unit in Galway. I ask my colleague, Ms O'Beirne, to come in on this. We have retained the capability to ramp up considerably at short notice should we see in increase in the R value or an increase in the number of positive tests or contacts.

Ms Niamh O'Beirne

I thank the Deputy for the question. In contact tracing we have consolidated to one centre in Galway with a capacity to do 150 positive tests. We have agreed with all the centres that have worked with us that if we have three days of 100 tests consecutively, we will step up the other centres again. We have 1,700 people trained in contact tracing and everyone who worked with us is committed to coming back in that timeframe.

Where someone has been identified as positive, and the contact tracing is being done, are all the people who he or she has been in contact with provided with a test?

Ms Niamh O'Beirne

Yes. Over the past number of weeks we have been doing automatic testing of the contacts of confirmed cases on day zero and day seven. Everybody is offered a test and it is scheduled for him or her and then he or she is told to self-isolate for 14 days. The person tests a second time within the 14-day incubation period.

What kind of numbers are we talking about, in terms of people who are contacted as a result of a person identifying positive and who had to test?

Ms Niamh O'Beirne

The number is 2,600.

Is that people who were contacted?

Ms Niamh O'Beirne

That is people who have been contacted and had tests arranged for them.

How many of that 2,600 were then identified as positive?

Ms Niamh O'Beirne

I will come back to the Deputy with the exact number but the positivity rate is about 10%.

I thank Ms O'Beirne.

I will go on to the issue of people coming from abroad. What is Dr. Henry's view on people coming in from abroad? The number of people being identified positive has greatly reduced and we have suppressed the virus. I understand in the UK there is a large number of people being identified positive every day. What is Dr. Henry's view of the best way of managing this if there is a full resumption of travelling here from the UK, Europe, or outside of Europe?

Dr. Colm Henry

I am a member of NPHET, where there is considerable discussion about this and other matters. I would say, referring back to Professor Mallon's opening statement, that it is far too soon for us to forget how transmissible this virus is. The events in Melbourne, Houston, Germany and several US states remind us that with poor social measures and rapid easing of social restrictions we will see a rapid return to community transmission of this virus on a scale which will be hard to deal with if it is not brought under control very quickly. Clearly there would be concerns, particularly about people coming from areas of high impact. In the Covid environment, unfortunately, we have to treat every person as being potentially positive, given the uncertainty that pertains right across Europe.

If someone is coming in from the UK, he or she is advised to self-isolate for 14 days. Does Dr. Henry think adequate measures are in place to make sure that is followed through on?

Dr. Colm Henry

The advice is given to people and the hope is that people would comply with it.

Dr. Colm Henry

Advice is given to people and the hope is that they will comply with such advice. It is up to individuals, as they have done since 27 March, to comply with the advice and guidance given in order to break the chain of transmission. That is the advice for people coming in from the UK.

Does Dr. Henry believe that adequate measures are in place to ensure that advice is complied with?

Dr. Colm Henry

We do not have a system in place whereby we track and trace every individual who comes into our country for 14 days. We give very stringent advice to people that this is what we consider appropriate in the context of the transmissibility of Covid-19 and the potential of somebody coming into our country transmitting that virus unknown to them. We do not track and trace people who come into the country at this stage.

On Tuesday last, the INMO advised that over 8,000 people working in healthcare have been identified as Covid-positive. We have now been advised that over 60% are still on sick leave. Is that an accurate figure in the context of numbers of people who are still on sick leave as a result of being identified as Covid-positive?

Dr. Colm Henry

The figures I have from the HPSC indicate that, thankfully, 90% have recovered. Clearly, any of our healthcare workers in the front line, be it in the community, in nursing homes or in hospitals, are a concern to us given that they are delivering care for patients. That care is sometimes of a very personal nature in the case of older frail residents. It is as important to us, as it is to the INMO, that we can provide a safe working environment for our healthcare workers.

Dr. Henry disagrees with the figures furnished to us on Tuesday; he says that 90% have recovered.

Dr. Colm Henry

Our figures from the HPSC are that 90% of the total number of healthcare workers who contracted Covid-19, comprising 32% of our overall figure, have recovered.

Do we have a full breakdown of the 8,180? From what facilities - nursing homes, hospitals etc. - do they come? Is it possible to identify where the 90% have recovered? The figures provided on Tuesday were totally different from those Dr. Henry has given.

Dr. Colm Henry

We have a breakdown based on the healthcare setting and based on professions in terms of those associated with outbreaks. We can provide figures to the Deputy after this hearing.

How much work will be involved in resuming CervicalCheck? When will we have the full comprehensive service we require? How long will it take to have it fully operational?

Dr. Colm Henry

As with any other service we are resuming that was paused on 27 March, as part of the wider package of pausing non-essential services, there are two assumptions that are important for all of us to consider. This is a valued and valuable service to us and to women in Ireland. I acknowledge the work of the 221 group and other advocacy groups in ensuring that we focus on restoring our services. There are two main assumptions: that the community transmission level remains low; and that there is a continued easing of social restrictions. If we see a scenario play out as we have seen in other countries and some US states where there is sudden rapid community transmission, clearly it would give us reason to pause resumption of services, be they screening or otherwise. To answer the Deputy's question directly, our hope is that notwithstanding those assumptions by October we will have caught up with all those who would have had cancelled appointments through this whole pandemic since 27 March.

One of the positive aspects of cervical screening is that we are now moving to HPV screening, a more sensitive form of screening and one which-----

I thank Dr. Henry. We will be having an upcoming session on cancer screening, among other non-Covid-related activities. We will also have another session on infection rates of healthcare workers.

On the issue of travel, does Professor Mallon have a view on the adequacy of the current measures? Is there confusion over legally requiring people to fill in a form and then requesting that they quarantine and so on?

Professor Paddy Mallon

I have two views on the matter. When one looks at what countries around the world in the same position as Ireland have done with the resurgence of cases, the majority of resurgences are occurring because new infections are introduced to the country, either through people travelling into the country or perhaps through the movement of some goods. From that perspective, the importance of containing infections at the border becomes higher as the levels of community transmission drop off because that becomes the greatest threat of resurgence of cases. From a policymaker perspective, if one wants to maintain community transmission at a minimal level and is working on a series of complex interventions to do so, it is important to have robust screening methods at the point of entry into the country. What those methods are is open to debate. We could screen everyone or, as is being proposed and which might make more sense, we could judge our screening, restrictions and follow-ups based on the epidemiology of the outbreak in the country from which the person is coming. For example, at the moment the risk assessments would be very different for someone coming from New Zealand compared to someone coming from Texas. That might be a pragmatic approach, certainly within the European setting, to enable limited travel. At the same time, one should focus testing, follow-up restrictions and monitoring to get the most return for investment of time and expense.

Professor Mallon did not answer my question about the adequacy of existing measures.

Professor Paddy Mallon

As regards the adequacy of existing measures, it would be useful to know the extent to which the new cases reported in the past few weeks have arisen because of inward travel, because that is information we do not have. To be able to comment on the adequacy of existing measures one would need to know to what extent travel is a component of our existing transmissions.

I thank Professor Mallon. I call Deputy Stephen Donnelly.

I thank the witnesses for their preparation and time, which is much appreciated. I also acknowledge the great work the committee secretariat has been doing. The briefing notes have been excellent.

I will start with Professor Mallon. In his opening statement he said: "I and others in the infectious diseases clinical community believe that it is inevitable that we will experience a resurgence of cases as we relax restrictions and permit more travel". In his view, and in the view of the infectious diseases community, how extensive is that resurgence likely to be? Critically, could it lead to more mass closures of healthcare facilities, businesses, schools and so forth?

Professor Paddy Mallon

To get an idea of the extent of re-emergence, the best thing to do is to look at international examples from the past few weeks in countries that have low levels of community transmission. For example, in Germany there has been a large outbreak associated with one particular occupational factory, which has led to the lockdown of 600,000 people. The state of Victoria is currently grappling with the re-emergence of cases in multiple hotspots within the community, which has led to severe restrictions throughout much of the state. More than 1 million people are currently under restrictions where they almost cannot leave their homes. This can emerge very quickly. In the case of Victoria, it has emerged in a matter of days and Australia has gone from a country that had been largely Covid-free to having to introduce quite severe restrictions for a large segment of an urban population. When one looks between the lines in Victoria, the other lesson to learn is that it is scrambling at the moment to upscale its testing capacity. That is a lesson we also need to learn. We cannot get rid of all our testing capacity and expect to switch it back on overnight. The ability to respond to these sorts of outbreaks depends on days rather than weeks.

In Professor Mallon's expert view, given what he is looking at around the world, and given Ireland's current state of preparedness and capacity, is there a reasonable likelihood that we could see mass lockdowns again this year?

Professor Paddy Mallon

The likelihood of the lockdowns really depends on two factors. The first stress test for the system is going to be what happens in August, as the Irish people decide whether they travel overseas or not, because we will inevitably have imported cases coming back into the country and that is going to stress the testing system. The second big stress for the testing system is going to be the onset of seasonal influenza because we will be getting a large number of people with symptoms consistent with Covid seeking tests at one time, and we need to be responsive to that. Within those two settings, the likelihood of re-emergence of infections is high and the likelihood of re-imposing restrictions really depends on two factors. It depends on the geographical spread of the infections so, for example, if they are all localised in one geographical setting, one could argue for a geographical restriction. It also depends on the number of cases and the rate of increase in those cases.

Professor Mallon is giving a very good academic and medical answer and he is giving me all the criteria. What I am asking him is whether, given all those criteria, in his expert view, it is likely we will see another mass lockdown.

Professor Paddy Mallon

I think it is inevitable that we will see restrictions being brought in. The Deputy talks about mass lockdown. The inevitability of a mass lockdown depends on what happens with the new cases. One could argue that, within Ireland, if we set up the testing and contact tracing system appropriately, we could place restrictions locally, as they are doing in the state of Victoria and in Germany. However, if we get a large number of people returning to the country from overseas and there is wide geographical spread of community transmission, and we cannot test and contact trace efficiently, the only way we are going to control that is by returning to mass lockdown.

Professor Mallon said in his opening statement that infectious disease physicians have called for a written, detailed, coherent plan dealing with the control of Covid-19 on the island of Ireland and that this should include a detailed end-to-end testing and tracing plan. Can I take it from that he is saying that there is not currently a detailed end-to-end testing and tracing plan and that we do not currently have a detailed, coherent plan dealing with the control of Covid-19 on the island of Ireland?

Professor Paddy Mallon

That would be the view of the infectious diseases physicians in the country.

Thank you for that. In terms of how we might deal with another future outbreak because, obviously, we have to do everything we can to avoid future mass lockdowns, are the advances in home testing, in mass testing way beyond the current capacity, in antibody testing and so on - are the advances in those technologies such that Professor Mallon thinks it likely that, this calendar year, those technologies could be deployed en masse to help with a much broader test, trace and isolate regime?

Professor Paddy Mallon

The simple answer is “No”.

Thank you. With regard to measures around international travel, where is the technology in terms of being able to test people at the airports, specifically in terms of the turnaround times? My understanding is the very rapid, 15-minute testing is not advanced enough right now. If we were to put labs in the airports and the ports, could we do testing and have passengers wait for one hour, two hours or three hours, for example, instead of having to potentially self-isolate for two weeks?

Professor Paddy Mallon

There is availability of a rapid test - a nucleic acid-based test, which is the gold standard - and that would give a turnaround time of between 40 minutes and one hour. We will not for the foreseeable future get access to enough of those kits to make it feasible to place at the point of entry for airports.

Given whatever technology is available, if we were to put labs at the points of entry, how long would passengers have to wait to get a test result?

Professor Paddy Mallon

I would estimate the quickest turnaround time would be three to four hours, with batch testing and PCR-based assays.

The other caveat is that, as previously mentioned, that will identify the day zero positivity rate, which at the minute for contacts is 10%, but it does not predict if that person is going to develop symptoms. Therefore, it is useful for that day to remove people who are infectious but it does not solve the problem of ensuring that we follow up those people who are coming from high-risk areas to ensure they do not subsequently develop infections over the coming days, because that will still transmit and cause infections in the country.

If we were to have a regime whereby, for example, one was tested at the airport, waited three hours for the result and then one had a follow-up test three days later, would that be an equal level of biosecurity to asking somebody to self-isolate for two weeks?

Professor Paddy Mallon

Every time one tests, one improves. The testing is not predictive so what it does is remove positive cases from the pool. With every test carried out, one removes more positive cases. One could test every day for seven days and it would be better than testing on day one and day three. It is never going to be 100%. Along with any plan for testing, there will still be a requirement for the individual to behave responsibly and report symptoms. In my view, given the impact of the community transmission of this virus from a public health perspective, as has been demonstrated in Victoria, as well as its economic impact, it is difficult to see how something would improve quarantining for 14 days.

Professor Mallon stated in reply to one of my previous questions that we need to have a very robust test, trace and isolate system in place to avoid future mass lockdowns. In his opinion, is the regime currently robust enough to deal with that?

Professor Paddy Mallon

The regime needs to have a 24-hour turnaround time to be ideal. That is feasible-----

I understand that but, in the interests of time, I am asking about where we are right now. Are we there yet?

Professor Paddy Mallon

We are there in the majority of hospitals. In the majority of hospitals, the turnaround time is within four to five hours and no more than 12 hours. All tests are back within 24 hours. That is where it needs to be in the community and I am not quite clear, with these different testing tracks, what the average turnaround time is or what proportion of community testing is actually picked up in 24 hours.

I have another question and I apologise for cutting across Professor Mallon. The INMO and others have called for daily temperature checking for health professionals coming into hospitals. Other countries deploy it for workers going into office blocks and, I believe, even for bars and restaurants. Advanced regimes such as those in South Korea, Taiwan and other countries do that. Does Professor Mallon believe that this should become one of the tools in our arsenal for containing or, ideally, eliminating this virus in Ireland?

Professor Paddy Mallon

It is useful in terms of a complex interaction to reduce transmission, but it must be part of a package of measures. To introduce temperature checking alone and think one is going to solve the problem would be naive. What is required is a complex series of interventions which-----

As part of that package, would Professor Mallon be in favour of us introducing it?

Professor Paddy Mallon

Anything that reduces the impact of Covid-19 within our hospitals will be useful.

Does Professor Mallon think this would help with that?

Professor Paddy Mallon

It would definitely help.

I thank the Professor Mallon.

Professor Mallon mentioned the shortcoming of the PCR-type testing and stated that there is another type of testing which is not available because of logistics. Does that suffer from the same disadvantages, namely, if one is tested in the first day or two after contact, one may subsequently develop symptoms but one will not test positive?

Professor Paddy Mallon

That is true. It still suffers from the same limitation of it being a point-in-time test. It will tell if one is positive at that point in time, but it does not tell if one will develop the infection if one has been exposed.

Even the first type of testing that the professor mentioned.

Professor Paddy Mallon

Yes, both tests.

I thank Professor Mallon. Deputy O'Reilly has ten minutes.

I thank the witnesses for the information they have given us. My first question is for Dr. Henry. We are very constrained by time so many of the answers I am seeking are either one word or one number, if he does not mind. The experts are telling us that testing and tracing need not necessarily be perfect under lockdown but it must get much better and should be perfect as we exit lockdown. Is Dr. Henry confident that we will be able to hit the necessary end-to-end targets from the first call to the GP to quarantining contacts? The target is 72 hours. I am not sure that we are there yet, or anywhere close to it. I received a response to a parliamentary question from the HSE which indicated that the turnaround time from the request for a test to the start of the contact tracing process is 1.76 days. That was on 19 June. As we exit lockdown and there is more pressure on testing and tracing, would Dr. Henry be confident that we will be able to reach that 72-hour target?

Dr. Colm Henry

In short, yes. We are around 90% within 72 hours, but I will ask Ms O'Beirne, briefly, to give the Deputy the median times from the past week. I know we are under time constraints.

Ms Niamh O'Beirne

The median is 1.7 days for end to end, that is, from the point of referral to the end of contact tracing.

It is 2.1 days in the community and 1.54 days in the acute sector.

It is 2.1 days in the community. Does that include the instruction to all contacts to quarantine?

Ms Niamh O'Beirne


Does it include a test for all contacts?

Ms Niamh O'Beirne

It refers to the moment we contact contacts to let them know that their tests are to be scheduled.

Are 100% contacted within that 1.76 days?

Ms Niamh O'Beirne

That is the median.

It is the median. That figure is not being hit in the community. Am I correct that it is much higher in the community at 2.1 or 2.2?

Ms Niamh O'Beirne

It is 2.1 days from end to end in the community.

It is 2.1 in the community. That is two days. We are still a wee bit off there. Has the target of 100,000 tests per week ever been met?

Dr. Colm Henry

In short, no. We have built up the capacity to carry out 100,000 tests but, as a result of reduced community transmission, the number of tests being carried out has decreased. The number of tests being carried out on those who conform to the case definition and on those who fall under our other testing strategies in respect of, for example, nursing homes and healthcare workers has now fallen below 20,000.

Is Dr. Henry confident that the service could scale up to hit that target?

Dr. Colm Henry

In short, yes.

I am not being funny but on what is that based if it has never been done?

Dr. Colm Henry

We have developed the capacity to do so but we have not had to use it yet. That is fortunate for all of our sakes. The capacity remains. We have purchased laboratory capacity. Mr. McCallion can brief the Deputy further in that regard. The capacity is also based on the testing centres. Throughout the pathway, we have built up a capacity to carry out 100,000 tests per week. The fact that we have not had to use it does not mean the capacity does not exist.

We are all grateful that we have not had to use it. Professor Mallon's submission refers to a "detailed end-to-end testing and contact tracing plan, embedded with rapid turnaround times and clear key performance indicators". That is not there. Is it on its way? When will we have that?

Dr. Colm Henry

As my colleague, Ms O'Beirne, described, we expect to have it by August.

Ms Niamh O'Beirne

We had produced a plan by the end of April to reach our capacity and turnaround times of three days for 90% of cases by 18 March and we have delivered on that plan. We are working to an existing plan. We are now building a long-term sustainable model for the coming years. That is to be in place by August. That will involve new organisation, technology, KPIs, business case and processes. We are building a sustainable model that assumes the disease will be with us for the coming years.

Experts tell us that testing capacity alone can be meaningless unless it is fast. South Korea views the speed of testing and tracing as important to prevent and suppress outbreaks. Its health officials have stated that testing needs to work not only for identification but also for isolation. To do this, it must be fast. According to Dr. Tomás Ryan, the science shows that if this is too slow, it will defeat the purpose of lockdown altogether. In his opening statement, Professor Mallon made the point that, as society reopens, the public is handing back some of the responsibility for controlling the virus to the State and that, if the programme of testing fails to work effectively, we risk losing the gains achieved. Will he outline what he sees as the necessary underpinnings of any successful testing and tracing plan as we exit lockdown?

Professor Paddy Mallon

Any successful testing and tracing plan needs to be, at the very least, capable of responding to the onset of a new flu season when the rate of people with flu-like symptoms will increase exponentially over a short period. This can be modelled. Looking at our most recent flu season, which just preceded the onset of the Covid-19 pandemic, it can be estimated that approximately 103 of every 100,000 people were reporting flu-type symptoms to their local GPs every week. That would correspond to an expected need to diagnose more than 5,000 positive cases per week. We need to be able to go from diagnosing about 100 cases per week to potentially dealing with 5,000 people with symptoms a week, or even more. It should also be taken into account that, if people with Covid-19 slip through the gaps because of delays in testing these higher numbers, not only will we be faced with flu-like illness but also with Covid outbreaks. That will increase the capacity required yet again. That is what we need to be ready for. We need to be ready to roll that out within days. That is where end-to-end testing comes in.

Does Professor Mallon think we are ready?

Professor Paddy Mallon

Our readiness has not been tested but the closure of many of our testing hubs, the fact that we still do not have a clear written plan for how testing hubs are to be upscaled, and the multiple steps outlined in the document I provided that need to be taken in respect the referral and reporting pathways are all critical issues and must be looked at to decrease the time involved.

At the moment, I do not think the times are good enough, with a low rate of community transmission and a turnaround time of two days. With that low level of community transmission, we should be at one day.

If we do not have the necessary plan in place, should we be opening up at the rate we are? Should we not wait for the plan before doing so? I have my own view on this but I am asking for Professor Mallon's view as an expert in the area.

Professor Paddy Mallon

I believe the opening up that is happening at the moment is being undertaken generally responsibly because we have good data on community transmission. Provided we can watch community transmission, we will be able to see the impact of the relaxation of restrictions. I had a lot of concerns that we were doing it too quickly but those concerns have not played out in increased rates of community transmission. I will still be concerned, especially as we move into the next phase when we will see much more movement of people. That is going to be a real test. At every stage, we need to watch, but as long as we are able to accurately observe the community transmission rates, we will get the information we need in order to know whether we are going too fast or too slow.

If we open up our airports and open the country up to travel, that obviously will increase the risks. Do we need to be scaling up on testing on a much quicker basis if we are going to be accepting people coming in as tourism and everything else restarts?

Professor Paddy Mallon

As tourism restarts, if there is no consideration for where the tourists are coming from, we are really giving ourselves a rod to break our back. I think we will have dissemination of tourists from a number of different countries around the island. In terms of how we cope with that and monitor it, the big consideration is that the Irish people are on the ball with this and have been engaged with it from the beginning. People coming in from other countries will not be in the same mindset and may not have the same knowledge in terms of reporting symptoms and how to get tested. The whole system around monitoring and contact tracing will, by definition, be less robust for tourists. That needs to be taken into consideration because it will increase the risk.

At the moment, we have very low numbers of people arriving through the airports. I know this because Dublin Airport is in my constituency. Those numbers are likely to increase soon but even at the current low level of incoming people, we are not getting things right. I heard Cáit O'Riordan on the radio the weekend before last talking about how when she came home from America and self-isolated and quarantined, nobody phoned her and nobody checked where she was. If we cannot manage to do that for the tiny numbers that are currently coming in, what are our prospects of being able to manage it if we go back even to 50% of normal passenger numbers arriving here in the next couple of weeks?

Professor Paddy Mallon

It will be a test for the contact tracing platforms that have been put in place. That is the major concern. If we just completely open up our airports to all comers, the risk, in my view, is one that is not worth taking because of the potential consequences of widespread, unwitting geographical community spread of Covid-19 by people coming into the country.

I thank Professor Mallon.

Professor Mallon has repeatedly referred to the need for a written coherent plan for this island. Are we any closer to that in this jurisdiction than they are in Northern Ireland, or are we each at a similar distance?

Professor Paddy Mallon

I thank the Chairman for his question. One of the most frustrating things about this pandemic has been the comparison of what we are doing versus what is being done in other countries. It is very clear to me from a pandemic scenario that we are unique. We have a unique healthcare capacity, which is lower than in many other countries, and a unique community engagement. When considering the characteristics of how we manage this pandemic, we need to focus on what is required within our country. We can take lessons from other countries but I do not think we are going to be able to pull off the shelf a written end-to-end testing policy or contact tracing policy and say that this is how it is being done in the UK and, therefore, we are going to do the same. I just do not think that is going to work.

We continually talk about people coming in through the airports when there is a very sizeable number coming in across a land border, which is inevitable.

Professor Paddy Mallon

It is something I have brought up repeatedly. One of the approaches we have not taken which other countries around Europe have taken is that we have not, until recently, adopted a very strict approach at our borders. We have a large landmass border with the UK in respect of which we have applied no restrictions. Even if we put restrictions in place at the airports, we will still have people travelling across that land border.

I recognise the limitations with that but when one looks at other countries around Europe with large land borders, they have been much more restrictive in terms of movement across those borders than we have.

I wish to start by asking about the cost per test. There is a marginal cost and there is also a cost for fixed capital, recruitment and everything else. In general, labs have an idea of how much each test costs. In simple terms, could Dr. Henry give me a number for that?

Dr. Colm Henry

I will ask Mr. McCallion to answer the question.

Mr. Damien McCallion

There is a wide range of costs. I will quickly break them into two groups. The marginal cost in terms of hospitals broadly averages out at approximately €75 per test but there is a significant variation between the hospitals and between the testing platforms that are used. We are being very careful in terms of the commercial rates because we are still negotiating with laboratories and trying to build further capacity going forward but, broadly speaking, they range from €140 down. We have rates which are well below that at present. The average budgeted rate is typically around €120 per test, and we are operating below those levels at the moment.

I would like to ask about the PCR equipment that was acquired, presuming that large additional quantities of such equipment was acquired and also that staff were deployed in respect of it. Is that equipment adaptable for use in respect of other diseases that may come along? Are they generic machines, as it were, that can be used with different types of reagent if another pandemic comes along or for testing, say, for influenza?

Dr. Colm Henry

I will ask Dr. De Gascun to answer the Deputy's question.

Dr. Cillian De Gascun

In the context of time, the short answer is "Yes". Most of these platforms would be usable for things like influenza, as the Deputy alluded to, or for sexual health or blood-borne viruses like HIV, hepatitis B and hepatitis C. The PCR is quite an agnostic technology which one can use for a variety of infectious pathogens.

What is needed to get staff skilled up to use the PCR machines? What kind of staff do we need for that? Do they need to be at PhD level or could one retrain clerical staff if needed?

Dr. Cillian De Gascun

Ideally, we are looking for somebody with a background in science. Most of our staff would be either technical officers or medical laboratory scientists. There is a shortage of medical laboratory scientists across the country at the moment. From the point of view of training people up to operate these machines, they are very capable and many of them would have transitioned from existing work to work on Covid-19 testing. As the Deputy is aware, a lot of the demand in the health service declined significantly due to Covid-19 and we saw the same issues in the laboratories so people were transferred from operating perhaps in the sexual-health screening area and came across to work on Covid-19. It is well recognised that we need to invest in medical laboratory scientists.

I want to ask about testing at airports. One of my relatives who is an Irish citizen arrived in Hong Kong airport recently and was tested on the spot and kept in the airport for five hours until the results came back. There was a five-hour turnaround time for the test. The person was then confined to their home with a tracking device for a period afterwards. Are we going to test people arriving at airports? It seems that if we can completely suppress the illness within our island, if we reopen transport to other countries, presumably we are exposing ourselves to huge risk.

Dr. Colm Henry

Bearing in mind the concerns of Professor Mallon and others, as we reopen our airports and allow increased travel, it is clear that we must consider anything which reduces the risk of transmission. As Professor Mallon pointed out, it is a point-in-time testing. Releasing people who have positive results, whether they are asymptomatic or not, would clearly have to be considered. It is not something that we are doing at the moment. It is under active discussion by NPHET and will undoubtedly inform our own testing policy. It is not something we are doing at present, but anything that would reduce the dissemination of the virus should be seriously considered.

So it is under consideration. I just want to point out that it is actually happening in other countries. There is an international precedent for that, even if we do not go that far.

In terms of antibody tests and serological tests, the science is advancing all the time, is there any understanding yet as to whether there is any point to being tested. I see that people can go to a number of private serological testing clinics in Dublin. Do we have any idea how long immunity lasts, if at all, if a person has antibodies? Is there any plan to do scientific research to see the extent of antibodies in the Irish population?

Dr. Cillian De Gascun

Last week we began the SCOPI, study to investigate Covid-19 infection in people living in Ireland, seroprevalence study, which is intended to look at the proportion of people in the Irish population who would have been infected with SARS-CoV-2. At this stage, the plan is to call forward or invite just over 5,000 individuals who will be representative of the population at large and offer those individuals a blood test to look at the level of antibodies in their blood.

At this point in time, we do not have an indication as to how long immunity to SARS-CoV-2 will last. If an antibody is present in an individual's blood sample, based on previous coronaviruses like SARS and MERS, it is possible that immunity will last for one to two years. At this point in time, however, it is too early to say that.

My understanding is that there is a significant amount of research ongoing in the area of antibody testing.

Professor Paddy Mallon

In terms of the national research piece, we have a cohort study called the all-Ireland infectious diseases cohort study which is running in 12 centres around the country, recruiting patients both with and without Covid-19. We just put through 1,000 samples from patients with three antibody tests. We are awaiting the results of those which we expect in the next day or two.

What is emerging is that if one has a mild infection, the chances of having antibodies are lower, the level of antibodies are lower and the chances of those antibodies hanging around are lower. It seems to be that those who are more severely infected may have higher antibody levels. How that corresponds to any protection from future infections, we really do not know.

I thank the witnesses for answering my questions. Thank you, Chairman.

Thank you Deputy Smyth. I call Deputy Gannon.

This has been a fascinating session. It is also quite frightening in that it has left me in no doubt that we should respect a resurgence. If a second wave should happen, what would we do differently with testing and tracing? What lessons have we learned from the past couple of months?

Dr. Colm Henry

The lessons we learned from having to respond very quickly the first time was about having a capacity to deal with a number of potential positive and suspect cases, as well as targeted strategies among healthcare workers or nursing homes or otherwise.

Echoing what Professor Mallon and others said, the turnaround time, the response, is important. This is reducing all the time. In mid-April, when we had significant problems with each step of the testing pathway through shortage of swabs or reagent, we had to compete in a very tightly competitive international market to secure the swabs and reagents to allow the pathway to continue. Through those contracts, thanks to my colleagues in the HSE some of whom are here today, we have secured those different things which enable each step of the pathway.

The turnaround time in the community is a second thing. It is already at one day in most hospitals because of the nature of the patient being there. The second lesson for a second surge, whenever it comes and whatever form it takes, is how quickly we respond to cases, how much we increase awareness among the public about the importance of presenting early with symptoms and how doggedly we pursue close contacts of each known case to test them also.

Have we enough reagent now should there be a second surge?

Mr. Damien McCallion

This is a constant challenge at the moment. We have a secure supply and we are comfortable with what we have, beyond even the levels of testing that are there today. If a number of countries got a resurgence at the same time, however, in a global sense, there would still be challenges there. The market has obviously invested a lot in manufacturing to increase that. We have also looked at diversification across platforms to ensure we are not completely dependent on one or two platforms which could present problems then if such a situation arose globally.

Dr. Cillian De Gascun

One of the things we did learn at the time was that we in the National Virus Reference Laboratory and a number of the hospital laboratories around the country were pulling from the same global supply chain. This was because one of the platforms was particularly good from an extraction perspective. With the help of HSE procurement, over the recent months we have ensured we have diversified across the hospital laboratory network. Hopefully, we will not get caught in the same situation again.

I shall now turn to the strategies in care homes at the minute. How much ongoing testing of patients and healthcare professionals in care homes is happening now?

Dr. Colm Henry

There are two things. First, in April we had a blanket exercise across care homes, residential settings, disability settings and mental health settings, which gave us limited information given there were relatively low levels of positivity, although there was geographical variation. This week we are starting a series of testing of all healthcare workers in nursing homes for four consecutive weeks to help to inform us more of the behaviour of this virus among healthcare workers. In view of the fact that we cannot always be certain where it was contracted, it will give us more information on how the virus was contracted and the behaviour of it among healthcare workers. My colleague, Ms O'Beirne, may also wish to comment on that.

Ms Niamh O'Beirne

Yesterday, we commenced serial testing of all healthcare workers for the next four weeks. We estimate that this will involve approximately 33,000 people across 586 nursing home settings. We will do this for four weeks and produce a report at the end of each week, and at the end of the entire exercise, to see what we have learnt from it and how it informs our testing strategy for healthcare workers in those settings as we go forward.

How is the HSE using its existing capacity considering the somewhat low demand currently? Is the HSE doing asymptomatic testing in high-risk settings such as meat factories, for example?

Dr. Colm Henry

Testing is used in a couple of ways. First, people may conform to the case definition because community transmission has fallen so much. It has fallen to very low levels in terms of demand. Second, it can be used to support specific strategies guided by public health. This could be in the context of outbreaks, which have also fallen because of the fall in rates of community transmission. Third, testing can be used for specific strategies to inform us of the behaviour of the virus among healthcare workers in nursing homes or to inform a strategy that we have just developed and passed through NPHET, which is a broader strategy of how we use our testing capacity to test healthcare workers in different settings to inform us about how it behaves and how it is transmitted among this population, as I said earlier. Much of the capacity at the moment is, thankfully, unused but we need the capacity for any surges which, as Professor Mallon said, are more likely than not to appear in the coming autumn-winter season.

On a point of order before I start my questions, given there are not as many committee members here will we get a chance for a second round of questions? Now that we have our experts-----

If we get a chance for a second round, everyone will have an equal opportunity to come in. There are not many members here now but people are coming and going, as Deputy Boyd Barrett has come in to ask his questions-----

I have been watching the whole thing, but for public health guidelines-----

The Deputy, and others, are following the discussion from their offices.

It is for precautions.

Will the Deputy take the first round of questions?

Yes. I was just asking if we will get a second chance.

Yes, if there is time left over.

I wish to put formally on the record my request that the minutes of the expert advisory group are published up to date. I do not know how many times I have asked for this. It is boring how many times I have had to ask. It is even more important that these minutes are published and that we know what the experts are saying at a time when there is very significant pressure from industry to lift restrictions. We have heard about some of the dangers that could arise from lifting restrictions, and we do not know what the expert group thinks. There is a five-week lapse in the information available to us about what the experts are saying. I am currently limited to five minutes to ask questions of the experts. It is just preposterous, frankly. This is a formal request that we have the minutes of the expert advisory group published as soon as they are signed off, and put up on the website.

Does Deputy Boyd Barrett want to put that to Dr. De Gascun or just to put it on the record?

It would be great if we could get an answer on whether there is any difficulty with that.

Dr. De Gascun is in Committee Room 1 if the Deputy wants to ask that.

A "Yes" or "No" would be great.

Dr. Cillian De Gascun

I received correspondence from this committee after our last appearance here. The minutes and advices up to the middle of May were sent through yesterday evening. I will take on board Deputy Boyd Barrett's comments. We are conscious of not having matters in the public arena that are under active consideration with ourselves or NPHET because that could impinge on the work of the committees. We are certainly working to get things out as quickly as possible in conjunction with NPHET. We are a subgroup to NPHET after all.

I wish to state for the record that although the extent to which the public should be aware of the deliberations of the expert advisory group is debatable, members of this committee and other Deputies, as those who are responsible for oversight of this effort, should know the substance of those debates. I read the most recent minutes of the debate within the expert advisory group on the use of masks. I do not have time to go into detail, but it was a very interesting debate. However, it took place five weeks ago. Deputies have to make decisions now. I wish to know the most up-to-date advice on masks and face coverings and the debates that are happening within the expert advisory group. I hope my request will be taken on board.

Could we have more information about who is becoming infected? We are told there is community transmission, although I acknowledge that current rate in this regard is low. Surely the committee needs to know who is becoming infected now. Do the witnesses know that? If not, why? Given that certain restrictions are to be lifted, will that be tracked in detail? Approximately two months ago I asked whether we should at least know the occupations, sectors and categories of people who are contracting the virus in order that we can understand from where outbreaks may come. Is that reasonable for Deputies to know? Do the witnesses know the position in this regard?

Professor Paddy Mallon

The answer to the Deputy's question on whether it is reasonable for Deputies to be given that information is "Yes". As to whether I know, I get the same information as the Deputy.

Is it not a bit of a problem that those responsible for infection control do not know who is contracting the disease? We have heard that young people are contracting the virus. Are they young people who were drinking cans on the banks of the canal or are they young people in direct provision? There is a big difference between those things and we need to know them in order to make informed decisions.

Does the Deputy wish to ask that question of the representatives of the HSE? They are in committee room 1. Do our guests from the HSE wish to grasp the hot potato?

Dr. Colm Henry

That information is assessed as part of ongoing surveillance by the HPSC and discussed by NPHET. At its press conferences, which used to be held daily, information is provided in respect of occupations, particularly as regards healthcare workers, in the context of outbreaks and their background. A significant amount of information on positive cases is collated by our public health departments. That was the case even when there was a large number of cases. The information is not exhaustive to the degree suggested by the Deputy, that is, that it narrows down each case of infection to the person's occupation and one particular place, but it gives broad indications in terms of healthcare workers, age, occupation-----

In my final few seconds, I ask for more information to be provided. For example, I have been contacted by hairdressers. They are glad to be going back to work, but they are worried.

I would not mind being contacted by a hairdresser.

I had to dig out a shaver to get this cut. My point is that people are worried about the guidelines, whether they are adequate and how they will be policed. One way to test whether the guidelines will work in various sectors is to know whether there are particular outbreaks among hairdressers, transport workers or airport workers or, if we reopen schools, among schoolchildren. Surely that kind of information is critical. Is that not a reasonable thing for us to know?

Dr. Colm Henry

The locations of outbreaks are tracked by public health departments.

Is it not reasonable for us to know that information?

Dr. Colm Henry

That information is provided. Deputies are aware of the outbreaks in meat plants and healthcare facilities. This information is given out at NPHET press conferences. Those press conferences used to be held daily and are now held twice-weekly. There is intense interrogation of those figures by the media. Certainly, Deputies also deserve to know. If there is a report that the Deputy needs, Dr. Smith, the deputy CMO, will relay that to the NPHET secretariat. We will provide the Deputy with any information he needs.

Will the information being requested by the Deputy be made available?

Dr. Colm Henry

I am sure that any request in writing-----

As a general proposition, will information about occupation, age and so on be made available going forward? In fairness, the Deputy has made a valid case for that to be done.

Dr. Alan Smith

I can certainly take that request back to the Department of Health and NPHET. An effort is always made to put across information that is as clear and detailed as is readily available. I will certainly take that request back and we will endeavour to make the information as freely available as possible.

I thank Professor Mallon, Dr. O'Brien and Dr. O'Connell for their wonderful work very early on in the context of securing PPE supplies from China. Those supplies were badly needed in the teeth of this pandemic.

Earlier it was said that the geographical spread will determine further lockdowns. Obviously we need contact tracing and testing. I represent the constituency of Waterford where we have, thankfully, managed the Covid pandemic very well largely because of the provision of isolation rooms in the new Dunmore wing at University Hospital Waterford. I called for, potentially, Waterford and the south east to be allowed to open in advance of Dublin and stated that we were pegged with what was happening in Dublin. I agree with him that without a doubt we will have sectoral outbreaks in the country. I know it has been said that a written plan is being sought. Is there any plan that would allow regions of the country to continue to operate if there are clusters around the country?

Professor Paddy Mallon

I thank the Deputy for his question. The short answer, in terms of the development of plans, would probably be best addressed by our colleagues in the HSE because they develop the plans. To date, I do not know of any plans that are in draft form, that I have seen. Again, there may be others that are in the background that are being worked on.

I might address some of the members of NPHET. Last night, here in the Dáil, I asked the Minister for Health to consider the mandatory temperature testing of healthcare workers. Does anybody in NPHET care to comment on that?

Dr. Colm Henry

As the Deputy may know, there is already daily screening of healthcare workers as they enter nursing home facilities in recognition of the particular risk in those facilities. Our own occupational health lead, Dr. Lynda Sisson, has provided guidance for healthcare workers and reminded them of their obligation throughout. That is a message sent out repeatedly and, most recently last Friday, of their need to be alert for the symptoms of Covid and to isolate themselves as quickly as possible.

In terms of obligatory screening, as yet there is no obligatory temperature taking of staff entering acute hospitals facilities. Such a measure is under consideration as it happens in nursing homes and residential care already.

I have been involved in a number of large factory re-openings where mandatory temperature testing is required. If we take the case of a hospital like the University Hospital Waterford, where we have 500 beds and 2,000 care staff transiting through there, I do not think this measure should be delayed any longer. It is a simple zapping of temperature in the morning when healthcare workers are coming in and out, and I am not sure why we are delaying on it.

Dr. Colm Henry

I shall ask Dr. De Gascun to comment, if that is okay Deputy.

Dr. Cillian De Gascun

To add to what Dr. Henry has said, we are aware the organisations had started implementing this unilaterally. We are conscious of the fact that there is no guidance in the area. We have asked HIQA to perform an evidence census for us in this area. As Professor Mallon alluded to earlier, it is certainly possibly one of a suite of measures but while temperature was a significant element of the disease in China, back in January, we know that at this point in time that the majority of our patients in Ireland do not actually have a temperature associated with Covid-19. HIQA is conducting an evidence census for us at this point in time on the role of temperature screening to inform our practice and the possible development of guidance in the coming weeks.

I thank Dr. De Gascun. Can I ask about travel in and out of airports? Earlier, Dr. Henry mentioned that newer screening techniques were coming through that would shorten the screening time. I am aware of screening techniques that are coming through which will give a Covid response test in 20 minutes, potentially. I wonder if such a test can be made available would NPHET encourage that all people transiting into this country, particularly from affected countries, undergo a screening test at the airport and await a Covid response test before being allowed to leave?

Dr. Colm Henry

As was referenced earlier, the implementation of the rapid test would depend on its widespread availability across all airports and for all travellers. The information that I have is that that is not the case at the moment. The other test - the polymerise chain reaction or PCR test - that we do takes four to five hours. To achieve that turnaround would involve detaining people at airports for at least that time interval. As I said earlier in response to one of the Deputy's colleagues, as we begin to re-open and if we are going to resume passenger travel at the scale, or even a fraction of the scale pre-Covid, we would have to consider any measure we have, particularly coming from countries where there are higher levels of community transmission.

I am talking about a Covid response test with probably a 20-minute turnaround.

Perhaps I could discuss it further with Dr. Henry after the meeting, if possible.

Dr. Colm Henry

Yes, that would be fine.

I welcome our guests and thank them for being here. I have a number of questions. I will begin with questions to the witnesses for the Department and the HSE.

In response to a question I put to the Taoiseach three weeks ago, I was told that testing for Covid-19 cost €200 per test. My presumption was that was the cost of testing carried our in German laboratories. Earlier, we were told that the cost of a test is €120. In my investigations I have found laboratories in west Cork that can carry out Covid-19 tests for under €50. Everyone has a different figure. Why did the HSE not use Irish laboratories, which are up to 75% cheaper in terms of testing?

Dr. Colm Henry

I will ask my colleague, Mr. McCallion, to respond to that question.

Mr. Damien McCallion

There is variation in the rates paid. There are different rates as well. The tests we use within our own hospitals vary significantly in cost. When we looked at trying to get capacity up to 100,000, we looked to where we could get high volume to deal with the high volume going through. All the laboratories that we use have to be accredited and work under a clinical laboratory service. We looked at all possible laboratories in country and out of country. We needed high volume laboratories for some of our community testing such that the systems in place would ensure we got the results through in a timely manner. In regard to the rates we are using, we are being very careful in terms of the commercial rates because we are still negotiating on those and we do not want to prejudice those discussions. We are happy that we have achieved good, competitive rates relative to the rest of Europe.

The cost referenced by the Deputy does not refer to the German laboratory. Its rates are competitive, as are all of the on-island rates. There is a degree of fluctuation, often down to the nature of the test. There are other factors as well the cost. We have to ensure that all the IT is enabled, from the GP referral through to the appointment, the laboratory result coming through and feeding back into the contacting tracing system. A sophisticated IT system has been built up as we have moved through this process. We have engaged with all possible laboratories and, at one stage, we were getting 50 to 60 leads per day. We have a team who sifted through all of those to identify those that would give us the quickest return. I may be aware of the laboratory to which the Deputy referred. It would not be appropriate for me to get into a discussion on it here but I am happy to have that discussion outside. We have engaged with every possible laboratory that could offer a service. Currently, we have the capacity and, as mentioned earlier, the volume is running at a lower level.

At a meeting of this committee last week I was told that testing has cost in the region of €500 million to €600 million. Did this factor in the purchase of a PC-12 by the Air Corps to take Covid tests to Germany?

Mr. Damien McCallion

In regard to the costs that were referred to, if we were to run 100,000 a day every day that would be the cost to the end of the year. Clearly, that is not the case. The capacity was built to deal with surges, not for every day such that costs at the moment are under that. They are set out in the briefing paper that we provided today. We have used the Air Corps on a small number of cases when no courier services were available from Dublin Airport, which is built into our price. The Air Corps has been very helpful. I take this opportunity to recognise the Department of Defence and the Air Corps for their support at times, not just in regard to the transport of samples but also in regard to contact tracing, where the cadets were very helpful to us and invaluable in the early stages as well.

Has the HSE looked at investing in Irish laboratories such that they can up their testing capabilities at a fraction of the cost to date?

Mr. Damien McCallion

The bulk of the cost in terms of HSE investment to date has been in Irish laboratories. In case there is any doubt, the bulk of that investment has been in our acute hospitals or laboratories such as the National Virus Reference Laboratory and other associated laboratories. As stated earlier by Ms O'Beirne, we are developing a strategy that seeks to beef up the capacity on-island to cater for the flu season next year, for example, other potential surges and how to build on that in a sustainable way. It is not, unfortunately, just a case of purchasing the test. It is about staffing, the logistics, the infrastructure, the buildings and the IT, which is crucial. Earlier, a Deputy mentioned the learning. Not having all of that technology and building on it as we moved through this crisis has been one of the biggest challenges. We are continuing to invest in trying to improve the turnaround times through all of those small process changes. There is very significant investment. The bulk of the costs set out in the paper and provided to members are in regard to our own services on-island.

For the past number of weeks I have been asking the Taoiseach and the Minister for Health to create a system that provides for quick turnaround testing at our airports and ports to enable our areas to reopen and to ensure citizens are comfortable that people coming here are Covid-19 free. Animal Health Laboratories Limited in Bandon, which I visited recently, can produce results within four to five hours at a cost of €50 per test, as, I assume, can other laboratories here. Why are we not putting these test centres in place at our airports and ports?

Dr. Colm Henry

As I responded earlier, this is a matter we need to give serious consideration to as our airports reopen. It is being discussed at NPHET.

It is something we have to consider seriously. I cannot give the Deputy any further information at the moment because it will inform our overall testing strategy. Clearly, it will be all the more important as we begin to open up travel into our country.

Why are doctors and nurses in local clinics and hospitals not able to carry out Covid-19 testing?

Mr. Damien McCallion

They would be. I understand more than 40 hospitals are carrying out testing. It is not simply a case of doctors and nurses doing the tests. Laboratory services and all of the other necessary elements are required. The test involves relatively complex PCR testing. A number of things have to be in place in order to undertake tests. I am not sure if the Deputy has a query about a particular hospital that we could follow up on. In general, the process involves the scientists Dr. De Gascun has referred to, all of the equipment, which can be quite expensive, the reagent, IT systems, etc. If some hospitals are not testing it is because those things are not in place. They will be clearly aligned to a larger hospital or a hospital close to them. Most geographical areas are covered.

Are we still paying for testing we are not utilising? At the start, the State had to book a certain capacity but that was due to run out at a certain point.

Mr. Damien McCallion

We are managing that very carefully at the moment. We are not incurring costs over and above what we are testing. In some cases, we have had to stock up on tests. In the public hospital system we have tried to purchase ahead so that we are not caught with some of the problems we had at the start and ensure we have a stockpile that brings us forward in terms of reagents, test kits and so on. In some cases we are advance purchasing so that we do not get caught with supply chain difficulties further down the line.

Okay, but we are not paying private labs for X number of tests even though we are only utilising-----

Mr. Damien McCallion

At the moment we are not in that position, but it is a challenge. It is inevitable that if we want to sustain capacity, whether private or public, we will have to pay some amount towards that. We are working with laboratories to minimise anything around that. It is not an issue at present, but it is something we are conscious of and we also have to be aware lab capacity will become a problem when there are surges, as Professor Mallon said, across Europe. We do not want to have to compete again with bigger players than ourselves in terms of trying to find capacity, reagents or supplies from big global companies. It is a challenge for private labs and our public laboratories.

I thank Mr. McCallion. I call on Deputy Duncan Smith.

I am happy to wait. I am happy to let the natural rotation go through.

We are going to go to the second speakers from the larger parties. Is Deputy Fergus O'Dowd taking five or ten minutes?

He cannot take ten minutes as I am taking five.

That is clear, five and five.

I did not realise Deputy Brophy was there.

I have been here the entire time.

I have an important question. Can I get a note on the number of people currently working on contact tracing and the number of volunteers, and how those numbers have changed over time? I ask for a note on the difference between the use of and recommendation on face shields compared to face masks. A number of people have contacted me about the use of face shields because they can speak while wearing them and they are easier to wear than face masks which people cannot talk through.

I refer to the relationship between the United Kingdom and Ireland. There are different rules in both jurisdictions, depending on whether people live in the North or the South or in the UK. Do the witnesses not think that we need to address this issue in a significant way? People travelling to the UK through the North do not have to fill in any forms on their return, whereas people from the UK coming into Ireland through the South are required to. There are serious ambiguities.

My next question addresses a key point. I agree with Professor Mallon about the problem being exacerbated by the flu if there is a return of the pandemic. What should we do in terms of the flu vaccine? Should it be mandatory and available to everybody free of charge or should health workers, older people and so on be prioritised?

I have an important question.

The WHO tells us people aged over 60 and those with underlying conditions should use medical grade masks. People are told in the newspapers that medical grade masks are not available. People can go into Dunnes Stores, Lidl or pharmacies to buy masks but they do not know the quality of the masks they are buying. If people aged over 60 and those with underlying conditions are at a greater risk medically, surely it is incumbent on us to make sure those people get masks, that they get them for free if they are on low incomes, and that those masks meet the medical need, if that is what the recommendation is.

Dr. Colm Henry

I will go quickly through the questions. Ms O'Beirne will answer the question on the people in contact tracing and I will ask Dr. de Gascun, in his role on the expert advisory group, to comment on shields versus masks. We will supply the Deputy with the information if we do not have it to hand.

Ms Niamh O'Beirne

On 16 March, we set up nine contact tracing centres and trained 1,700 people. Of these, 300 people were deployed to the public health departments to support them in contact tracing and up to 700 were placed in the nine centres. We have consolidated our contact tracing centres into one centre in Galway, which is operating with 34 staff. This number of staff can comfortably deal with 100 positive cases per day. Yesterday, we had five positive cases so the centre is capable to do much more than it needs to do. The agreement we have, as I mentioned earlier, is that once we get three consecutive days of 100 cases, we will open up other test centres or remotely ask contact tracers who are trained to step up that capacity again.

Dr. Cillian De Gascun

We have not looked specifically at the issue of masks versus shields. Obviously shields do not provide the same level of contact with the skin but it is not an issue we have considered. Certainly we can look at it and revert to the Deputy.

Dr. Colm Henry

We are extending the flu vaccine this coming winter to younger age groups in recognition that they are an important reservoir of flu even though they are often not as severely affected by it. That order was put in and secured by the HSE one month or so ago. We are also focusing on our healthcare worker uptake, which has improved significantly in recent years. It is voluntary, as the Deputy alluded to. It has gone from 30% to 60%. It needs to improve further and there will be a big push on this.

Should it not be mandatory?

Dr. Colm Henry

On whether it should be mandatory that is not really a decision for us.

Does Dr. Henry have a view on it?

Dr. Colm Henry

Wearing my health hat, my belief is that it should be mandatory but it is a policy decision. Speaking with my medical hat on, I cannot see why any healthcare worker would not get it unless there is a specific contraindication.

Professor Paddy Mallon

I agree the flu vaccine should be mandatory for healthcare workers. I also fully support the expanded availability of the flu vaccine as a public health measure. The one thing about public health measures in general is that an expected uptake of any measure will always be dented if it comes at a cost to the public. This can be either the provision of the vaccine or the provision of masks or, as the Deputy said, the provision of higher grade more expensive masks to certain cohorts in the population, particularly members of the population who may not have the financial stability to secure them. Any consideration of a public health measure needs to take cost into account. If it is something that is expected to be widespread and expected to be effective, as the flu vaccine and mask use will need to be if they are to be useful, then we need to examine whether it should be made freely available. It is only by doing this that we will get the maximum impact from the intervention.

Dr. Colm Henry

As is well known, we faced a considerable shortage of PPE in this country. We were able to secure supply lines but in recognition of the particular risk in healthcare settings, it was introduced for healthcare workers. The WHO reflects this in its guidance, recognising the particular importance of providing and having a supply of masks for healthcare workers. Now that we have secured a more promising supply, we will have to factor in how much more we will need for particular at-risk groups in the community to make sure they feel safe and ensure they have access to those masks free of charge. It was a considerable effort for us as a country to secure the PPE we needed for healthcare workers in our hospitals and community system.

I thank the witnesses for attending the committee again today and for the documentation they have provided. I will start with Professor Mallon. He stated in his opening statement that the lessons learned from the first wave of Covid-19 need to be translated into actions and resources and that we have a very narrow window of opportunity. As we look forward and try to learn from the past three to four months, what lessons were learned and where do we need more resources to be directed as we face a potential resurgence of the virus?

Professor Paddy Mallon

We are talking about contact tracing and testing today and we have underlined how vital a component that is. Moving forward towards the early autumn, our hospital settings will be critical. People in Ireland will expect to be able to attend a clinical care facility and to be treated in a safe environment and it is paramount that we maintain safety within our hospitals and prevent Covid-19 infection from entering the hospitals. The two main ways Covid-19 will enter hospitals will be through patients attending hospitals through the emergency department or through outpatient clinics with symptoms - so we need to pick people up at that stage - and staff attending the hospital unwittingly bringing the infection in. These are lessons we have learned from the first wave.

In my view at the moment, we do not have a clear process in place to be able to at least deal with the staff issue. That is part of the idea around the need for this written end-to-end testing strategy. As we retreat rapidly from our use of private hospitals, there is an expectation that we will all be able to squeeze back into the same healthcare footprint we had back in March, be able to deliver the same services in a safe manner. I cannot see those expectations being realistic. We have emergency departments where the footprint is far too small; we had a trolley crisis that went on for months on end up until March when we had in excess of 900 people on trolleys on some days and where we are unable to physically distance. Even with the adequate testing and turnaround in hospitals, the current environment within a lot of our hospitals is simply not adequate to be able to safely manage increasing community transmission of this infection. We have a window to fix that but that window will only be open between now and September because it is at that stage that I expect cases to increase.

I wholeheartedly agree with Professor Mallon that critical planning is essential because we are facing into a winter when we will have Covid-19 patients and non-Covid-19 patients. Then we could have the normal winter surge, the winter vomiting bug and the winter flu. We all know about the issue of the late discharge of patients and the late transfer of care and the number of bed days lost as a result of that, which I have raised consistently for the past four years and which we discussed with the Minister for Health in the Dáil last night. We have to put a clear emphasis on throughflow through the hospital so that when patients arrive, the correct wraparound supports can be put in place for those who need to be sent home as a matter of urgency.

Professor Mallon referred to "the memories of those who have died from Covid-19, some avoidably". In this committee, I have constantly raised the question of what would have happened if patients were tested prior to entering residential care settings throughout March and April. For example, we know that in March 1,300 patients were transferred from acute hospital settings to nursing and residential care homes. We know this virus has borne down hardest on our older people, with 63% of all deaths occurring in residential and care homes. Professor Mallon speaks about avoidable deaths so does he believe that if these patients had been tested prior to entering nursing homes, some deaths could have been avoided?

Professor Paddy Mallon

When I refer to avoidable deaths, my experience of this is when an individual attends a hospital without Covid-19 but with another illness and enters the hospital environment sick, fhat person does not expect to contract Covid-19 and die within that setting. We need to maintain safe environments for the public to be treated for their illnesses. From the point of view of a physician and on a societal level, that is critical. Whether it is in acute hospitals or in nursing homes, the same thing applies because the consequence of the sick, the vulnerable and the old acquiring this infection is death.

That is a fairly stark consequence that we simply cannot accept. We can talk about bed days and social distancing, but if we enter September, October and November knowing what is coming and we still end up with people dying within our healthcare facilities from nosocomial infection, then, in my view, we have failed.

I understand that we were learning, everything was done in good faith and capacity was not available, but does Professor Mallon accept the following? I firmly believe that if the capacity had been available in March and April to test people who were being transferred to residential care from acute settings, and if patients had been tested prior to being returned to nursing homes, they could have been isolated for 14 days. It would have certainly made a difference.

Professor Paddy Mallon

There are probably a number of factors that contributed to what happened in the nursing homes. I had the experience of going out to visit nursing homes during the pandemic. There was huge variation in what was happening in nursing homes. There could be a nursing home being decimated in one district, with all staff and patients infected with Covid-19 and a number of people dying, yet one could travel 200 m to 300 m down the road and see a nursing home that was completely unaffected. We can talk about hospital discharge and nursing homes, but it is not the only story. There is certainly something at a managerial level within nursing homes that some nursing homes were able to do excellently to maintain the safety of their residents and staff throughout the whole pandemic, but other nursing homes were unable to do. That is the key. What were the nursing homes that avoided this doing right? We need to learn from what they did right-----

Professor Paddy Mallon

-----and make sure all the nursing homes follow those sorts of practices because they worked.

I wish to ask Dr. Henry a question about the ongoing testing in nursing homes. We know "test, trace and isolate" is the mantra by which we have to learn. We understand that medical staff in nursing homes will be tested for the next four weeks, which is very welcome, but I wish to ask Dr. Henry about the other staff in the nursing homes - for example, the caterers and the housekeepers - and the patients. Does Dr. Henry feel it is sufficient to test the medical personnel only and not the rest of the staff or the patients in nursing home settings?

Dr. Colm Henry

All staff, including those in the disciplines to which the Deputy has referred, are being tested. We are not confining testing to the disciplines she mentioned. I will add, based on the Deputy's remarks on testing and transfer during March and April, that in the past 100 days we have learned so much about this virus from a very low base. I am speaking now with my clinical hat on again as a geriatrician. What we know now that we did not know then is the importance of atypical presentations in older people and asymptomatic transmission. It should be remembered that testing was directed by the case definition. People had to conform to the case definition, which was originally quite narrow, and testing depended on the presence of a fever or respiratory symptoms. That guided testing. What we know now, and what only became clear through international experience towards the end of March, is the importance of atypical presentations in older people and asymptomatic transmission.

I thank Dr. Henry for the clarity because we received different information last week, when we were informed that only the medical personnel would be tested. Housekeeping staff were not included.

Dr. Colm Henry

To clarify, it is all personnel.

I thank Dr. Henry for that but I ask him again whether he thinks the patients should also be tested.

Dr. Colm Henry

There was a blanket exercise in testing all patients - in the order, I think, of 30,000-odd - in nursing home facilities. That was carried out in April. To go back to what the test actually does, it provides information at a point in time. It tells one something about a particular time on a particular day; it does not tell one anything about the following day. What we will do in the next four weeks is serial testing of all healthcare workers, including all the disciplines the Deputy mentioned, in nursing home settings. This is to inform us in a deeper manner about the mode of transmission and the behaviour of this virus among healthcare workers, who have the power to transmit the virus while asymptomatic. That has potentially been an important source of transmission in a very vulnerable healthcare setting.

According to Dr. Henry's opening statement, Ireland is one of the few countries to offer automatic testing for contacts of a confirmed case. How important is this to control the spread of the virus? I know that one of the other speakers said tests are carried out on day zero and day seven. Does Dr. Henry think we need to continue doing this on an ongoing basis, and how important is it?

Dr. Colm Henry

I will give the Deputy two figures. Among symptomatic contacts the positivity rate is 14% so far. The next figure underlines how important this process is. Among contacts who have no symptoms, the positivity rate is 9%. For that reason, we are aggressively pursuing all contacts and we need them to engage with testing and be tested. Just because they do not have symptoms does not mean they do not have the virus and could not potentially be transmitting it to other people.

We received a submission at 9:32 this morning on testing and tracing from the HSE. That submission is dated 16 June. Could the Business Committee do an examination of the reason it arrived so late? Was it related to the HSE or just a bureaucratic issue? Clearly, it is difficult to engage in questions to witnesses when receiving a document two minutes after the meeting has started. Without making a big issue of it today, perhaps it is something the Business Committee will examine on Friday.

I thank our guests for coming here. Professor Mallon and Dr. Henry and his team are all busy people and we appreciate their presence here. I wish to ask Dr. Henry about workplace incidences. We have discussed meat plants previously and when Dr. De Gascun was here, I asked him whether there was any specific type of workplace outside of healthcare centres, other than meat plants, that had experienced a prevalence of Covid-19 cases that would cause concern. Dr. De Gascun's position was that he was unaware of any other workplaces. Can Dr. Henry confirm that meat plants were the only workplace where there was a prevalence of cases, outside of the healthcare services?

Dr. Colm Henry

That is a good question. The Deputy should bear in mind that meat plants were included in the category of essential services as we gradually closed down and social measures kicked in on 12 March and 27 March. Many other workplace settings either went back to home-based working or closed down completely. That said, our experience has been replicated abroad. In Germany in the past week, there has been a significant outbreak in a meat factory setting similar to what we have experienced. I am not aware of other clusters in a particular workplace setting other than meat plants and healthcare facilities, but I will come back to the Deputy with more accurate information from the HPSC.

I thank Dr. Henry. Recognising that meat plants have been a particular issue not just in Ireland but internationally, for obvious reasons, what level of focus is Dr. Henry's team keeping on meat factories to ensure that we do not see other spikes in cases within those settings?

Dr. Colm Henry

The Deputy raised this previously and is correct to do so as they are vulnerable settings. There is a particular configuration of workers there, who are often foreign and do not have English as their first language. The mode of transmission is as likely, if not more likely, to have taken place outside the work setting, relating to how they live in congregated settings and so on. Our public health lead, Dr. Mai Mannix, has led on this and produced a report for NPHET, which I am sure we will be happy to share with the Deputy. This report gives a summary of the total number of outbreaks and the total number of workers affected, which I think is now in excess of 1,000. Again, I can supply the Deputy with exact figures. The management of it was predominantly by a focus on our public health workforce, led by Dr. Mannix, who liaised with the owners of factories, the Department of Agriculture, Food and the Marine and directly with the workers themselves, employing, in many cases, translators of Portuguese and other languages. It was a considerable undertaking, with-----

The prevalence of cases seems to have reduced in those settings. Is the work and monitoring by the HSE and the testing and tracing teams ongoing in meat factories?

Dr. Colm Henry

Yes, it is. Fortunately, we have seen a marked reduction in outbreaks as community transmission has fallen. The events in Germany underline how transmissible this virus is and how quickly it can get a foothold in a workplace setting, such as a meat plant, where other factors play into transmission and not just people working together. I reassure the Deputy that among the measures brought in by the public health team were having staggered shifts and smaller groups of people working in hubs. Measures were introduced in co-operation with the meat factory owners.

If that report could be provided to the committee, it would be useful.

Regarding healthcare workers, Phil Ní Sheaghdha of the INMO made a very powerful presentation to the committee the other day. She made the comment, which stands up to scrutiny, that in Ireland the prevalence of Covid-19 infection among healthcare workers is the highest in the world. The Taoiseach has tried to undermine those figures by quoting a different set of figures. Does Dr. Henry accept that the prevalence of Covid-19 infection among healthcare workers as an overall percentage of the population infected is the highest in the world?

Dr. Colm Henry

The concern is as much to me personally as it is to the Deputy, everyone in the HSE, the unions, Phil Ní Sheaghdha and everybody else. That said, I do not accept the characterisation of it. While every case would be troubling to any of us who work in the health service, given that we have friends and family and others working as front-line healthcare workers, the denominator - the number of people we tested throughout the pandemic - has varied. At one point we were testing small numbers of people owing to the difficulties we had in securing testing equipment and laboratory facilities, but at all times we prioritised healthcare workers, so that-----

That is not up for discussion at this point. On the basic tenet of the point made, does Dr. Henry accept that Ireland's percentage of cases in the healthcare sector is the highest in the world?

Dr. Colm Henry

I cannot accept that we can compare like with like country by country. That is what I am saying to the Deputy. I do not dispute the figure of 32%. However, because we have been measuring healthcare workers as a priority from the absolute go even when we had testing difficulties and because we had a very wide definition of healthcare workers - much wider than other healthcare systems in other countries, to me that is as likely a reason as-----

I have other questions. Does Dr. Henry accept that 32% is too high and that we really need to strive to improve that figure?

Dr. Colm Henry

Any case is not just a disappointment, it is a huge risk for us and for healthcare workers. Every case is wrong, and we have to do whatever we can to protect our healthcare workers, be it with PPE, masks, infection and control measures, and education and training. Many of these cases took arose outside acute hospital settings in community settings.

I ask Professor Mallon to give me opinion. As the committee heard on another occasion, a number of people have called for a change in the regulations to categorise instances of Covid-19 that were contracted in the workplace as notifiable occupational illness that would then be notified to the HSE. The Minister for Business, Enterprise and Innovation could change the regulation at the stroke of a pen. Does Professor Mallon believe that should happen?

Professor Paddy Mallon

I definitely think it would be a useful addition. At national level, we have no sight over the impact on a workforce of a large number of people within that workforce contracting Covid-19. Anecdotally, from my personal experience, having run a follow-up Covid clinic for the past five weeks, the vast majority of attendees at that clinic have been healthcare workers from a variety of settings. The majority of them did not initially contract the disease sufficiently badly to require hospitalisation. As we mentioned, some people have acquired a flu-like illness and have still not recovered three or four months later. It is really vital to our economy that we recognise the extent and the nature of that and be able to characterise it. There is no reason that the recovery of healthcare workers should be any different from the recovery of those in any other part of the workforce. For example, if we are going to open up our economy, we need to know the expected impact in terms of absenteeism and recovery times of any resurgence in cases in the community.

I come back to the HSE. I have less than a minute. We know what the capacity is or at least what we hope the capacity is.

Does Dr. Henry have a figure for the highest number of daily tests that were performed throughout the pandemic and the equivalent weekly number? What were the highest numbers of tests carried out on any given day and in any given week?

Dr. Colm Henry

We peaked at more than 20,000 tests in one day. I will come back to the Deputy on that question because those figures go back to mid-April so they escape my memory right now. However, we peaked at huge numbers during the peak of community transmission. I ask Mr. McCallion-----

I only have a number of seconds left. Do we have an analysis of the number of people that entered into healthcare settings, presumably without Covid-19, and then subsequently contracted the virus within those settings?

Dr. Colm Henry

I ask the Deputy to give me the specific question again because I am not-----

I am asking for the number of people who entered hospitals or other healthcare settings without Covid-19 and who subsequently contracted the virus. I know one can never say for definite that those people did not have it going in but presuming that they did not, what would the numbers be?

Dr. Colm Henry

It is somewhat difficult to say. We have done an analysis of healthcare workers, who are usually self-reported, but whether the virus was contracted in a healthcare setting or in the community is unclear. For this reason-----

My question relates to patients.

Dr. Colm Henry

For patients, we carry out an analysis of every case to try to see whether it community acquired or nosocomial, that is, healthcare acquired. It is not always straightforward because of the number of contacts and the amount of exposure patients would have had before coming into hospital and before first developing symptoms. As a result, there would be limited information on that issue.

I call Deputy Brophy.

I will start with the HSE. First, I record our thanks for all the work everybody throughout the entire HSE and the health service has done. I will make a few quick points before asking questions. I am very supportive of the testing programme and the work that was done in getting the laboratories, including the German laboratory, on board. It is vital that the HSE continues to deliver that service in the best possible way and is not influenced by the individual requirements of companies in different parts of Ireland looking for business, no matter who is selling it on their behalf. I would like to see the HSE continue to provide that service based on the best possible clinical practice, results and outcomes. That is important to put on record.

I am conscious of the time being very limited. Dr. Henry has said a number of times that the HSE has capacity for X or that 20,000 odd tests were being done in a day and so on. However, our testing requirements are now much lower. Maybe this is a real layperson's view but I cannot understand why, if the numbers being tested have gone so low because of a lack of community transmission, the HSE still cannot get the turnaround time down to a day. The median figure and the average number of days was quoted earlier. The infrastructure is there and the witnesses say it can be turned on at the drop of a hat. If we have the existing infrastructure, the capacity of which one of the witnesses from the HSE said was in excess of what is needed at this moment, why are still not delivering the same turnaround times in the community as we are in, say, a hospital setting?

Dr. Colm Henry

I ask Ms O'Beirne to come in on that.

Ms Niamh O'Beirne

The process in the community is different from that in hospitals. When a person feels unwell, he or she contacts a GP and the GP then has to refer him or her for a test. That person will then get a call or a text message to organise a test and there is a time for that test depending on where he or she is in the country and his or her availability. We track that-----

I am sorry but I know all that because Ms O'Beirne has explained it to other Deputies already. We have been told that we should be doing tests within a day. Is she telling me that is not possible? I ask her to give me a simple answer.

Ms Niamh O'Beirne

It is not possible for that referral pathway. The laboratories turn the tests around within 24 hours for the vast majority of cases. They are-----

What would Ms O'Beirne say to people who say the HSE should be doing tests within a day for the system to work?

Ms Niamh O'Beirne

The targets we set ourselves in early May were to perform 90% of tests within three days and to go from referral to swab within two days.

We are achieving the metrics we set out to achieve. Our community settings have that----

I ask Ms O'Beirne what she would say to people, including our other witnesses here today, who say this type of thing should be done in a day. Is Ms O’Beirne saying, in a blanket way, that is not possible and that we cannot do that?

Ms Niamh O'Beirne

Within our current infrastructure and our process, it is not always possible to achieve that. For example-----

Should it be possible to do it?

Ms Niamh O'Beirne

When we are building the new longer-term operating and testing service, we will look again at our metrics and our pathways, but at the current moment, we-----

I hear what Ms O’Beirne is saying. Is it the objective of the new system that goes live in August to bring that down to one day?

Ms Niamh O'Beirne

We will look at that objective in line with what we actually build and what we feel is feasible within our country in line with our country's ability to have laboratories within our shores, and depending on the volume we expect to have. We have to build something very flexible that will be able to go with small numbers of tests per week but that will also be able to flex when we get into winter and are in the middle of flu season.

I hear all that. Unfortunately, as other Deputies have noted, we are very restricted on time. Is it the objective in the August roll-out to have a one-day response time and is that the most desirable situation?

Ms Niamh O'Beirne

We have not defined our KPIs yet for that work as it has only just begun in the past week or two. We are currently meeting the targets we set for ourselves and we will look again at what we believe, particularly in light of the nature of our country and the pathways in which we can have testing, would be feasible and most desirable. There are varying views on what is to be achieved.

I want to comment on one other area, which is not necessarily for Ms O’Beirne to deal with. In the context of testing individuals entering the country at airports, a number of people are trying to sell kits that do these 20-minute tests, 40-minute tests and one-hour tests. Most of the international research so far is very dubious on the effectiveness of those tests. I would be very anxious that in their programme, the HSE and NPHET would be advising the development of air corridors with areas of like infection, rather than going with some half-baked testing idea that gives us no real protection. To be honest, I would not have anybody coming into the country from the United States at this moment, regardless of whether he or she has passed a test at all, be it a 40-minute test or a four-hour test. I do not think we should have people from the United States coming into our country. I would be interested to hear that the view is as I hope it is, namely, that we would stick exclusively with like-for-like air corridors.

Dr. Henry should be brief.

Dr. Colm Henry

I agree with Deputy Brophy. As referenced, the test is a point in time. When we look at the tests that are being offered, and perhaps not always validated, they may not have complete sensitivity.

What of the issue with the United States or the with north of England for that matter?

Dr. Colm Henry

Clearly, there is marked variation within the United States so, as with any other-----

Let us say Texas or the north of England, where there is a high incidence.

Dr. Colm Henry

Clearly, it is not just an issue of testing but of the quarantine when people come in. The testing will miss cases because it is not 100% sensitive. Rapid access tests, to which the Deputy refers-----

I thank Dr. Henry. I am anxious to hear from Professor Mallon and we will then move on to Deputy Duncan Smith.

Professor Paddy Mallon

I have two points. First, the public should be warned against doing any test that is not officially validated. For example, the public may undertake an antibody test that would take 20 minutes but it really tells us very little when they think they are getting the reassurance of a point-of-care nucleic acid test. We really need to put the message out there that people need to get tested through the official channels so they are tested right.

As I have said previously, we need to be very careful in terms of allowing people from the outside into the country. If we allow unrestricted movement of people from any area of the world, whether it is the United States, South America or parts of eastern Europe or Asia where there is uncontrolled community transmission, we will be making trouble for ourselves.

I apologise to the Chair, to my colleagues and to the witnesses for being late to today's session. If any of my questions are repetitive, my apologies. I will be quick because I know time is against us.

In regard to the tracing app that we understand is currently being tested by the Garda, do we have a view on when it will be ready to go?

Are there any GDPR concerns regarding its use and will it be freely available to sports clubs and community groups? Is the HSE working towards a test from home model? If so, how would that work? Would testing kits be free to all? Third, were there many instances of members of the public who refused to engage with the tracing process and, if so, what were the consequences of that? What lessons can be taken from it?

Finally, where the virus has re-emerged in other countries, it has emerged in superspreader events such as on public transport, in clubs and the like. Are the witnesses confident that our testing and tracing system as it is currently set up will be able to respond to that type of superspreader event at short notice in a particular location?

Mr. Muiris O'Connor

I can take the questions about the app. I can confirm that development of the app is complete and in a technical sense, it is ready to be deployed. The purpose of the app is to enable the health service to improve the speed and effectiveness of contact tracing. It has three basic functions: the contact tracing, a symptom tracker and a trusted source of information relating to Covid-19. It will add value by identifying more contacts than is possible in a manual tracing process. This particularly applies to strangers who might become close contacts, and those cases will increase as we return to normality and lift restrictions.

The issue of timing has featured during the debate. The app provides a capability to provide rapid notification to all close contacts who are app users within three hours. That is a very significant gain on the alert and the guidance that will apply. The app will be free to all citizens. It is a population health initiative and we want all citizens to engage with it. In that context, we have arrangements in place to have English and Irish versions and we have worked with the National Council for the Blind of Ireland, NCBI, to ensure full accessibility.

The app has two critical success factors as we assess it. The obvious one is population take-up. The other one is interface with the testing and tracing services. On the interface with those services, I assure the committee that enormous work has been done to plug it in properly into the wider testing and tracing operation. The issue of population take-up brings us to the GDPR issues and the assurances people can have about their privacy being managed in how the app is designed. We have taken enormous care to ensure maximum privacy. The development of the app over the past 12 weeks or so has been a journey towards the maximisation of privacy. The Irish Council for Civil Liberties and others have contributed substantially in setting out key principles that must be observed, and we are confident that we have observed those principles.

The app is voluntary. It operates a decentralised architecture that avoids any data being held centrally by the health services or the Government. Additional data of statistical value is provided by users on the basis of user preference. All the details about the data and the privacy considerations are set out in a detailed data protection impact assessment, DPIA, document. We completed that a number of weeks ago and it has been considered in great detail by the Data Protection Commissioner, who has responded. The Minister committed in the Dáil and the HSE committed in statements in recent weeks to making these publicly available and it is our intention to do that tomorrow morning. That will be good in terms of transparency and it will set the ground-----

Perhaps Mr. O'Connor could provide the additional information to Deputy Smith in writing. I appreciate the detailed answer he is giving. Is it open source?

Mr. Muiris O'Connor


Did Mr. O'Connor say "yes"?

Mr. Muiris O'Connor

Open source?

Mr. Muiris O'Connor

No. I do not understand the question.

Will the app be open source? Will people be able to look at the coding in it?

Mr. Muiris O'Connor

The Chairman is referring to the source code. Yes, the source code will be-----

What about the other questions Deputy Smith asked?

Dr. Colm Henry

I can take them in writing. That is fine.

Dr. Henry will deal with them in writing. I have two brief questions and Deputy Boyd Barrett also has a question. There was a great deal of information provided by the CSO recently, although it was obviously retrospective, on geography, gender, socioeconomic background, occupation, age and so forth of people who had tested positive and people who unfortunately died.

I take it that would be very useful from Professor Mallon's perspective.

Professor Paddy Mallon

All of this information is useful when trying to plan, especially at a population level. One of the aspects that will probably become apparent in protecting our health service will be the pay, living conditions and overcrowding of some of those working in the service. How all of this contributed to the epidemic will be an important factor. Those data will feed into that conversation.

Would it be useful to receive that information on an ongoing basis?

Professor Paddy Mallon

The more information made available to society in general and to the people managing the epidemic, the better.

Will NPHET and the HSE be providing that information on an ongoing basis rather than retrospectively?

Dr. Alan Smith

An increasing amount of information is publicly available on the Department of Health website. This includes a lot of the demographic data, incidence of cases, the number of laboratory tests and maps of where cases are happening. I can direct the committee to the specific part of the website so that members can examine it to see if the information is sufficient. We certainly anticipate adding to it.

Was the HSE eventually able to trace all contacts of those who tested positive in the meat factories or are there ongoing difficulties?

Dr. Colm Henry

There were difficulties both within the meat factories and outside. I will have to come back to the Chairman with specific information but my understanding is that we did manage to trace the contacts of everybody within the work setting and almost everybody outside. I would prefer to come back to the Chairman with an accurate figure.

With regard to the Chairman's question and my earlier question, I would still like more affirmative confirmation that we will get additional information about things like the occupations and workplaces of cases. That will be critical as we open up the economy. I just wish to make that point.

I have two very quick questions. Did Professor Mallon say that recovery times were considerably longer for healthcare workers?

Will Deputy Boyd Barrett ask his second question? I am just conscious that we will have to get people out.

Sure. Has that got something to do with the viral load they may have been exposed to because of the nature of their work? Is that a factor in how sick people get and how long they remain sick? I am just curious about that.

I will move to my second question. I totally agree with what Professor Mallon said about the footprint. We will be putting a square peg into a round hole with regard to capacity come September, if not before. To what extent does he believe issues like understaffing, the consequent long hours that people may have to work and the stretching of staffing are factors in the increase in infection rates among healthcare workers?

I thank the Deputy. I will allow time for an answer.

Could Professor Mallon put a figure on the amount of additional staffing and capacity we need across the health service in order to deal with both the pressures existing before Covid and the additional need for Covid care?

Professor Paddy Mallon

To clarify, the point on the prolonged recovery period comes from my clinical experience, which has predominantly been in dealing with healthcare workers. I have no comparator group. There is, however, a much more prolonged period of recovery than would ever be expected for people with a mild initial infection. That is what we do not know.

In the context of the footprint, I completely agree with the analogy of the square peg in a round hole. To give an example of how relatively understaffed we are, this morning I compared our gross domestic product with that of Norway. Ours is approximately 30% lower than Norway's. Norway has more than 100 infectious diseases specialists for a population not dissimilar to that of Ireland. We have fewer than 20. I am sure it would be the same for every single medical specialty including nursing and for intensive care unit capacity. We got away by the skin of our teeth largely due to the biggest non-pharmaceutical intervention the country has ever taken, which was mediated by the public. We did not get away with this because of the capacity in our healthcare system.

To ask our healthcare system and the people within that system to do again what they have done over the past three months would be similar to asking the population to undergo the three-month lockdown again. There needs to be a recognition, going forward, that we cannot operate safely with the current footprint and current staffing levels.

We are out of time. A question I still have is one to which I do not expect an answer today. It is about whether we can expect the public to lock down again in circumstances where it is a question of assessing our economic response - it is a horrible question - having regard to the fact that 99.5% of the people who died of Covid-19 had underlying conditions or were over 65. The question is to what extent we take out the entire economy for the benefit of that group of people or the extent to which we can afford to do so. However, that is a broader question to be answered by lots of people in this Chamber at a different time.

I thank the Deputies who asked questions and the witnesses who came in to answer our questions and stayed longer than anticipated in order to do so.

Sitting suspended at 11.40 a.m. and resumed at 12 noon.