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Special Committee on Covid-19 Response debate -
Tuesday, 21 Jul 2020

Covid-19: Infection Rate among Healthcare Workers (Resumed)

Deputy Michael McNamara took the Chair.

I welcome the witnesses from the HSE. I thank Mr. Woods for coming back so soon after being here last week. I also thank his colleagues from the HSE, including those from the Health Protection Surveillance Centre, HPSC.

I advise all witnesses that by virtue of section 17(2)(l) of the Defamation Act 2009, they are protected by absolute privilege in respect of their evidence to this committee. If they are directed by the committee to cease giving evidence on a particular matter and continue to so do, they are entitled thereafter only to a qualified privilege in respect of their evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and 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 way as to make him, her or it identifiable.

I ask Mr. Woods to introduce his colleagues from the HSE and to briefly outline the key points of his submission to the committee, which has been circulated to all members.

Mr. Liam Woods

I thank the Chairman. My colleague, Dr. Kelleher, will do that. I note the Chairman's comments about the submission of the statement.

Dr. Kevin Kelleher

I will quickly introduce the people around the table. They are: Mr. Liam Woods, national director of acute hospitals; Dr. Lynda Sisson, chief occupational physician, who works in the HR department as well as carrying out clinical work; Ms Anne Marie Hoey, national director of HR; Dr. John Cuddihy, director of the HPSC; and Dr. Lorraine Doherty, national clinical director for health protection.

As Mr. Woods and the Chairman said, the committee has received our submission, so we will not make any comments on it. I will, however, make a few opening comments. As an organisation, we take very seriously our responsibility to safeguard all our staff and all our patient clientele. That is a fundamental aspect of our role as an organisation. Clearly, the people around this table are intimately involved in that.

We cannot express our gratitude to, and pride in, all the staff in the health system and those who have joined from outside for how they have performed over recent months. They have worked way beyond what anybody could have expected. They have put in days and weeks of immense work in dealing with this problem for the people of Ireland. As members will be aware, we have come out of it fairly well compared with a number of other countries. Our number of cases is proportionately much lower than in other places. Somebody told me today that Idaho in the US, which has a population of 1.5 million, is seeing 1,000 cases a day.

At the moment, they are seeing 1,000 cases a day, which would be the equivalent of 3,000 to 4,000 cases a day here. We never went anywhere near that sort of number. We are immensely proud of the ICU nurses, the doctors in emergency departments, the doctor and nurses in primary care and the people who have moved from their jobs to work in other roles as part of the response. They have made immense contributions. Finally, I thank the public health staff, who have been going since very early in January and are still going at this quite hard, and especially our colleagues here in Dublin, which has been the main centre of it, so it has hit hardest on people in Dublin. We are very proud of everybody and we aim, as ever, to try and help them to work in whatever way we can. We are ready to take questions.

I thank Dr. Kelleher very much. The first member to speak is Deputy O'Dowd.

I welcome the witnesses. I agree fully with Dr. Kelleher's tribute to his staff and all those who worked to save so many lives. The tragedy is, notwithstanding that, families are deeply suffering and in pain right now.

I have a couple of questions arising from the briefing note we received from Mr. Ray Mitchell in the HSE on testing for contacts of confirmed cases. We are told that 1,314 people did not attend the day zero and day seven tests. They were contacts of confirmed cases. What is the response to that? The figure seems very high to me.

Dr. Kevin Kelleher

I will say a few words and either Dr. Doherty or Dr. Cuddihy will add to it. We recognise that this is a major issue for us. There is a difference between how many people take the test on day zero and day seven. Some of that may be a consequence of the test itself, but it is an issue we need to address. Dr. Doherty has been doing some work in this regard.

Dr. Lorraine Doherty

We had a discussion about this in the HSE just this morning. I thank Deputy O'Dowd for his question. It is a very important issue. We too are concerned about this because it shows that perhaps people are becoming a bit disengaged with the idea of having a Covid test if they are symptomatic, or if they are a contact, because they understand the implications of having a test on day zero and again on day seven and the need to restrict their movements. In particular, people in the workplace may be reluctant to be tested. What I need to emphasise is that our public messaging is very strong on the need to have a test if a person is symptomatic and also if one is a contact of somebody who is symptomatic.

Of the 2,900 people who were confirmed positive, it is very serious that 1,300 of their contacts did not turn up for their tests. Notwithstanding Dr. Doherty's reply, we need to interrogate the situation more and learn more about the status of those people, if there is an age profile and whether there was a cluster of cases. We need to know more. I do not doubt her intention to find out more but I am most concerned. It is very serious if we not do turn up when we are a contact of a confirmed case. In theory, we could have it and pass it on to many more people. I say that notwithstanding all the good work Dr. Doherty is doing. How does she intend to follow this up? Can she get more data? Should it be a mandatory requirement for a person to turn up for a test if he or she is called? One is protecting other people if one does attend and one is not protecting them if one does not.

Dr. Kevin Kelleher

I agree with what Deputy O'Dowd said and thank him for his support in saying it, because it is very important. We need to look at how we do this. I will hand over to Dr. Doherty to continue.

Dr. Lorraine Doherty

I reassure the committee that we do not take this lightly at all. We make every effort possible to find people who are not answering phones who we have not been able to get to come for the test. The initial contact is made within the contact tracing centres. At least four or five attempts are made to contact people. Where there is an inability to do so, their details are passed to the local public health department, which might have local knowledge on how to find the contacts.

We put a lot of time and effort into trying to find them.

Regarding the data, as I said this morning, we have been looking at these data and we intend to do further analysis on them and to look at what factors might be influencing the reluctance to come to testing and whether there is a particular demographic that is not turning up for testing.

It is a very high figure. It is a huge figure and the witnesses need to do more work on it. This may mean the Garda calling, because these people are known with known addresses. The Garda should call and ask them, in the interests of public health, to turn up.

The second question I have relates to the uptake of the flu vaccine, as well as to the certainty of the return of flu and the probable return of Covid-19. From my reading of what the witnesses gave us, the rate of take-up in the HSE is 44%, which is far too low. In other words, if less than half of the workers in acute hospitals and healthcare settings are taking the vaccine, that puts everybody, including themselves, at serious risk. What steps does the HSE propose to change that figure significantly?

Dr. Kevin Kelleher

I will speak on the figures and then Dr. Doherty and Dr. Sisson will come in on the healthcare workers.

We have not got the final figures for last year because Covid impeded us from doing it but our understanding is close to 60% of people in the acute sector will take the vaccine. It is likely that in the long-term care facilities, the figure will be in the high 40s or around 50%. These are significant increases from over the years. Likewise, we know the uptake among the elderly over-65s is 68% and of people in residential care facilities it is around 90%. The figures have been rising over a number of years. We will put a big effort into what needs to happen this year. We have taken major steps to change what we will do in the coming year compared to what we did in previous years in respect of to whom we offer the vaccine and how we do it.

Dr. Lorraine Doherty

I will start with a general comment and then hand over to my colleague, Dr. Sisson. The issue of flu immunisation among healthcare workers is a worldwide challenge. We know that, for some reason, there have been healthcare workers who have been reluctant in the past to avail of the free flu vaccine. I should make clear that enough vaccine has been procured and is available to immunise all our healthcare workers. All healthcare workers receive the offer of influenza vaccine and it is offered in the workplace to facilitate their access. It is an important part of our overall strategy for prevention of infection this winter to make sure that healthcare workers avail of the free flu vaccine. I will pass over to my colleague, Dr. Lynda Sisson, who will update the committee on some of the more specific measures we will take.

Dr. Lynda Sisson

I thank the Deputy. We are actively looking at the flu season coming up and we will start vaccinating on 20 September. I will outline two of the main drivers in increasing flu vaccine, the first of which is to increase the availability of the vaccine. The second concerns increasing the education and communication around it. In terms of increasing availability, we have an enormous peer vaccinator programme in the HSE, which has allowed other nurses in local areas to provide the vaccination to their peers. This year we will include paramedics and pharmacists and we may also include some of the allied health professionals. We will increase the number of peer vaccinators that are available on site to give the vaccine to staff in their local area. In previous years, that has really increased the number of people who have taken up the vaccine. In addition, we are looking to see if we can get healthcare workers vaccinated in their local GPs and pharmacies free of charge and that will hopefully be an option for us in September. Educating healthcare workers is an ongoing thing. We have developed HSeLanD modules and we have a number of communications. We have a number of areas where we try to break down some of the myths about the flu vaccine and we have been working hard on that.

The next step is to start looking at risk-assessing front-line workers and requiring them as part of a risk assessment to partake of the vaccine. That is something that we are exploring at the moment and it is something that has been very successful in increasing flu vaccine uptake in Australia. We may be developing a model on that for this year because, as the committee knows, it will be critical for our healthcare workers to be vaccinated this year, especially-----

I hear everything Dr. Sisson is saying but I am not hearing enough about outcomes. If we have an outbreak of Covid-19 again in the autumn, coupled with the flu, it will be an appalling vista in our hospitals and especially our accident and emergency departments. The HSE perhaps needs to consult with all of us, the Oireachtas, the Government and everybody to ensure that there is a huge campaign. We are going to have to insist that people receive it because if people are working in a hospital environment or with older people they will place them at risk if they do not take the vaccine, notwithstanding exceptions on medical grounds. The HSE needs a much tougher, more resourced and more focused campaign.

I have a quick question supplementary to those from Deputy O'Dowd.

Dr. Doherty was saying that the HPSC is looking at those who are not presenting for testing to see if there is any particular demographic. Has it ascertained that there is any such demographic, as of now?

Dr. Lorraine Doherty

We do know that there has been a change in the epidemiology which my colleague Dr. Cuddihy has much more information on. We are now seeing more infections in younger people------

I was referring to people who are not presenting themselves for testing, the people who are not showing up to be tested.

Dr. Lorraine Doherty

I do not have that information Chairman but I am happy to get it for the Chairman and present it at a future meeting.

If there is any such information it would be interesting.

Deputy Cullinane has ten minutes.

I welcome all of our witnesses and wish them the very best in their work over the next while as they battle with this virus and all of the other health issues that must be tackled.

I wish to begin with Mr. Woods. I do not know if he has read the submissions that the committee received from the healthcare trade unions who were present this morning. The INMO's submission was very extensive and in fact made a lot of good recommendations. One of the things that jumps out of their submission is the very high levels of front-line staff in this State, especially nurses, who contracted Covid-19. It seems to be very high in comparison to Europe and globally as well. Can Mr. Woods explain first of all why so many front-line workers in this State contracted Covid-19 in comparison to other states?

Mr. Liam Woods

We do not get to see the opening statements until after they have been taken at the committee but I look forward to seeing them. I did however hear some of the commentary this morning. Dr. Cuddihy from the HPSC has knowledge in this area and he might address the Deputy's question.

Dr. John Cuddihy

The first thing to say is that in Ireland we have a very broad definition of healthcare worker. It encompasses anyone who works in healthcare, either public and private. In other European countries this is often much more specific, sometimes down to doctors and nurses but in some cases healthcare staff who work in the front line. Second, from the outset of this pandemic in Ireland healthcare workers have been prioritised for testing. Even when availability of testing may not have been as good as it is now, healthcare workers were prioritised so more healthcare workers were tested as a result. Third, even in the course of this pandemic when the number of cases were low, healthcare workers in hospitals and residential care facilities continued to care for patients with Covid-19 so their risk of-----

I apologise to Dr. Cuddihy. Notwithstanding that we may not be comparing like with like, he must accept that there were very high levels of infection among healthcare workers in this State.

Leaving aside the differences in comparisons, it is very high in European terms. I asked why the rate was so high for front-line workers in Ireland, leaving aside other variations that may not be fair. Even building them in, it is still very high. Why is that?

Dr. John Cuddihy

The Deputy said that the rate is high in comparison with other European countries. I was just explaining that our definitions of healthcare workers are quite different to those of other countries. Similarly, we have very much prioritised healthcare workers in this country. The other factors regarding levels of infection in healthcare workers relate to their risk of exposure as described even when cases are low, but also the nature of their work. Where they work and where they live may put them in close proximity to other healthcare workers. I will ask Dr. Sisson-----

I will ask a follow-up question. We heard very strong testimony from the trade unions this morning. One issue that came across was the directive given to front-line workers not to wear masks. The INMO said that at least one member of staff was disciplined for wearing a mask and that was a huge concern. Why was that decision made and that directive given to nurses and front-line staff not to wear masks in the early stages of the pandemic? Did that decision have an impact on the higher levels of contraction of the virus among healthcare workers?

Dr. Lynda Sisson

I will take that question. We have had an opportunity to look back at the possible causes of transmission for some 2,000 cases. There is no doubt that in the very early stages, undetected cases in the hospitals contributed to huge numbers of infection in healthcare workers. The other thing we have noticed was the inability to practice social distancing, or a lack of awareness around it, in hospitals at the very beginning. Some of our hospitals do not lend themselves to physical distancing.

The decision on masks was made by NPHET and we did not recommend mask-wearing at the very beginning. However, as PPE became more available, mask-wearing was commenced. The differences between the earliest stages and later stages were largely due to the Covid and non-Covid pathways in the hospitals, the earlier detection of cases, the implementation of social distancing and the closing of the canteens. The other issue, to which we alluded earlier, is the change in the culture of healthcare workers coming to work when they were sick. That was one of the big challenges for us because healthcare workers traditionally show up to work with symptoms.

Basically, Dr. Sisson is saying that the decision to advise healthcare workers not to wear masks in the early stages was taken by NPHET and not the HSE. Is that what she is saying?

Dr. Lynda Sisson


Okay. I will move on-----

Dr. Kevin Kelleher

Can I say something on that point?

I have many questions to ask and I only have a few minutes.

Dr. Kevin Kelleher

Advice from March clearly indicates that staff should wear masks in the appropriate circumstances as dictated at that time. It very clearly indicated they should wear masks when dealing with people who might have an infectious disease like Covid.

The advice changed.

Dr. Kevin Kelleher

No, that was our advice in March.

What I am putting to the witnesses is what was said to us this morning by the trade unions that represent those staff. They said that their staff were told not to wear masks and that in a number of incidences, members of staff were disciplined for doing so. We can argue about the timeframes but what we have heard from the previous witness is that a decision was made by NPHET whereby it was not the case that front-line staff should wear masks. That advice was changed, we all accept that, but I am trying to get an answer as to why that decision was made. That has been dealt with.

I want to move on to the next issue because it is an important one. I ask Mr. Woods to answer this question. A survey was conducted by the INMO of the impact Covid has had on front-line staff. Much of that impact relates to fatigue, while some of them experienced nausea, breathing and respiratory problems and headaches. Mental health was also a huge issue. The term used by the representative from the INMO was "post-traumatic stress", which is a big challenge for those front-line workers. What practical supports are being considered by the HSE and the Department to support all those front-line workers who went through a huge trauma while trying to deal with this virus? In some cases, they watched people die, saw their colleagues contract the virus and worried about contracting, or did contract, the virus themselves.

For those who did contract it, and all of the stresses they are now under, what practical supports is the HSE looking to put in place?

Mr. Liam Woods

I thank the Deputy for the question. I heard Ms Murphy's evidence this morning as she related her personal story to the committee. This is Dr. Sisson's area of expertise so I will pass it to her because it is an occupational health matter.

Dr. Lynda Sisson

Levels of psychological supports were in place from the very beginning. We have five levels of support for staff. We have general information and communication, self-help supports and peer supports up to professional supports and, if necessary, escalation to mental health services. These have been in place for staff from the very beginning and they remain in place.

If Dr. Sisson and Mr. Woods read the submissions the trade unions made to the committee, they will see they are calling for the HSA to have a much greater role in occupational health issues in healthcare settings. They should examine this and support the recommendations they have made.

My final question for Mr. Woods goes back to a discussion we had earlier this week. All unions were very strong on the need for additional capacity in acute beds, rehabilitative care beds and more physical infrastructure, and retaining the capacity we have. When will the HSE publish a comprehensive plan on increasing overall capacity in our system? We all know we face a major challenge in dealing with Covid care, non-Covid care, all the infection-control measures, public health guidelines and the need for catch-up programmes. We have the winter flu coming at us. We have the potential of an increase in Covid if it happens. It is a perfect storm that requires a plan. Will Mr. Woods explain to us when we will see the bones of this plan that will outline all the additional capacity that will be put in place to make sure we can at least keep up, if not catch up, with all of the missed care?

Mr. Liam Woods

I thank the Deputy. We are preparing our winter plan in the consciousness of Covid. One of the witnesses this morning summed it up very well by saying the system needs more staff, equipment and space. This is precisely what we are looking to optimise as we move into winter. We are also looking at how and where care is provided. With regard to the Deputy's question on when, there is a process within the HSE that subsequently will involve the Minister. The question of the timing of publication of such a plan is a question that is ahead of us but we are doing it now and we expect we will conclude it within the coming weeks.

The next slot is Fianna Fáil and Deputy McAuliffe is going first.

By agreement with the Chair, 20 minutes have been allocated but we propose to take-----

Yes, that was an error. It will be two ten-minute slots.

I propose to take five minutes, as will Deputy Devlin, with the latter ten minutes towards the end.

I want to come back to the testimony Ms Murphy gave this morning. While she was making her own case, she was speaking on behalf of many nurses about the mental health impact and post-traumatic stress of experiencing exceptional circumstances, which, nonetheless, have left many healthcare workers with a trauma. The experience she outlined seemed to indicate the HSE was relying very heavily on very low levels of intervention, including the use of an app and peer support. Will Dr. Sisson elaborate on the supports available? The HSE seems to indicate there is sufficient support but the INMO clearly stated through personal experiences that there is not.

Dr. Lynda Sisson

I thank the Deputy. We have a model of internal and external care for staff counselling in the HSE that is well established. Employees have a choice of going to somebody in their own area or accessing an external service.

This service is, as I said, completely free and can range from group to individual interventions. Staff who become unwell can also go to occupational health and, if they need additional mental health services, including specialist mental health services, they can be referred to those services. We have specialist psychiatrists who deal with post-traumatic stress disorder and we have a range of supports from an app to specialist mental health services for staff.

Dr. Sisson is saying that every staff member has access to the sort of external debriefing that the INMO said in the previous session was not available.

Dr. Lynda Sisson


If that is the case, then there is clearly an issue. Those who are representing the workers and the workers themselves do not believe that is available and she is saying that it is. That means there has been a failure to communicate the availability of those services to people. I imagine, given that they are in a state of trauma and are going through a mental health crisis, there is an obligation on the HSE to ensure that communication is correct.

Dr. Kevin Kelleher

We accept that fully and we will take that information back with us. It has to be recognised that two separate things are happening. One is what the Deputy has described, that is, how people have had to cope with the work impact and everything else. Separate to that is the fact that this virus, like all viruses, has its own longer-term impact on people. We have to be careful about trying to make sure that we deal with both of those issues because they are both very important.

All viruses have longer term sequelae that we need to be clear about, and we have to learn about coronavirus and its longer-term sequelae. We are trying to do both of those things at this point. We will take on board what has been said because we want to make sure that staff get access to the appropriate advice. I am not sure I want to keep using the term "post-traumatic syndrome", but that, along with the longer-term impact of the virus, are the issues facing staff in reality.

I thank Dr. Kelleher. As I said earlier, the world was catapulted into this scenario. There was clearly a lack of preparedness, not by design although there were systematic shortfalls. We struggled to keep up with what was an unexpected pandemic. There will be additional waves. We will not be able to rely on the same response and will have to be more prepared.

The figures for healthcare workers are interesting. The HPSC mentioned 32% of the 8,219 cases. A figure of 48% for phase 2 has been mentioned by Mr. Mark Roe, a postdoctoral researcher in UCD. A figure of 58% for the health service east region has been mentioned in respect of health care workers who have been impacted. I accept there are different definitions. What are we doing at this point to ensure that the level of infection is reduced in any future localised outbreak?

Dr. Kevin Kelleher

We are under time pressure. The overall approach to infection prevention and control includes organisational and individual approaches. It is very much about ensuring that people undertake all of our advice on infection prevention and control and that PPE is used, as appropriate in the circumstances, to protect patients and healthcare workers. That is what we have learned. As a consequence of where we have come from to where we are now, we are beginning to see that it is having some impact, but it needs to be reinforced in all circumstances and that is what we accept we need to do if we have to deal with another wave.

I thank Dr. Kelleher and Deputy McAuliffe.

I thank the witnesses for being here today and answering our questions. I only have five minutes and I will be brief. I hope the responses will also be accurate and brief.

Deputy McAuliffe referred to the testing available to healthcare workers. I am conscious that we need to be prepared for a second wave if it comes. I refer to the supply chain for PPE, in particular the roll-out in the early stages of the first phase of the pandemic to public hospitals and private settings.

What assurances can the witnesses give that sufficient stock exists and that PPE will be rolled out to the various community and public health settings?

Dr. Kevin Kelleher

There is very clear advice, led by our national infection prevention control teams, about what PPE is appropriate in what circumstances. As a consequence, we have been seeking to source that PPE. Mr. Woods will take that matter up in more detail.

Mr. Liam Woods

The HSE has built, and is building, significant stock reserves. As the Deputy has referenced, that is sensible as we approach winter and our stock requirements are likely to rise. We have a significant distribution network through our logistics function which is part of procurement. That network is supplying hospitals, communities and other healthcare providers with high volumes of PPE, well beyond anything we have experienced previously.

Our supply chain and its sources are bringing in an adequate supply at the moment. While there is a global market and there have been problems in accessing PPE, right now the HSE is sourcing a sufficient supply. We have good contracts, are building stocks and have good distribution. Of course, we must keep a close watch on that in the coming weeks as we move towards winter.

I thank Mr. Woods for that. It brings me to my next point, which is the potential loss of step-down and convalescent services that will be acutely needed, particularly in the winter months. These types of services are needed and it is essential that we do not lose them. We need them in order that patients can leave acute hospital settings and convalesce elsewhere. From a public health point of view, having an alternative venue for people to quarantine or have respite is desirable. What interactions does the HSE currently have in respect of securing and maintaining those services?

We heard about the funded workforce plan from union representatives during our first session today. I understand that is currently being discussed. What information can our guests give us about that matter?

Mr. Liam Woods

Can I get specifics from the Deputy on the step-down arrangements to which he is referring?

Does Mr. Woods mean the question I asked about convalescence?

Mr. Liam Woods


I represent the Dún Laoghaire constituency and there are a number of such settings. Caritas Convalescent Centre, in particular, was in the newspapers last week. While it is a private setting and decisions are made independently of the HSE, it would remiss of the State not to have access to those facilities. We must ensure that no other closures will happen because we will need those settings in the next few months.

Mr. Liam Woods

I agree with the Deputy. I will not address the specific instance he mentioned, but it is our intention to maintain and grow capacity. As the Deputy has said, the step down from acute services is the key to enabling us to have effective flow through the service and there are specific proposals on expanding rehabilitation services to allow for a step-down process for Covid-19 patients. Specific work in going on in that regard.

We are also looking at expansion and have invested in expanding the capacity of community sites in the past couple of months. Our winter planning will also include the provision of as much care as possible at home and effective use of community assessment centres.

The Deputy asked a specific question about the funded workforce plan, which I might ask Ms Hoey from human resources to address.

Ms Anne Marie Hoey

It is fair to say that, in recent months, we have grown our workforce through a number of means in response to Covid, including direct recruitment, redeployment, increasing the numbers of staff on part-time hours, rehiring retirees with specific skills and so on. We have also targeted recruitment through specific groups. Student nurses have been employed as healthcare assistants. Medical laboratory scientists have been employed in their sphere, as have radiography graduates.

We have seen an increase in employment over the past number of months. As of the end of June, employment had increased by just over 4,500 staff members. We are continuing various initiatives to address our recruitment requirements as we plan for winter and the Covid environment.

I thank our visitors for their presentations. My first question goes back to the issue of the flu vaccine. I would like to ask Dr. Sisson a few questions in that regard. I commend the work being done to improve the uptake of the vaccine among healthcare workers. It is really important that we boost this year's figure in comparison with those in recent years. I also note that last week the European Commission advised member states to start their vaccination programmes earlier than normal because of the Covid threat. Has that impacted the HSE's proposed timescale? That is the first question.

My second question relates to additional orders for vaccines. We heard last Friday that an additional 200,000 vaccines had been ordered. This seems to be quite a small addition given the need to substantially increase uptake. What is Dr. Sisson's view on that?

While I welcome the extension of free vaccination and vaccine availability through GPs, is it intended to extend these measures to pharmacies? Those are my three questions.

Dr. Kevin Kelleher

I thank the Deputy. I will start and then Dr. Sisson will provide further detail. We are ordering close to 2 million vaccines for the coming year. This comprises 1.4 million doses for the groups we usually target, which is an increase on previous years, and an additional 600,000 for the campaign to vaccinate children. This is a crucial part of the overall process.

My question was whether the HSE is of the view that the order for 200,000 additional vaccines for adults is adequate.

Dr. Kevin Kelleher

Our calculations indicate that approximately 1.4 million to 1.5 million will require the vaccine as per our guidance from the national immunisation advisory committee. This includes those over 65 and those under 65 who have medical conditions. We believe we will have sufficient doses for those people and to cope with the other groups such as healthcare workers. We do not believe we will have a problem vaccinating every healthcare worker if required.

I hope that is the case.

Dr. Kevin Kelleher

It is. I would be very happy if we got to use every single dose because we never do.

Will pharmacies provide the vaccine to healthcare workers free of charge?

Dr. Kevin Kelleher

That is being discussed at the moment. The Department of Health and HSE are negotiating with the various organisations involved.

I will go back to some of the points mentioned earlier. I have two questions for Mr. Woods. On the need for a funded workforce plan, I note the points that have been made about additional staff and so on but a very graphic example was given this morning. At the height of the Covid pandemic, there were 19 nurses working in a particular Covid ward, 12 of whom came down with the virus and went out sick. This placed a great additional burden on the remaining staff. This highlights the inadequate number of staff and facilities in our public health service. Is work to prepare a workforce plan to ensure adequate staffing levels under way? I would also welcome Mr. Woods's comments with regard to the request to make Covid-19 a notifiable disease to the Health and Safety Authority.

Mr. Liam Woods

With regard to staff planning, work is certainly under way in the acute sector. In fact, the INMO referred to it this morning. A safe staffing framework is in place and academic work has been carried out to look at staffing requirements by ward and hospital area. That work will expand to the community area. This means that this year, before the Covid situation arose, we were putting resources in place to increase the number of nurses across the system.

There is some work under way. It is a multi-annual programme. Nurse numbers in the acute area were up by almost 1,600 in June. That includes bringing in students. On the wider point, as was reflected in this morning's dialogue, there is a process under way, which has an academic base. As was referred to, it is based on an 80:20 ratio. That process will expand to other areas of service.

What is the timescale for the completion of the workforce plan?

Mr. Liam Woods

The work in the acute area is likely to take up to the end of 2021. In the community area, the work is commencing and it is likely to take longer than that. It is very substantive. It is very much unit by unit and ward by ward. Deputy Shortall referred to the rate of staff attrition. No workforce plan will provide for that. We continue to have a very high absence within the health sector associated with Covid.

The community work is commencing now. There is a group in place that is looking at that. Ms Hoey or Dr. Sisson might take the question on notifiable disease.

Dr. Lynda Sisson

As members are aware, Covid is a notifiable disease under the public health legislation. The HSA specifically excludes notifiable disease because it is notifiable under the public health legislation.

It seems strange, however, that where a health-related disease is contracted within a work scenario in the health sector, it would not be notifiable to the HSA. Surely it would be desirable to have the HSA overseeing the situation.

Dr. Kevin Kelleher

I am sorry, but we are not in control of that. It is an issue for the HSA and its governing body to sort that out.

I appreciate that. I was just looking for the view of the witnesses on it.

Dr. Kevin Kelleher

We have no view on it at the moment. It is an issue for the Health and Safety Authority and its parent body.

Okay, I thank Dr. Kelleher.

I will start with a couple of questions for Mr. Woods. I would like to come back in afterwards and make some other points in the allotted time.

Why did the HSE not pay staff who went into precautionary self-isolation, as per the roster, and will it do so now, going forward? Does Mr. Woods accept the argument we heard here this morning from workers' representatives that the decision to deduct overtime and premium pay from workers going into precautionary self-isolation created a disincentive and not only increased the prevalence of Covid in the workplaces for which the HSE is responsible, but probably cost lives as well? I would like a comment on that.

Mr. Liam Woods

I will ask Ms Hoey, who is our HR lead, to address that.

Ms Anne Marie Hoey

The public health advice has always been clear in terms of staff self-isolating in the event that they have symptoms and are awaiting testing. In terms of the payment of premiums and overtime, these would not normally be paid when staff are on sick leave. The issue is a broader one for the wider public service and Civil Service. The unions have in fact referred this issue to the Workplace Relations Commission, WRC, and the case is being heard there. We await the outcome of the case, but it comes back to a public pay policy issue. The Department of Public Expenditure and Reform is the lead Department in that regard.

Does Ms Hoey accept that it did in fact increase the prevalence of Covid in the workplace for which the HSE is responsible?

Ms Anne Marie Hoey

SIPTU stated this morning that it potentially impacted on the decision of staff to attend in the workplace. That is not something we are aware is an issue. The public health advice was very clear to staff on their responsibility to isolate if they became unwell.

Okay. Am I correct in saying that the HSE would like to see a relaxation of the 2 m rule in hospitals? Do the witnesses accept that any such relaxation could, and probably would, negatively impact on infection rates among health service workers?

Dr. Kevin Kelleher

I will start and then I will ask Dr. Doherty or Dr. Cuddihy to come in as well. We have to look at the evidence about the spread of the disease from a public health perspective and then look at how to run a healthcare system to provide the healthcare that is needed both in a general sense and more particularly when a disease such as Covid is in the system. We have to put those two together. There is a lot of evidence around about how to do it.

The 2 m is primarily a social distancing issue. One does not need to have that in every aspect of healthcare work if there are other means of compensating for it via PPE or doing other things to get past that issue. There can be a mixture of those things. Clearly, we seek to maintain 2 m in areas where there is social contact. There is no need to have 1 m when people are in waiting rooms. They should try, as Deputies in the Chamber and we in the committee room are observing, to keep those 2 m. In other circumstances, 1 m distancing is appropriate. Then one needs to use the infection prevention and control guidance we have, which is general and relates to PPE. Dr. Cuddihy or Dr. Doherty may wish to add to that.

Dr. Lorraine Doherty

I will make a short comment. Dr. Kelleher has covered most of what I wanted to say. I want to make the point that a healthcare environment is a more controlled environment than is one where one might have gatherings of other people in close proximity. We also have very good infection control guidance in place and training in place for healthcare workers and we have PPE available. Those are all mitigating factors in limiting the spread of infection within that environment. When we look at healthcare environments, they are not like social environments. We take advice on infection prevention and control from experts in that field who advise that it is safe to decrease the distance from 2 m to 1 m of separation. We need to take advice from people who have expertise in the field.

Would the witnesses support the recategorisation of Covid contracted in a HSE workplace as a workplace injury?

Dr. Kevin Kelleher

I think we have already answered that question. We have not been asked formally and we need to consider it but it is a decision for another Department and the HSA. If they come to us we will give our view at that time. We have not directly considered that at this moment in time.

I thank our contributors this morning. I refer to an item in the HPSC report regarding sources of transmission, within which is a figure of 11.4% for close contacts confirmed. The figure for travel is down at 1.7%. Have the witnesses looked at that ratio since flights have started to open up in a larger way? Do they know from what time period that data set was taken?

Dr. John Cuddihy

To answer the Deputy's first question, in relation to the more recent data we are seeing an increase in the number of cases associated with travel, both people who have travelled and cases among their contacts when they return here.

Can I ask Dr. Cuddihy to put a percentage on that with reference to the previous one of 1.7%?

Dr. John Cuddihy

The 1.7% is specifically in healthcare workers. In the general population at present, travel-associated cases in people who have travelled are still in relatively small numbers. We have, however, seen significant transmission, when people return to the country, among their household and other contacts.

Dr. Cuddihy highlighted that the take up of contacts who had been identified was relaxing quite a bit. Do the witnesses have plans to seek a legal remedy to be implemented to require those on a contacts list to take a Covid test when they are so approached?

Dr. Lorraine Doherty

Obviously, this issue is an area of concern. We need to get more information on this particular cohort who are not appearing for testing and try to understand what the barriers for testing are before we consider any further measures.

Decisions about whether to put in place legislation are obviously not for the HSE or the Department of Health. This would have to be considered if it is shown that there is a complete refusal to have testing and that there are no other barriers that we can seek to address.

The HSE should put some urgency into that.

I mentioned infection-control protocols through the winter in our earlier session. I have witnessed some things that most people would see in hospitals. There are healthcare workers coming down to community areas such as canteens in their scrubs and then going back up to the wards. It may not be happening in Covid wards but it is certainly happening in the general hospitals. It is something that needs attention paid to it. There is also the issue of visitors transiting through the hospitals with no protection over their footwear, which is provided for in other hospitals engaged in infection prevention. The HSE needs to examine these issues and to become far more stringent about the movement of visitors through hospitals to maintain effective infection control. Perhaps this is something the HSE would look at.

This morning I also brought up the issue of doffing and donning PPE and fatigue. The HSE needs to go back and look at doing more than training videos; it needs to be done in hospitals and time needs to be given to nurses in between shifts to take some time out. Certainly they should be helped with donning and doffing on Covid wards.

I engaged with Mr. Woods at our meeting last Friday and I remind him of the commitments that he gave me then on pressuring the cath lab modification situation at University Hospital Waterford. I hope to hear from him in the coming days with an update on that.

On the issue of specialist registrars, SpRs, who are out of contract, is there any opportunity to give them extended work contracts and to create consultant contracts in the workforce, considering we heard all morning about the complete under-supply of staff?

Mr. Liam Woods

Yes, we are actively working to grow the number of consultants. It is up by 132 since the start of this year but clearly it needs to grow and that is fully acknowledged. We have been recruiting quite extensively within the acute environment since late January-early February and we will continue to do so. We are pursuing opportunities relating to consultants and SpRs through our doctor training programme.

I mentioned the idea of extending diagnostic lists on Friday, considering machine time and people are available who are less busy because of the Covid protocols, and would be able to do additional hours. There is the possibility of bringing in expanded working through use of an instrument from the NTPF. I would appreciate it if Mr. Woods could get back to me regarding the cath lab at University Hospital Waterford.

Mr. Liam Woods

I acknowledge the point about University Hospital Waterford. On extended day and indeed access to diagnostics generally we are, as part of our winter planning, working to facilitate further access to diagnostics for GPs. We are also working with the NTPF to see what we can do to optimally use the equipment we have with the staff resource we have. We have done that over the past couple of winters and it has worked very well so we are seeking to grow that now.

One final issue I want to highlight is Irish manufacturers who are trying to supply PPE to the HSE. I am aware of two manufacturers who were in very protracted discussions which have gone cold, to a degree, on the HSE's part. These companies have been engaged with by the HSE, they have been brought quite a distance and they spent money to set themselves up to supply the HSE but all of a sudden the executive has gone dark. I would appreciate it if the executive would re-engage with those companies to move everything along. This all part of securing our future PPE pipeline in Ireland.

Mr. Liam Woods

I agree with the Deputy on that approach. It makes eminent sense to have a domestic supply and there is engagement with a number of companies. If the Deputy wants to flag those companies to me separately, I will certainly raise the issue relating to them.

I appreciate that and thank Mr. Woods.

I thank Deputy Shanahan and call Deputy Michael Collins.

I thank the witnesses for coming in. When Covid-19 was first identified internationally in late 2019, what steps did the HSE take to procure additional PPE? Was additional PPE ordered internationally? If so can, anyone give me dates and quantities?

Dr. Kevin Kelleher

As soon as it became apparent that we were going to move into this, which was from the last week or so of January, we started doing those sorts of things. I do not have the figures here and now but I can try to get them to the Deputy. At that time, we started seeking to procure whatever equipment we considered appropriate for what we thought was going to come, which included PPE, other equipment and drugs if necessary. We can seek that information but I do not have it right now. We had a meeting in the last week of January and the preparations started virtually from that point.

When Covid-19 was first diagnosed internationally, was a risk assessment done by the HSE? Did it identify the at-risk groups, and what steps were taken to safeguard them? On what dates were those actions taken?

Dr. Kevin Kelleher

Both the WHO and the European Centre for Disease Prevention and Control were giving us advice at that time and we were using their advice and debates and discussions about those risks. We were also in contact with colleagues elsewhere in the world and in the UK, so we were aware of those risks, which were brought into the meetings that started at the end of January within the HSE. NPHET also began meeting at that stage and each of those meetings involved the discussions the Deputy is talking about and looking at what the risks were and what we would face. We very clearly saw the impact Covid was having in China and we took that as our main source of where we might need to go. When it came to Italy, which was the next big change, we took what was occurring there on board as well. Those influenced what we were doing. As the Deputy said, it was a new disease, so our ability to foresee what would happen was not as great as it would be today. We have much better knowledge today. We were making assessments at all those meetings, which were very frequent at two or three times a week, about what we knew, what that meant and how we had to adapt as a consequence.

Many people feel that if the HSE had been quicker in responding to Covid, fewer people would be affected and more lives would have been saved. The public has been asking whether the HSE was behind the curve on this. Was it?

Dr. Kevin Kelleher

That is a very difficult question to answer. I think we were on the curve. I do not think we were behind it. We reacted very rapidly to what was happening. We had things in place throughout February and were strenuously trying to make sure we identified cases as quickly as possible. We did that at the end of February and we moved on through that process. It is clear that countries can be easily overwhelmed and one can still see that today. I do not think we have been overwhelmed in any way that is comparable to some other parts of the world. Some parts of the world may have done slightly better but even they are now having difficulties. It is difficult. It is my own personal belief that we reacted as well as we could have at the time. Of course one can do better. We know we could have done better when we look back with the knowledge of today, but we did not have that knowledge at that time.

Apart from EKO in Ennis, County Clare, what other Irish companies have been commissioned to produce PPE as an essential element of protecting our healthcare workers in the ongoing battle against Covid?

Dr. Kevin Kelleher

We can get that information for the committee. I do not think any of us knows that off the top of our heads.

Are healthcare staff better prepared to deal with a second wave of Covid? Based on what we have learned from dealing with this virus, how will the second wave be managed differently?

Dr. Kevin Kelleher

A number of us could answer that question. I think we have learned a lot. We are better prepared and have better resources available to us, both in the knowledge we have gained as an organisation and having staff who now know what needs to be done. We have a lot of guidance, we have PPE in place and we know where we need to go. I will ask Mr. Woods and Dr. Doherty to comment on that as well.

Mr. Liam Woods

We have grown some capacities in the system. We have also grown our equipment base of ventilators and other essential equipment, which is helpful. As Dr. Kelleher said, a range of guidance is available, much of it on the HPSC website. There is training in place and we are growing staff numbers and physical facilities. The challenge will be that of tackling the winter with Covid on top of it, as has been flagged by both members and witnesses at this committee.

I call Deputy O'Reilly, who has ten minutes.

I will put a ten minute timer on my phone because I do not want to eat into anyone else's time. I have a number of questions, several of which relate to staffing. We all know, and the witnesses know as well as I do, that low staffing levels contribute to an inability to practise proper infection control. When a place is short-staffed it makes it almost impossible. This morning, we heard from the INMO that nurses are still being issued with three-month contracts. As we face the prospect of a second wave, which we all hope will not arise, I have to ask Mr. Woods about the issue of these three-month contracts versus permanent contracts. Where does he stand on that? Is it the intention of the HSE to issue permanent full-time contracts to people where, let us be honest, there are permanent and full-time vacancies, or is it intended simply to muddle on and plug the gaps with three-month contracts?

Mr. Liam Woods

With regard to full-time vacancies, we intend to offer full-time contracts. There are some contracts that will be for three months because the nurses filling the roles may be students who are recording as healthcare assistants. Retired workers who have returned may have wanted a three-month contract. On the Deputy's core point, we are looking to grow the number of permanent staff and I agree with the Deputy's initial comments.

I have been hearing for decades from employers that it is the workers themselves who want the flexibility of precarious work. In my experience, that is not the case. While I respect there may be a small number for whom three-month contracts are sufficient, the vast majority, as articulated by their representatives, want those permanent contracts and it is good to see that commitment. When will these contracts be issued?

Mr. Liam Woods

I would have to understand more about the specific locations throughout the 48 acute sites and the community services. It is the broad intention that permanent available posts will be filled permanently and that this will happen as soon as we can arrange it. It has been happening and there has been significant growth in the whole-time equivalent number in nursing and elsewhere in the employed number in the HSE since the start of the year. It has increased by more than 4,000. Last Friday, I indicated the number was 32,071 and our June data show an increase of more than 4,000. An ever-increasing number of permanent contracts are being offered and staff are coming into place.

This morning, we heard from representatives on engagement on planning for a potential second wave. I will not get into the ins and outs of the infection rates but we have had acknowledgement that the infection rates among healthcare workers were unacceptably high and we know staffing has a contribution to make in this regard. I assume the HSE is planning, even if it is not talking to the representatives of healthcare workers, for a second wave. Has it factored in the need for some staff who have accrued annual leave to be able to take it? Some staff will not be able to come to work. Is the workforce plan based on the HSE having full staffing? Has it taken into account the fact there will be reduced numbers of staffing, as there was during the most recent peak?

Mr. Liam Woods

On the wider planning, the calculation of the appropriate number of staff, and nursing staff specifically, is based on a ratio of 80:20. There is work being done on this, as I referred to earlier in answer to Deputy Shortall. It is also based on known patterns pre-Covid of attendance and leave. This work was done but to answer the Deputy's question, the pattern of absence over March, April and May and the likelihood of this recurring are matters we are very aware of and they are part of our planning framework for our winter process. We are very alert to this and very aware of what it might mean.

At the moment, our restriction, in fact, is the total available number of staff to employ in those cohorts. We are doing everything we can, as we have been for some weeks and months, to attract as many staff as we can into the HSE and voluntary bodies funded by the HSE.

The HSE always factors in a certain amount of absenteeism, sick leave, maternity leave, etc. into the workforce plan, winter initiative, winter planning and all the rest. What percentage is it factoring in for this plan in terms of healthcare workers who may be absent as we face into a potential second wave?

Mr. Liam Woods

At the peak of the first wave, nearly 5,000 staff were absent at any one time. While it is difficult to anticipate what the impact of a second wave would be, we hope that with early intervention and the improvements that have taken place in testing and contact tracing we will not experience the same level of surge. We have to plan on the basis that it is still a possibility.

As the Deputy is aware, what happened in the first wave resulted in a significant number of closed beds simultaneously. I understand 2,200 beds were closed. There was also a significant change in the pattern of public attendance at hospitals, which gave rise to a backlog in demand for services that we are now trying to deal with. The Deputy will be very alert to that. From our point of view, we have to plan on the basis that we may see a recurrence at the level we have seen before but we also have to work to avoid that.

Absolutely. We heard evidence today from a trade union that staff were so worried about the prospect of losing their premium pay and other allowances that there was a suggestion they may have come to work sick. Is consideration being given to ensuring people are not out of pocket in any way? The witnesses know as well as I do that the basic rate is the basic rate, but many people working within the health service have, given the 24-7 nature of the operation, an entitlement, legally or under collective agreements, to benefits such as additional premiums for unsocial hours worked. Is consideration being given to ensuring money is not a factor when people are considering whether they have to take time off work in order to isolate, etc.?

Mr. Liam Woods

I will ask Ms Hoey to address that from a HR perspective.

Ms Anne Marie Hoey

I thank Deputy O'Reilly. We touched on this issue earlier. The predominant principle, based on public health advice, is that staff should not attend work when they are potentially symptomatic. That has been very clear from the beginning. Our experience is that staff take that responsibility very seriously. In terms of the Deputy's question, overtime payments would not normally be made in a situation where a staff member is on sick leave. The issue that has presented is across-----

What payments would be made, if overtime is not being paid? Would the unsociable hours premium, twilight or anything like that normally be stacked into the payment? Is there a flat basic rate?

Ms Anne Marie Hoey

Basic pay can be made up of different elements. Some allowances are part of basic pay, but it has to be taken on a staff category by staff category basis. The issue across the wider civil and public service has, I understand, been referred to the WRC where it is under consideration. It is a public pay policy issue and will be considered and decided on in that context.

My final question relates to the HSA. I understand the line Minister responsible is the Tánaiste, Deputy Varadkar. I have raised an issue directly with him. As it currently stands, the HSA does not have a role in inspecting healthcare facilities. Acquiring Covid in the workplace is not considered to be an occupational injury, notwithstanding the fact that it was acquired as part of a person's occupation. I thought it was a no-brainer, but I have been out of the industrial relations game for some time. To me, if someone acquires an infection as part of his or her work it is an occupational injury. Would the witnesses have a view on that?

Dr. Kevin Kelleher

We have answered that question. Our view is that is, as the Deputy said, a matter for the HSA and-----

I am asking if the witnesses have a view as to whether an infection acquired in the workplace should always be considered a workplace injury.

Dr. Kevin Kelleher

We do not have an explicit view at the moment but we will have a view when we are asked. We need to have an internal debate before we can give a view before the committee.

Is Dr. Kelleher saying that internal debate is ongoing within the Department, between the Department and the HSE, or with the representatives of workers and all stakeholders?

Dr. Kevin Kelleher

I said that we need to have that debate when we are asked to do so, and we will. We will have that debate and will use our mechanisms to consider how to reply. It is not a decision for us as an organisation.

I am asking the HSE to have that debate. Is there someone specific who would need to ask Dr. Kelleher in order to spark that debate? It strikes me as an important debate.

Dr. Kevin Kelleher

We will take up the Deputy's request after this meeting. It will be a part of our process in the next number of days and weeks.

It is a fairly urgent matter so it would be much appreciated if it were dealt with in days rather than weeks. Dr. Kelleher might correspond with me to advise at what stage his thinking is. It seems to me that the matter does not require a scientific interpretation. It is simply a fact that an injury acquired as a part of one's work is considered an occupational injury under normal circumstances. I am glad that Dr. Kelleher is going to take up the offer to have the conversation and I would appreciate if he could follow up with me either by phone or in writing.

Dr. Kevin Kelleher

We can certainly do that.

I thank Deputy O'Reilly and Dr. Kelleher. The next speaker is Deputy Colm Burke.

I thank the witnesses for their attendance.

Is Deputy Colm Burke going to take ten minutes? Is he the final Fine Gael speaker?

I presume I am.

The Deputy has ten minutes and if another Fine Gael Deputy wishes to come in, we have time.

I thank the witnesses for their presentations and the work they are doing. I will refer to the report of the profile of Covid-19 cases in healthcare workers in Ireland. On looking at the report, I note that 58.5% of the 88,260 healthcare workers who were identified as positive for Covid were in the HSE east region. While there is a larger number of healthcare workers in that area, in analysing comparable figures was a higher percentage of healthcare workers in the east affected in overall terms, taking into account the total number of healthcare workers in the area? Has any effort been made to identify why that occurred?

Dr. Kevin Kelleher

Dr. Cuddihy will answer the question in more detail but, generally speaking, the virus has been focused in the east of the country regardless of the healthcare system. The virus has been focused on the Dublin and eastern areas.

Dr. John Cuddihy

As Dr. Kelleher has said, the highest incidence per 100,000 population has been in the east. That proportion of incidence in the general population is closely mirrored in healthcare workers. That relates to the number of hospitals, residential care facilities, community services and so on located in the eastern region to serve that higher population.

We have seen the breakdown of numbers on nursing homes but is there a similar breakdown for hospitals where there was a higher incidence compared to other hospitals of a similar size throughout the country?

Dr. John Cuddihy

We have not seen that distinction in our data. We have seen significant numbers of healthcare worker infections in residential care facilities and outbreaks in hospitals but the proportions, relative to the populations and numbers of facilities, have been similar across the regions of the country, generally speaking.

Has any effort been made to identify where errors were made as a result of which healthcare workers contracted Covid-19? What measures now need to be put in place to make sure there is no reoccurrence? We have a lot of information and data. Have we analysed those data?

For instance, some healthcare facilities, including 56% of nursing homes, had no positive cases of Covid, while many others were affected. The case is likewise with hospitals and mental health facilities. Has there been any serious examination carried out to identify why cases occurred in some places while very similar operations in totally different parts of a HSE area saw no outbreaks at all?

Dr. Lorraine Doherty

I thank the Deputy very much for his question. It is very important to try to understand why healthcare workers are becoming infected. Under Dr. Cuddihy and myself, the HPSC has commissioned a study with UCD which will involve an enhanced investigation of more than 400 healthcare worker infections. This is quite an intensive study as it will involve interviewing all of those healthcare workers to determine exactly what their practice was in their particular healthcare setting, what PPE was available, how they were trained to use it, and how they applied the use of PPE and hand hygiene. When the results of this study are available, towards the end of August, they will give us vital information and will help us to identify areas in which we might need to take further action to prevent the infection of healthcare workers and to support them in their practice in preventing infections.

Of the 8,260 workers who were diagnosed with Covid, a number were associated with a location in which there had been an outbreak. Some 4,634 contracted Covid independent of an outbreak. Has the source of these 4,634 infections been identified? Page 6 of the report says that 4,634 were not linked to an outbreak.

Dr. John Cuddihy

That is right. The health protection surveillance system looks separately at the infection rates of patients and healthcare workers associated with outbreaks and at the rates of sporadic cases. With regard to those healthcare workers the Deputy mentioned whose cases were not linked to outbreaks, there are a number of likely sources of transmission. These may be related to their work settings or to close contact with a confirmed case either in the workplace or in the community. Some are also related to travel. A proportion relate to community transmission. Despite our intensive contact tracing process and investigations-----

Will Dr. Cuddihy give me a more detailed breakdown of that 4,634?

Dr. John Cuddihy


That would be helpful because it is not in the report.

Dr. John Cuddihy

I can certainly get a breakdown of that figure for the Deputy.

I will again raise an issue I raised this morning. It relates to the number of healthcare workers who have been identified as having Covid. Some 2,878 of these had an underlying medical condition. That figure is very high. Where a person had an underlying health problem, were serious efforts made to ensure they were not put at risk? Was a protocol in this regard available to each and every healthcare facility and hospital? Take, for argument's sake, someone who had previously had treatment for cancer and who was now working on a ward where they may be vulnerable to contracting Covid. Was a protocol in place for hospital managers and managers of wards for dealing with such employees?

Dr. Lynda Sisson

Yes, indeed. At the very early stages, we developed a guideline document for pregnant healthcare workers, very high-risk healthcare workers and high-risk healthcare workers. We put that up on the HPSC website.

We identified the different risk assessments that are assigned to different people. We divided our workers into those who were working with patients in direct care and those who did not have direct patient care. This was a guideline that identified by name in some cases all of the different underlying diseases that were of concern. We had a whole process in place for those who did have underlying diseases to assist them either in being redeployed, to cocoon if it was appropriate, and to support themselves in terms of the PPE etc. that they would need when working.

When was that devised or made available to the people in charge of the various facilities around the country, be it hospitals, healthcare facilities or congregated settings?

Dr. Lynda Sisson

We issued the first guideline document in the middle of March and we continue to update it. We now have version 6 online, which was last revised on 26 May. As we learnt about the disease we were able to revise the guidelines throughout that time.

Does Dr. Sisson think more could have been done, in the sense that 2,878 people identified with Covid were people with underlying medical conditions?

Dr. Lynda Sisson

Deputy Burke needs to remember that of those 8,000 workers, some were out of the workforce but who identified as healthcare workers. We are aware that some people were out having treatment. They were admitted to hospital and subsequently diagnosed with Covid. They were not all necessarily in the workforce at the time.

Do we have a number out of the 2,878 people who were in that category?

Dr. Lynda Sisson

I have identified 5,037 healthcare workers in the acute hospital sector, and in the community for the HSE and the voluntaries.

We hear various percentages referred to in the context of the 8,000 healthcare workers identified with Covid in this country. There are various figures. What is Dr. Sisson's view of the percentage of the total healthcare workforce? We got a breakdown from her in the report on the profile of Covid-19 cases among healthcare workers and it cuts across all areas from administration to care assistants to nursing staff to doctors. Approximately 135,000 people work in the HSE between full-time staff and part-time staff. Probably another 30,000 work in private nursing home facilities. Reference was made to 8,000 workers, but in real terms, what is the calculation of the percentage of workers who were affected by Covid-19?

Dr. Lynda Sisson

We speak for the public health system but my calculation is just under 5%, about 4%.

Is that taking the staff in both the public and private facilities?

Dr. Lynda Sisson

I do not have access to the private figures. That is based on the 135,000 that are currently working in the public sector.

Is the 8,000 not made up of people from private nursing homes as well?

Dr. Lynda Sisson

It includes private nursing homes as well.

Therefore, if we take the 135,000, plus around 30,000 in the nursing home sector, is Dr. Sisson talking about 8,000 out of that total number?

Dr. Lynda Sisson

Yes, but the 8,000 includes people who are not in the workforce at all, but who do identify as healthcare workers. The number could include a retired GP, for example, or somebody out on maternity leave who identifies as a nurse.

Could we get a breakdown of the numbers who were not in the workforce but who are identified as part of the 8,000?

Dr. Lynda Sisson

My calculation is that we have 5,000 out of the 135,000 in the public health sector, which is just under 5%.

That identified with Covid.

Dr. Lynda Sisson

Yes, that are currently working in the public sector.

To be clear, is Dr. Sisson saying that of the 8,000 who had Covid that were identified as healthcare workers, 5,000 of them were working in the healthcare service at that time?

Dr. Lynda Sisson

In the public healthcare sector.

Okay, public as opposed to potentially working in private hospitals.

Dr. Lynda Sisson


We are aware that the UK and many EU countries put systems in place for the children of healthcare workers to ensure that these very valuable workers could continue to work.

This was largely not the case in Ireland, where no proper childcare facilities were made available to the healthcare workers. Is there a plan in place for children of healthcare workers should we be hit with another wave of Covid infection?

Ms Anne Marie Hoey

The issue of childcare for healthcare workers posed some challenges. The HSE engaged cross-sectorally with Departments on supports for healthcare workers. Several options, as we know, were explored. True to public health advice and so on, it was not possible to reach an early resolution. The crèche facilities have now reopened. However, the HSE was as flexible and creative as it could be in facilitating staff to be able to work different shifts, rosters and days. We have a 24-7 service to run so there are many opportunities for us to provide flexible working arrangements for staff to enable them to balance caring responsibilities with the working environment.

Is the HSE following the advice of the leader of the Irish Medical Organisation, IMO, who recommended that the Government stockpile supplies of PPE to protect healthcare workers from the impact of a second wave of Covid-19?

Dr. Kevin Kelleher

That is a debate we are involved in and we need to get clarity around that process. It is a NPHET-Government decision but we are involved in that debate.

Does the definition Dr. Sisson just gave reflect what Dr. Cuddihy meant when he said Ireland had a different definition of healthcare workers from other countries? I was struck by that comment earlier.

Dr. John Cuddihy

That is part of it. It is a complex definition. In Ireland, it includes anyone who works in healthcare, both public and private, whereas, as I mentioned, in some other countries it is a narrower definition. It may include just front-line workers or, in some cases, particular categories of workers such as doctors or nurses. In Ireland, it is a very broad definition.

Do we know what determines who contracts Covid-19 and who does not contract it? Two people can have the same exposure, and one may contract it while the other may not. Does fatigue and being run down play a role in viruses generally and in this virus, to the extent that we have information about this virus?

Dr. Kevin Kelleher

If I knew the answer to that question, I would be up for the Nobel Prize in physiology or medicine as a consequence, unless my colleagues are up to that. It is one of those complex issues. There are so many different factors that affect people in how they react to a disease. It is not even that they would react the same today as they would react in three weeks' time or they reacted two years ago. It is very different. It is a very complex issue. We can somewhat understand it and that is what we use to try to give our advice on, but we do not understand explicitly why some people contract the virus, except some people have got either natural or acquired immunity as a result of a vaccine for an infectious disease. Does Dr Doherty want to add to that?

Dr. Lorraine Doherty

There are obviously issues in relation to individual susceptibility to acquiring an infection and issues that the environment might precipitate. I think one of the Chairman's comments related to fatigue. A healthcare worker on a ward who is fatigued may not pay as close attention to hand hygiene or PPE. Those are things we are aware of that need to be factored in to the overall planning for staffing in those scenarios. There is a great deal that we still need to learn about this infection. In flu season, we see children as super spreaders of flu and yet children do not seem to get high levels of Covid. Why is that? We do not know. There are many studies being done on the epidemiology and the modes of transmission and we continue to learn from those.

As we learn more about this infection it enables us to identify further control measures. One of the preventative measures that we are hoping to introduce globally in 2021 might be a Covid vaccine. Should a safe and effective vaccine become available in appropriate quantities we can start immunising people for further protection but in the meantime we have to have a very strong focus on our routine infection prevention measures.

Dr. Kevin Kelleher

If I could come back in, this session has discussed the infection rate among healthcare workers. One of the things we are well aware of is that a feature that historically people have been very good at, particularly healthcare workers, is that they come into work. They have such a work commitment that they come in regardless, sometimes, of their own health status. That has always been one of the great features and we know that is how our health service has continued; it has been one of the great things we have witnessed. I have done it in the past and l know that lots of other people have done it. However, in the current circumstances, actually having an infection and having the symptoms of an infection should mean that people do not come in to work. That is a big problem because that is not in the Irish healthcare workers' psyche. Their mindset is that they must come into work because they have patients to look after. How we get past that is a quandary. It is one of the biggest things we have to do.

Clearly a vaccine will make a difference but again we must ensure people take the vaccine. Getting people to understand has been a big issue for us. Members of the committee have heard us say repeatedly every winter that people should not come into work if they start having the signs of flu. I have been saying it for a decade or more. They should stay at home. It is the same here. I am not differentiating between the public and healthcare workers in those circumstances - everybody should stay at home and that goes for the healthcare workers too. It is a big problem for us however because there has been this great element of the Irish healthcare worker's approach that he or she comes in to work when not well enough. Unfortunately we must bridge that significant cultural issue as a consequence. It is a problem for us.

Does Dr. Kelleher think that that tendency of Irish healthcare workers to come into work, sick or not, because of the sense of duty they have to their patients has been overly relied on by the HSE in calculating staffing ratios and staffing numbers required?

Dr. Kevin Kelleher

I am not going to answer that directly. When we do those we rely on history and that is reflected in the history. In a sense the Chairman is correct but that is only because we have relied on the history of absenteeism. We do not deliberately say that we know people will come into work as part of that, it is just that we use the history and clearly from what we all now know, we know we have to change. That is a big cultural change. Everybody will then start saying that they have been told that absenteeism rates of 3% to 5% are inappropriate. However, I have said previously that I do not mind an absenteeism rate of 6% or 7% if we are stopping people with infections coming into hospitals to infect other workers in the hospital system or patients. It is a difficult thing to get over.

I thank Dr. Kelleher. We have had a number of campaigns in relatively recent years about this. I was previously a TD from 2011 to 2016 and during that time there was a campaign by the younger doctors' division of the IMO, which I think was called "24 No More", and nothing happened. I was contacted by an Irish GP trainee who posted on social media and I think I was tagged in it. She said: "26 hrs later I'm finally finished my shift. Absolutely shattered. Time to get a coffee before I drive home. Sadly many doctors have lost their lives driving home from work following these dangerous shifts." She added: "Would you want an exhausted doctor managing your loved one in an emergency on the ward? Would it not make more sense to reduce the hours we can work per shift?"

Added to the personal danger highlighted by that trainee, there is also an increased danger of slippage in PPE, in that people might not use their PPE properly. How much more do we need? I appreciate that it is a funding issue and ultimately funding is determined by the Dáil rather than anybody in the witnesses' committee room but we have an ongoing crisis with inadequate human resources in our healthcare system, which are presumably caused by inadequate monetary resourcing.

Dr. Kevin Kelleher

I have been a doctor for 40 years and I am ashamed that we still have the same problem today that I faced 40 years ago. It must change dramatically. Ms Hoey will speak a bit more on this but we are very much committed to making sure people work much fewer hours than they often do. As I said, some of that difficulty has to do with people's commitment to do the work. We have to get that difficulty across as we try to rectify those things.

Ms Anne Marie Hoey

I cannot comment on the individual case the Chairman referenced but it is certainly not something we would encourage or condone in the interests of the safety of both the staff and the patients they are managing. We rely on senior clinicians to manage such situations to ensure those long hours do not occur. We are also obliged to adhere to the EU working time directive.

As regards an increase in our medical staffing, we have increased our medical staffing significantly in recent months. In the year to the end of June, we increased the number of doctors in the system by over 1,100.

Earlier, Dr. Kelleher mentioned absenteeism during the flu season. Perhaps that rate of absenteeism needs to be greater. Typically, what percentage of the Irish population gets the flu and how many people are hospitalised for it during the flu season?

Dr. Kevin Kelleher

We have different ways of measuring that. One method is the influenza-like illness, ILI, rate, which peaks at around 100 or 120 per 100,000. That means there are 5,000 or 6,000 people with that disease that week. It is quite high. Hospitalisations have risen quite considerably-----

Is Dr. Kelleher saying that 5,000 or 6,000 people could have the flu in any given week?

Dr. Kevin Kelleher

That is at the very peak. That rate is an indication but the likelihood is that many more people have it because those are just the ones who have come into the system. Many people do not come into the system with the disease. In our field of public health, we often say that the number could be anything between three, four or ten times higher, depending on the disease. We have been measuring hospitalisations quite well over the least three or four years and last winter, we went up to 7,000 or 8,000 people being admitted with flu. Some of that is because of much better recording but it also indicates a change in patterns. Equally, there are seasons where flu is milder and the numbers are significantly lower. In some years, that rate would barely get above 40 or 50 per 100,000. It differs and it is about impact. It reflects the actual virus that year, how well the vaccine works and a number of other things. As we all know, how we are going to deal with flu is a very important issue for us this coming winter. Does Dr. Doherty want to add anything to that?

Dr. Lorraine Doherty

We cannot really say that all flu seasons are the same. Some years we have a bad flu season and some years a slightly less severe one. We have a very important flu immunisation programme, which is delivered annually and is to be extended this year to include children aged between two and 12 years old. We have an active process in place for planning for flu this season. We have already established our national flu planning group, which I chair.

We are working very closely with our hospital and CHO colleagues, the community and our GPs on preparing for this year's flu season. With regard to the epidemiology of flu this year, there has not been much flu in the southern hemisphere. Often, we try to extrapolate from there what might happen for us in winter. This may be related to the isolation associated with Covid or to other factors. What we can best do is make sure we have robust flu plans in place throughout the health sector and that we have a very robust immunisation campaign.

On the issue of a robust immunisation campaign, Mr. McCallion came before the committee last Friday and he told us there is to be a ramping up of the immunisation campaign, and that there will be free immunisation of children aged between two and 12 years. Earlier, Dr. Kelleher mentioned children being super spreaders. In any event, there will be free vaccinations for children aged between two and 12 years, and vaccinations for healthcare workers and those aged over 65. It was a clinical decision based on what was advisable but it seems to have been advised that there was no necessity for a vaccination campaign for the general population. Given that 7,000 or 8,000 people present in any given week, which I am sure creates severe stress and a major burden on our healthcare system, leaving out the stress from Covid, should we be looking at a general vaccination campaign? I do not suggest that it should be compulsory or mandatory but that the State should offer free vaccination to all members of the population in preparation for next winter.

Dr. Lorraine Doherty

The HSE does not set vaccination policy. The vaccination policy is advised by the national immunisation advisory committee, which is an expert committee. It bases its immunisation guidelines and recommendations on the best available evidence and having a targeted approach to protect those most at risk from flu in any one season. Over the years, we have seen an extension of what we call the at-risk groups to include a wider section of the population. We already immunise all of our elderly citizens and this year we are extending flu immunisation to children aged between two and 12 years. Next year, children up to the age of 17 will be included. We continually review policy on immunisation for all infectious diseases. For the flu season, this is done annually to make sure there is no particular risk group. The majority of fit, healthy adults can have a flu infection and not have severe effects or severe sequelae after that infection. This is a live issue that we consider when we review the evidence from each flu season to see whether there is a need for additional immunisation of other groups in the population.

Does Dr. Kelleher have a view he would care to proffer on the advantage or otherwise of a generalised vaccination programme?

Dr. Kevin Kelleher

The main change we are making this year is offering the vaccine to children aged between two and 12 years, as Dr. Doherty has spoken about. This is the most significant change we could make. Evidence from elsewhere in the world increasingly states that if we can get uptake of more than 40% or 50% in this age group, it starts to have a significant impact on flu in the overall population. Trying to do this is very important.

The flu vaccine works well for some individuals but it works best at a population herd level. International experience shows it is even better if we get the focus among children. Our colleagues in the North have been doing this for a few years and I believe significant benefits have been shown as a consequence. It is similar in other parts of the UK but the experience in the North has really shown benefits. The most important big change we have made is to focus on this. If we went through the whole population, we might not have the focus on children, which is the most important thing to do as a consequence.

I refer to masks. Dr. Kelleher said the policy or advice changed with regard to the wearing of masks in healthcare settings in March. Is that correct?

Dr. Kevin Kelleher

We heard the point being made in the discussion earlier. We have had policies over a period of time. I wish to point out that our policy produced in mid-March very clearly stated it was appropriate to wear masks in certain clinical situations. That did not stop people from wearing masks.

We have to bear in mind the position we were in at that point as a country. We, like other countries in the world, were dealing with having to access PPE. It was a very different world from where we are today. We had great difficulties. I heard comments about some of the PPE we had. We were striving strenuously to buy appropriate PPE at that stage. We needed to make sure that it was focused in the most appropriate places. We were not telling people not to wear masks. It was clearly appropriate to tell people they needed to use masks as appropriately as possible as per our guidance. That is what we wanted people to do. We wanted to make sure that, as a consequence, PPE was available for staff who were at the highest risk of being exposed.

I have to say I am somewhat surprised when I look at the WHO guidance on wearing masks, which is, of course, that masks should be worn in a medical setting, particularly when dealing with persons with Covid-19. Its advice on masks in the general population is still equivocal.

Dr. Kevin Kelleher

As the Chairman said, it is equivocal.

We had two members of NPHET before the committee on, I understand, 9 June. Their advice at the time was equivocal, but the advice in Ireland has changed since and masks are now mandatory in a public transport or any confined transport setting and their wearing is advised in indoor settings. Why is the advice of the WHO still so equivocal?

Dr. Kevin Kelleher

It is because the evidence is not as clear as people might think. Some people make out that it is clear; others do not. I am sure that the other witnesses in the room would agree that it is important that we have a multifactorial approach to this. Masks are not a magic bullet. They have to be part of an overall approach, which includes social distancing.

For the public the advice is still that social distancing and respiratory and hand hygiene are the fundamentals. That is what got us through the past four or five months. Wearing masks adds to that, but they are not a magic bullet. General infection prevention and control measures, specifically in healthcare settings and more generally in public settings, are very important messages. They are the things that will keep us going. We need to get people to remember that they still need to socially distance, have respiratory etiquette, ensure they practise hand and environmental hygiene and, as we have said, that they should self-isolate if they have symptoms. That is very important.

I am not denigrating masks. Rather, I am saying that people should not see them as a magic bullet. The real issue is very much that we need to keep up the other messages because the Irish people took them on board very well and that had a major impact.

Dr. Kelleher is heading up the expert advisory group on nursing homes.

Dr. Kevin Kelleher

No. It is my namesake, Professor Cecily Kelleher.

My apologies.

Dr. Kevin Kelleher

The Chairman has the wrong sex and the wrong person.

My apologies. I wanted to ask when the report was likely to be published. I know it is an independent group.

Dr. Kevin Kelleher


Having clarified that, I thank all of the witnesses for coming before the committee today and answering all of our questions.

As nobody else is looking to come in, I will adjourn the meeting. We will meet again in private session on Thursday to consider a report on Covid-19 in nursing homes and the State's response.

The committee adjourned at 2.40 p.m. until 9.30 a.m. on Friday, 24 July 2020.