Covid 19: Implications of a Zero-Covid Island Policy

We are back in public session. I welcome our witnesses who are physically present in Leinster House, albeit in committee room 2. They are: Professor Anthony Staines from the school of nursing, psychotherapy and community health at Dublin City University, DCU; and Professor Patricia Kearney, professor of epidemiology at the school of public health in University College Cork, UCC. Joining us from London on a link is Professor Susan Michie, professor of health psychology and director of the centre for behavioural change, University College London. Is the link up and running? We live in hope. Also present in committee room 2 is Mr. Dan O'Brien, chief economist at the Institute of International and European Affairs. I welcome Mr. O'Brien and thank him very much for joining us. We also hope to be joined presently on a Microsoft Teams link by Professor Carl Heneghan, to whom I spoke to a moment ago. Professor Heneghan is director of the centre for evidence-based medicine at the University of Oxford.

I apologise to all for this session starting slightly later than anticipated. We went over with previous sessions and we have to take time to clean the room and take a breath.

I advise the 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 in relation to a particular matter and they continue to so do, they are entitled thereafter only to a qualified privilege in respect of your evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise nor make charges against any person(s) or entity, by name or in such a way as to make him, her or it identifiable. For the benefit of Professor Heneghan, if he can join us, and Professor Michie, I have to add that the constitutional protections afforded to witnesses attending to give evidence before the committee may not extend to those giving evidence from locations outside of Leinster House.

Without further ado, I ask Professor Staines to make his opening statement and to confine it to five minutes or less.

Professor Patricia Kearney

I will speak first if that is okay.

Is Professor Kearney making the opening statement?

Professor Patricia Kearney

Yes.

I was misinformed, my apologies. Professor Kearney is welcome. I ask her to make her opening statement and to confine it to five minutes.

Professor Patricia Kearney

I thank the committee for the opportunity to speak today and good afternoon to everybody.

I will start by outlining the three reasons we are advocating for a zero-Covid island strategy. The first, of which the committee will be aware but it is important to reiterate what we know and what we do not know, is that Covid-19 is a serious and scary disease. We heard this morning that workers in meat packing factories are petrified about going to work and that Covid-19 causes death and disability. There is increasing emerging evidence of the long-term consequences, the so-called "long Covid".

Second, we know that we can stop the virus. There is evidence from different parts of the world where suppression strategies and going on to elimination have been successful. We also know that closer to home, Ireland’s response to Covid-19 early on was very effective. We saw that due to our efforts as a people, we avoided swamping our health service with the so-called surge and worked together to suppress the curve. The problem and challenge that we are facing now is that, more recently, the policy has become one of suppression of the virus to a so-called tolerable level. This is the idea of living with the virus. The challenge with that is that we are always seven to ten days behind the virus in our response. While we saw the success of the efforts that we made together and the declining number of cases, we have seen more recently how quickly that can change. The rising number of cases over the past few weeks has focused minds on where we go next.

The third reason we are here advocating for a zero-Covid island strategy is that we need clear and decisive action. We need our population to understand the goal that we are all working towards together and what we need to do to get there. We have seen that the Irish population can work to flatten the curve and we now need to work together to stop the curve.

I will explain what we mean by our zero-Covid island strategy. We are defining this as the absence for a suitable period of time of community transmission of SARS-CoV-2. How do we get there? We need leadership and we need our Government to be clear that will take a policy of elimination. The types of measures that we will need to take as a population are those that we are becoming increasingly familiar with. These are strong adherence to hand hygiene and cough etiquette with regular hand washing, being really consistent with our physical distancing, the widespread use of masks, especially indoors, and we need to have more active case finding, testing, tracing, and better support for isolation. We are also advocating that there will be no non-essential travel into what we are calling green zones. This is an approach which we will take within the island which my colleague, Professor Anthony Staines, will describe in more detail. We are also advocating for no non-essential foreign travel with testing, isolation and tracking the movements of incoming people at ports and airports. The reason for this is that we will have a shared goal and work together to support the recovery of our economy and society. Professor Staines will now give some more detail on the green zone.

Professor Anthony Staines

There are two other pieces in this. There are a number of objections posed to this is a policy, the most fundamental being that all of the pieces that are used to make it happen are imperfect. One of the central messages of public health is that if one does things which are in themselves imperfect but one does several of them, one can get really good results. There is also a great concern about further damage to the economy, which I believe Mr. O’Brien will address in a little while. We simply make the point that the limited evidence that is available, which is from the United States where every conceivable variety of lockdown has been tried and from South Korea where no lockdown was tried, is that the economic damage in a region of those countries was much more strongly related to the amount of infection. It really is the virus that drives the economic damage. This is the same as the message that comes from analysis of the 1918-19 flu.

The logic of the green zones is that there are many areas of the country where there are very few cases and these are mostly rural counties.

Roscommon is a good example. In those areas, it is relatively straightforward to stop the disease completely. As one gets areas to green, one can merge those areas and produce a larger and larger green area which covers the country. That is the position we were in in early June and we can absolutely get back to that position again because we have already done it. One goes from managing one outbreak which is spreading across the country, affecting many different counties, to 26 smaller outbreaks, many of which are tiny and involve single families or individuals and can be dealt with effectively and stopped from spreading effectively. In the areas in which infection is driven to zero, in green zones, which would initially be county-level areas, life can return substantially to normal. The price of that is no non-essential travel into those areas from other parts of the country. The plan is to expand those areas as quickly as possible to cover the entire country, hopefully in collaboration with the Northern Ireland Government, where there is a long history of co-operation, to extend it to cover the entire island.

It is the view of colleagues of ours who have dealt with epidemics of things like Ebola, malaria and cholera in the most difficult circumstances imaginable that this is entirely feasible. It is also a view supported by the evidence from other countries. One gets to the situation in New Zealand. In New Zealand, there has been an outbreak in the past two days which appears to have been caused by failure in the quarantine in one city. In that city, life is severely disrupted but the outbreak will be brought under control and life and business continue on the rest of the island. We are bringing our children back to school in September and it is crucially important that we do so. All the international evidence says that the lower the amount of this virus circulating in our communities, the safer it is for our children to return to school.

The alternative of living with the virus is difficult, as the people of Kildare, Laois and Offaly have discovered in the past week or so. Our expectation is that if we continue to live with the virus, such outbreaks, with rolling closures, will be a feature of life until a vaccine is available. It will be the middle of next year, June 2021 at the earliest if everything goes well, before large supplies of a vaccine are available for our population. If things do not go well, it could be a lot longer and we could be waiting for quite some time for a vaccine.

Mr. Dan O'Brien

Every country now faces extreme and unprecedented uncertainty. Never in my lifetime has it been more difficult to predict how the economy and indeed the world will look in a year’s time. The scale of the human cost of Covid-19 is well known and well articulated by those with medical expertise. The scale of the impact on livelihoods is less clear at this juncture even if it is visible in plain sight almost everywhere one looks.

I have two opening observations. Economies are like living organisms. A view commonly espoused since the pandemic struck is that they can be placed in deep freeze, but they cannot. Just as human cells quickly start to die off when starved of oxygen, the businesses which form the economy die off if deprived of trade.

My second observation is that the greatest economic cost of Covid is not the deficits governments almost everywhere are running in order to increase healthcare provision, support household incomes and save businesses, however huge those deficits are. It is instead the economic activity that has not happened as a result of the pandemic. The wealth that is not being created or the wealth that has been lost has been lost forever and this will have consequences down the line.

The scale of the slowdown in economic activity is becoming clear slowly as economic indicators for recent months become available around the world. Only yesterday our nearest neighbour, the United Kingdom, reported its figures for gross domestic product - the widest measure of economic activity - for the second quarter of this year, which was the worst period of the pandemic. In April, May and June, wealth creation in the UK collapsed by almost a quarter compared with the final quarter of 2019. That is a contraction utterly without precedent. The eurozone and the United States, which are, along with the UK, Ireland's most important trade and investment partners, have recorded slightly smaller contractions, albeit ones of historically large magnitude. Irish GDP data have yet to be published for that period and there is reason to believe that the headline contraction in activity here will be slightly less than in peer countries. However, there is also no doubt about the scale of the shock to the Irish economy from a range of available indicators, most notably those from the labour market. The latest data from the Central Statistics Office show that 500 million people were in receipt of jobless benefits of some kind in July. That figure is higher than at the worst point of the previous recession, which was itself a historically deep recession. Almost as many people again are having their wages and salaries subsidised. If one includes public sector workers, approximately half of the entire workforce is being supported by the State.

The single most important factor in ensuring the State can borrow to pick up the cost of these emergency measures is the willingness of the European Central Bank, ECB, to effectively print money. The ECB is committed to maintaining its pandemic purchase programme into next year. When and how it unwinds this programme is yet another source of great uncertainty.

As recently as 70 years ago, seven people died every day on average in the Republic from tuberculosis out of a much smaller population. The emergence of Covid-19 is in some ways returned to past times when fear of contracting a deadly disease was so prevalent. Our parents, grandparents and the generation before them lived with that disease. We will have to find ways of living with Covid as they did with tuberculosis.

I thank Mr. O'Brien. We will try the link with Professor Heneghan again. There seems to be a problem. We can see Professor Heneghan perfectly but unfortunately we cannot hear him, although the IT unit can hear him. I think the problem is at our end. Perhaps we will suspend for five minutes. Professor Staines wishes to make a suggestion.

Professor Anthony Staines

Perhaps we could hear from Professor Michie while we wait for the technology to be dealt with.

Professor Staines may have to take off his mask to be heard better, I am advised.

Professor Anthony Staines

I apologise. It might expedite matters if we hear from Professor Michie while we are waiting for the technology to be sorted out.

I did not realise Professor Michie was to give an opening statement. Shall we hear from her?

Professor Michie may go ahead. It seems we have the same problem. Can Professor Michie speak to us? We cannot hear her, I am afraid. We will have to suspend for five minutes while we get this problem sorted. I thank the witnesses for bearing with us.

Sitting suspended at 3.40 p.m. and resumed at 3.45 p.m.

I will go to Professor Heneghan. I am told that both links are working so let us hope that is the case. There was a time when every session here began with a prayer. Those of us who believe in the power of prayer can pray. Can Professor Heneghan hear us now?

Professor Carl Heneghan

Yes, I can hear you fine, Chairman.

That is great. I invite you to make your opening statement, which is limited to five minutes. I am very sorry for the inconvenience with the video link. I thank you very much for bearing with us.

Professor Carl Heneghan

That is not a problem.

I have heard the opening arguments. There are two schools of thought between endemic disease versus this strategy of elimination and I think it is incredibly important that the first thing one does is be very clear about what that actually means. Words like “suitable period of time” are unhelpful given the uncertainties, so one needs to be very clear about that definition. If one thinks about endemic, then it is a disease or condition that is regularly found among people in a certain area.

What we know is that this pathogen is now endemic in every part of the world. I will come back to New Zealand, but it is out there. The idea that we are going to eliminate it globally is a misnomer now. It is a problem if one is pursuing that path. When one refers to an elimination of a disease, then that is a deliberate effort that leads to a reduction to zero of the incidence of an infection caused by SARS in a defined geographic area. It is also important whether one is talking about Ireland or about southern Ireland. One can class elimination from a specific region without it being eradicated globally. There are examples of that like polio and measles, but it is important to understand that there are only two pathogens that can come under the list of where we have had complete global elimination of diseases: we have got smallpox and rinderpest. They have three things in their favour when one goes for elimination. They have an effective vaccine in place. They have no animal host as humans are the only vectors. Third, they have a political will globally to succeed in elimination. When I hear that school of thought around elimination I ask how are we informing this on what we have done previously. How are we considering that this is a zoonotic pathogen that communicates to animals and back, and has multiple routes of transmission?

The fact has been alluded to that lots of people use New Zealand as an example, and there are some helpful examples between it and Ireland. The countries have a very similar population of about 4.9 million, but in terms of density, we are talking about 15 per sq. km in New Zealand, whereas there is about a fourfold increase in Ireland. Ireland is much more densely populated than New Zealand. In addition, when one talks about New Zealand, one has to consider that its nearest neighbour is more than 1,000 km away, that is Australia, which is also one of the least densely populated countries in the world. I think that any comparison with New Zealand is unhelpful because not only is it locking down, it has to lock out. One cannot have a sort of all-or-nothing strategy.

There must be a strategy. Where countries have done this, such as in Hong Kong or New Zealand, we are talking about quarantine in hotels for two weeks and testing. Once people are let out, problems emerge. That is important.

With evidence gathering there is much uncertainty about what will happen next. We can look at the age structure of Ireland, for example, with a median age of 36.5 compared with 40.5 in the United Kingdom. We modelled this and examined deaths and there would be 10,000 fewer deaths because of that age structure. When people are doing comparisons, they must really bring in nuanced evidence to understand it.

We are talking about an elimination strategy and I have read the emails, and there is much emotion about such matters. We try to focus on the evidence. Whatever the strategy, and whether one is in the Sweden camp or the Spain camp, where they locked down very hard instead of keeping society going, there is the same problem that we have and that Ireland has. In Ireland, 62% of deaths were associated with care homes. It is still not clear to me why governments and their policy have not understood that this is where the problem is.

Looking at the age structure of who is affected by the disease, I have never seen a disease like it where age has such a major impact. We should remember that with influenza we saw many deaths in people under five but we are not getting that problem now. Fewer than 400 people aged under 50 with no comorbidities have died of Covid-19 in the United Kingdom. That is an incredibly small number. We can assume that the biggest problem in the middle age group is dealing with comorbidities and this is most important. The decision today if we go down the elimination strategy is to make it exactly clear what is being done, what evidence this is based on and, in doing that, what may potentially be ignored where the strategy is more important. I still do not see the urgency around protecting care homes and thinking through the issue.

I thank Professor Heneghan. I invite Professor Michie to make her contribution. I hope I am pronouncing her name correctly.

Professor Susan Michie

It was originally a Scottish name. I am a part of the United Kingdom Government's Scientific Advisory Group in Emergencies, SAGE, specifically the behavioural science advisory group. I am also a member of Independent SAGE, which works in parallel with the Government's SAGE committee.

Independent SAGE has really considered the evidence for many of the issues that have arisen. The three overarching concerns we have been addressing is how to minimise death and disability, how to promote and help to maintain as many jobs and get the economy going as efficiently and as soon as possible and also how to open schools safely. When it comes to jobs and workplaces, we are also talking about safety.

Our view is we have approximately three to four weeks before the autumn, cold weather and a decrease in the level of ultraviolet radiation sets in that will pose new challenges for us in driving down Covid-19. The influenza season will also set in. We speak about elimination but I will clarify the terminology, as I believe Professor Heneghan was referring to eradication. That is not what we are talking about; we are talking about elimination.

I could use the analogy of fires. In Ireland, like the United Kingdom, there is a zero fire policy, which means we want no fires and we take every measure we can to ensure, as much as we can, that there are no fires. However, we know fires will occasionally break out and we have systems in place to jump on those fires quickly so they do not spread into the awful examples we saw in Australia last year arising from large forest fires. That is what elimination and zero-Covid means.

I will try to add to what has already been said.

We feel very strongly that health and wealth should not be pitted against each other. We want to increase business and consumer confidence. To achieve both of those things we need transmission rates in the community to be at an absolute minimum alongside effective test, trace and isolate systems and, as has been previously said, border controls. As a behavioural scientist, I am especially interested in the behavioural aspects of the test, trace and isolate system, which needs to be addressed to make it effective. I am sorry to say we have not yet achieved that in the UK for various reasons which we may get on to.

Would the population really go with what is needed to eliminate coronavirus and reach a Covid-zero situation? It would mean over the next three or four weeks taking every measure, which includes restrictions and probably more restrictions than Ireland has at the moment on the basis that it would then allow the certainty and confidence which the business community and the population in general so want to be able to get on with their lives and their jobs.

The experience in Ireland, as in the UK and many other countries, is that when it is explained to the population why measures are needed, even though those measures require sacrifice on their behalf, they will adhere to them as we saw with the original lockdown. A couple of things are really important here. It is not only telling people what to do, but explaining the rationale so that people understand it. I believe that people would understand a zero-Covid policy if it was put to them. Also required is trusted leadership to communicate that in appropriate ways to the population and to do so with an understanding of which parts of the population find adherence most challenging. In the UK, as I suspect is the case in Ireland, it is young people and especially young men. It is very important to tailor strategies to those groups, using role models of various kinds like sportspeople, musicians and other celebrities.

This needs to be done in partnership and in consultation with the community so that as much as possible the policies are thought through together and the strategies to achieve the aims of the policies are co-produced with the community and not imposed from the top down on the community. I am happy to expand more on these points and other points during discussion.

I thank the many witnesses who are taking part. I may not be able to get to everybody. They are very welcome and I thank them for their contributions.

I address my first comments to Professor Kearney. The first question people will ask is what the difference is between a zero-Covid strategy and the strategy currently in place in the State, especially on the back of the new colour-coded system announced yesterday. What would be the red line issues or key differences between what is in place in the State and what is being advocated? That is a general question but I have a number of specific questions on the opening statements and some of the material provided to us in preparation for the meeting and I want to tease some of it out.

On non-essential foreign travel, I agree with testing, isolating and tracing the movements of incoming people at ports and airports. I know there was some discussion and movement by the Government on this in recent times. We have been told that NPHET and other advisers have argued against testing at airports because they believe it to be ineffective.

Why would Professor Kearney think that is the advice and what is her view on what type of testing and tracing needs to be done in respect of travel?

Professor Patricia Kearney

I will take the Deputy's question on what is different about the zero-Covid strategy first. I suppose it comes back to the distinction made by Professor Michie between eradication versus elimination versus suppression. To be clear, eradication, which Professor Heneghan spoke about, is when the virus is gone completely from the world. That is not what we are proposing. Elimination, which we are talking about, involves eliminating community transmission. We understand that there is still the possibility that people will cross our borders and come in but we would have appropriate measures in place so that if a person who is Covid-positive comes in, we can detect that, he or she can be isolated and we can avoid any further transmission of the virus. That, essentially, is an elimination strategy. We eliminate community transmission. What we have in Ireland at the moment is suppression. That made sense early on when we were still learning about this disease and when the focus was very much on not overwhelming our health system. It was also informed by responses, for example, to flu outbreaks. It was very much about trying to flatten the curve. What we have learned, and what is very clear in our experience in Ireland in the past few weeks, is that this virus will bounce back if given the opportunity to do so. We need to go that bit further beyond suppression to elimination.

What about in the context of travel?

Professor Patricia Kearney

I am not privy to the advice NPHET has been providing on non-essential travel or what the decision-making is there. I can say-----

Maybe I was not clear, and perhaps another witness can also take that question on whether part of the strategy should be testing as part of travel. I believe that the advice given so far has been that testing at airports is not really that effective. I am of the view that testing should be in place, but we are being told that that was partly the advice that was given up to now. What is the international evidence? Can the witnesses define for us the importance of testing at airports and why it would be helpful and necessary?

Professor Patricia Kearney

Testing is certainly part of the response but, and my colleague, Professor Staines alluded to this earlier, none of these measures, in and of itself, is perfect. There are problems with testing with potential false negatives, for example, and around timing whereby testing gives a result at a point in time. It is, however, part of the response. Around the world, we see the different measures and approaches being developed with regard to whether people have to test before they travel and whether they are tested again on arrival and during their isolation period. We put forward, and we agree, that in the first instance we take the elimination strategy and then work to figure out what is the best way to incorporate testing in the overall approach.

I want to follow through on the briefing document we received on a zero-Covid island policy, and some of the material setting out how we get there. One of the things was making sure that essential travel is important, and that if people are coming here it is only for essential travel. The document says that the responsibility for deciding what is essential travel lies with the individual. Some would argue that this is part of the problem and that it would be better if we had definitions of what is deemed to be essential or non-essential. Why is it the case that the group has opted to leave it to the individual to decide that as opposed to perhaps more clear definitions?

Professor Anthony Staines

The question on what is essential travel is very difficult to answer. There are lots of edge cases and there are many people who have a good reason in their own minds for travelling. Others, however, might not feel that it is a good reason. From a practical perspective, the person will make the decision anyway because he or she is the person who decides to travel or not. By placing the responsibility squarely on the person and saying "If you feel you need to travel then that is your choice but you must be willing to justify it", we are pushing back responsibility to the community. We are saying to people that we trust them to make reasonable decisions. Not everyone makes reasonable decisions. Again, this is imperfect, but the alternative is having a kind of "Is your voyage necessary?" checklist and some kind of travel-monitoring police at the airports and county boundaries.

That is not very practical either. It is about getting people to think about why they want or need to travel. Sometimes they will make the decision that they do need to travel, and sometimes they will not. There are peculiar issues, such as the town of Blessington, for example. It is in Wicklow but part of it is in Kildare. Does that mean that the people who live in the few streets in Blessington that are in Kildare have to go to Newbridge to shop, or can they go 100 yd down the road and shop in Blessington? Clearly, they will do the latter. We are telling them to think about it before they go.

I agree with Professor Staines that it would be almost impossible, never mind practical, to have definitions that would have to be enforced by police or port authorities. My question was more about having an advisory mechanism, because with clearer definitions, people might better understand what was deemed to be essential and non-essential, as opposed to making judgments that in the end may be wrong.

Professor Anthony Staines

It would make sense to expand the advice with a list of practical examples. We have not done so in this short document, but we have considered what might be necessary travel and what might not. For example, if someone is travelling for work and has to work in person at his or her place of work, that is essential travel. However, if that person could work from home, and it is feasible for him or her to do so, he or she should not travel. Working from home may not be feasible for everyone doing the same job. One person may be able to work from home while another may not.

I just have one more question for Professor Staines, and one for Mr. O'Brien, in the few minutes I have left. In the section of his statement discussing the goal of the policy, Professor Staines stated that "no large events will be allowed". How does that differ from the restrictions on numbers for outdoor events that are currently in place? What is the difference? He also referred to "[s]trict control over unsafe high density housing". What would that look like?

Professor Anthony Staines

The restrictions on large events would look pretty much as they are now. If the case numbers were rising, NPHET might wish to reduce that number. I think the limit is currently 100 people indoors and 200 outdoors, or 50 indoors and 200 outdoors. I do not remember the exact numbers. That would not be substantially different from what we have now.

One of the things we know about this virus, both from the experience in our country and other countries, is that it seeks out the weak points in a society. In our case, it was nursing homes. As Professor Heneghan has pointed out, many of the deaths in Ireland occurred in nursing homes and in many cases the virus was brought into the home by staff members. It is very important that people have access to living conditions that allow them-----

I have to stop Professor Staines as we are tight on time and I wish to put a question to Mr. O'Brien. What elements of the plan that has been presented to us would Mr. O'Brien find objectionable? That might be too strong a word, but perhaps he finds them impractical or problematic. Some of the measures seem to amount to better enforcement of what is already in place or getting a bit stricter on some of the recommendations for individuals, as opposed to anything that would be overly problematic from my perspective. From Mr. O'Brien's perspective, what are the more problematic or less practical measures that have been advocated here?

Mr. Dan O'Brien

Is the Deputy referring to the lighting system proposal?

I am referring to the zero-Covid Ireland plan.

Mr. Dan O'Brien

The question is what is success in the zero-Covid plan. Let us consider New Zealand. What happens to New Zealand if, a year from now, it is successful and there has not been a single case but the rest of the world has opened up? It will have to continue this policy of effectively sealing itself off from the world. If there is no vaccine, how long will it go on with that? Will it go on for one year, two or three years? It may eventually decide that this is not a sustainable policy and while it has been successful, it is going to have to open up. It will then have to go through what the rest of the world has gone through. I think the chances of success for that sort of policy are very low and that is before taking into account the issue of having two jurisdictions on one island, of which the Deputy is well aware.

To make an observation on the politics in the Northern jurisdiction, there seems to be very little probability of the devolved Government there agreeing to sealing off travel with Britain. It does not seem to me to be achievable politically or otherwise.

Is Mr. O'Brien saying that while, in the short term, it might deliver benefits he does not see it as a long-term solution?

Mr. Dan O'Brien

It is possible. We all have to admit that we just do not know and that the professors here could end up being correct on this. Perhaps New Zealand's approach is the correct one. We have to accept that we just do not know. New Zealand might come to the point where they decide they have been successful on this but there is no vaccine globally and they will have to try something else. It just does not seem to me to be a feasible option.

Could I ask a brief follow-up question for clarity? It is for Professor Staines and Professor Kearney. Do I understand correctly that the zero-Covid approach requires the Republic of Ireland either to seal its borders with the rest of the world, including Northern Ireland, indefinitely until the rest of the world sorts out the Covid problem or the island of Ireland together seals its border with the United Kingdom? I am not an expert on Northern Ireland politics but I think that would be distinctly unpalatable to at least one political tradition in Northern Ireland. Whatever about sealing its borders with the rest of the world, sealing its border with the United Kingdom might be difficult, at the very least.

Professor Patricia Kearney

To be clear, we are not suggesting that we seal our Border. It is important to mention that Scotland, which shares a land border with England, is clearly advocating an elimination strategy and is going about trying to implement that. The Independent Scientific Advisory Group for Emergencies, SAGE, is clearly advocating for a zero approach across the islands of-----

One can drive from London to Edinburgh to Stranraer to Banbridge without any checks whatsoever. One can drive from Banbridge to west Cork without any customs checks.

Professor Patricia Kearney

The reason our group is called Zero-Covid Island is because we are an island and it makes sense for us to work together. Separate from the political challenges, there is a history of us working together across health. There has been clear interest in Northern Ireland in taking a zero-Covid approach. We know that the route between Dublin and London is one of the most popular in Europe. In terms of some of the concerns expressed about the consequences if we were to succeed with this approach, the reality economically would be that we could get our economy up and running in Ireland and in the UK and then work together. As other places successfully eliminate the virus, we would continue with that travel. To be clear, we are advocating that people will still be able to come to Ireland. For example, people come here to study to be future doctors and nurses who will be needed to fight this infection internationally. Appropriate processes need to be put in place to make sure that people who need to travel do not transmit the virus, going back to the idea that our goal is zero community transmission.

I thank Professor Kearney.

I thank the witnesses for their presentations. I ask Mr. O'Brien about the Irish economy contracting. What stage are we at now? For instance, if we are in the same position with regard to trying to control the spread of the Covid-19 virus this time next year, what can the Irish economy handle in that difficult scenario? Many businesses are seriously affected by the pandemic, although some are not affected.

What is the highest risk business if the challenge facing us continues as is?

Mr. Dan O'Brien

The recession that the Irish economy and most peer economies have plunged into is the most dramatic and frightening I have ever seen or can be found in available data. That is the negative part. The slightly positive part is that most economies have bounced back a bit. They are well below what they were and how they functioned. Much of the bounce is being caused by governments rightly stepping in and giving significant support to households and businesses, but how sustainable that is over a longer period is questionable.

It is clear that any industry which involves people mixing together is facing very difficult times regardless of what policy choices are made - anything to do with travel and hospitality and, in second place, retail. That is because people are concerned about going indoors and some have lower incomes and feel they must save for precautionary reasons, which has a demand impact for retail. The retail sector is in second place in terms of vulnerability.

We must also take into account Brexit, which is only six months down the road in real terms. If an arrangement is reached between the EU and the UK, we should come out of it on the right side. However, if an arrangement is not reached, what will be the consequences and how will they add to our problems?

Mr. Dan O'Brien

The risk of import disruption may have been underestimated. We import a considerable amount from Britain. The risk of disruption, particularly in the case of a no-deal outcome, is something of great concern for all businesses and for the economy more generally. Agriculture, particularly the meat industry, is facing a difficult situation regardless of whether a deal is reached. It looks likely that even if a deal is reached, there will be implications for agricultural produce going to the UK, if not immediately, then over a longer period. This issue is coming down the line within a short time. On the export side, it will be most serious for the agriculture sector.

I wish to ask Professor Staines a question. Is he satisfied that Covid-19 has been handled in the best possible way to date? Are there particular pitfalls that we need to watch for over the next six months that are not currently being monitored or planned for properly? Will he go through his concerns in that regard?

Professor Anthony Staines

Covid caught every country on Earth on the hop. The virus is different from influenza and all of our pandemic planning had been focused on a recurrence of the influenza virus. We managed to avoid our health service being overwhelmed, which was not guaranteed when we started. That was an achievement. We managed to bring the rates of viral infection down to very low levels by the beginning of June. Again, that was not guaranteed, but it was done. The area in which we probably made the greatest mistakes was that of nursing homes. I am the chairman of the board of St. Michael's House, which is a large service for people with intellectual disabilities.

Within hours of hearing about Covid, we were making plans to keep our residents safe. I am ashamed to say that it never occurred to me to think about nursing homes until many deaths had occurred in the homes. I do not think anyone anticipated, as Professor Heneghan indicated, that this virus would prove so lethal to older people.

In terms of what we need to do now, our biggest weakness still is the test, track, trace and isolate function of the HSE. This has improved beyond all recognition but it has been scaled back over the past few weeks as the number of cases fell. As cases are bouncing up again, it is clear that we will need a permanent solution to testing, tracking, tracing and isolating. We are not doing enough tests yet but we have the capacity to do that. I am aware that there is work going on in the HSE as I speak to increase the capacity for case tracing Covid. I find that very reassuring.

It is incredibly interesting listening to experts at different points in the debate discuss matters with each other. In many ways, perhaps us listening to that more would be useful but I suppose where we, as public representatives, can contribute to the debate is in our experience of dealing with the general public. There was much talk at the beginning of this pandemic about flattening the curve - a well-understood and well-communicated concept - but when we got to the end of the process in that regard, we did not have a conversation with the people about the point at which we wanted to plateau. Looking at the United States, it is clear that it is plateauing at a very high, and perhaps unacceptable, rate. Then one looks at Ireland and Scotland, which have a much more conservative approach, and New Zealand. We must yet have that debate with the public because, even at the height of the pandemic and the debate on flattening the curve, there were people who clung to the rules and who wanted more rules and there were those who were willing to ignore them. In the past week or two, I have noticed increasingly different shades of opinion, with some even saying they do not believe this pandemic is real. It is clear that the pandemic is real and that is having a real impact on people's health and lives, but what is being said by some demonstrates how we need to bring the public with us in whatever debate we have.

On Professor Staines six recommendations regarding how we get to a zero-Covid island, a previous speaker indicated that it is really about a stricter implementation of what we currently have. I refer, for example, to the communications strategy in respect of hand hygiene and social distancing, the increased use of masks indoors, the commitment given by the Minister yesterday that we will sustain the level of track and tracing, the closure of some counties - and the consequent prevention of travel - and the instruction by Government on non-essential foreign travel. At the same time, we are leaving the latter to the discretion of individuals. In many ways, Ireland is pursuing the strategy which Professor Staines has outlined. Am I correct in saying that he would like to see the prevalence of the disease plateau at a lower level? In many ways, we have made the decision to try to be as conservative as possible.

Professor Anthony Staines

I thank Deputy McAuliffe. From my perspective, we are trying to do something very difficult. We are trying to live with this virus. The Government has articulated that policy clearly. However, it is very difficult to keep the number of cases at 20 or 30 a day. The likely outcome is that we will have periodic flares similar to those in Kildare, Laois and Offaly in other parts of the country. The endgame is that this will continue until such time as a vaccine becomes available. Hopefully, a vaccine will be available by the middle of next year but, as Mr. O'Brien articulated, if one never becomes available, we have to think about this differently. I am optimistic that there will be a vaccine in the not-too-distant future. The problem, from a businessman's perspective, is that one never quite knows.

A hotelier was interviewed in Kildare - it was a small family-owned hotel - who bought in €8,000 worth of food for an event at the weekend. All of that money is now gone. That is a substantial hit for that person and that business. It becomes difficult for businesses to make plans, particularly small, family-run businesses, which make up a large part of employment both in urban and rural Ireland. Businesses crave some level of certainty.

The other side is that of opening schools. What does one do if, for example, we open schools in Clare, as we fully intend to do at the beginning of September, and then a week later there is a lockdown in the county? The lower the circulation of the virus in the community, the safer the schools are. The basic point is that low-level circulation of this virus is like a fire in the wall of one's house. It is hard to confine it to one small area of the wall. It is likely to spread unpredictably. Bringing the virus down to zero, as the Deputy described, is an intensification of the measures we are currently taking. We would advocate for, at least, discussion of the idea of green zones.

On county travel, for example, given the incidence of Covid in Dublin, would Professor Staines close travel for people living in Dublin?

Professor Anthony Staines

Probably not. It does not make sense particularly to do this in a haphazard way. It makes sense to do this as part of a clear national strategy. The Deputy put his finger on it. The Government is elected. I am not elected. Nobody elects me to be here talking to the committee. The committee members are elected and they have to have the conversation with the Irish people to see if they feel persuaded by the argument that we have put forward and then to implement it. The big difference between what we are doing right now and what we are suggesting is the addition of restrictions on travel across county boundaries for non-essential travel.

Given the current numbers, which counties, other than the three which have been locked down, would Professor Staines lock down?

Professor Anthony Staines

I would not lock down any counties. Locking down is the wrong way to think about this. What one is trying to do is turn this from a national epidemic, which is what we have at the moment, into a series of local epidemics that one can kill off one at a time. As one kills them off, life opens up in those areas in which the virus has been killed off but people cannot freely come into those areas from other parts of the country.

For example, today we had representatives from the constituencies impacted by lockdown. Would Professor Staines consider it okay for them to travel outside of their affected counties? Yesterday, I met a woman from Portlaoise who travels to work in Dublin each day. Would she be permitted to travel? Would someone returning to a sick relative in another county be permitted to travel?

Professor Anthony Staines

This comes back again to the idea of non-essential travel. If one needs to travel for work, then one needs to travel for work. That is essential travel. If one can work at home, one does not need to travel for work. Then it becomes non-essential travel. If one needs to care for somebody, I would argue that it is essential travel.

This is not about having gardaí standing back to back, linked arm to arm around the borders of the counties. Even if we wanted to do that, we could not do so. This is about asking people in the counties if they need to travel. If they need to travel, then off they can go with the blessings of God on them. If people do not need to travel, then they should not travel and should stay in their county. That lets us pick off the epidemic in pieces.

I am straining to see how that differs from the current strategy which talks about holding firm, as well as caution among the general population, and then quite severe local restrictions in each county.

Professor Anthony Staines

I think we would get less severe restrictions across all counties. It has never made great sense to me that pubs that serve food are open or were allowed to open while pubs that did not serve food were not allowed to open.

We have risk-based assessments. If, in a particular county, cases start spreading wildly, then we take more drastic action. However, we are doing it at county level and we are doing it with a purpose in mind. We are not saying that this week we are closing Kildare, next week we are closing Donegal and the week following that we are closing Galway. We are not playing whack-a-mole with outbreaks of the virus throughout the country. We are trying to get ahead of the virus.

The Chairman has indicated I have only 30 seconds left.

Professor Heneghan, do you wish to come in?

(Interruptions).

I am afraid we are back to our sound problems. Can we try one more time to get Professor Heneghan?

(Interruptions).

We can ask whoever is working on our information technology to see what can be done. We can go on to the next speaker and then bring in Professor Heneghan. We will know when the link is up-and-running again properly. I apologise again.

I apologise for cutting across Professor Staines.

I had indicated that Professor Heneghan was indicating that he wanted to come in. The next speaker is Deputy Jennifer Carroll MacNeill.

Can we hear from Professor Michie? Do we have the same issue? I want to check in advance - perhaps we do not.

Both links are down. There seems to be a problem with the sound.

We will go on anyway and perhaps come back if the opportunity arises. This is why I wanted to bring in Professor Michie. It is around the behavioural aspect of what Professor Staines said about pubs and the difference between having a meal and not having a meal. As I understood it, one of the big issues was impacting the behaviour of people while they were there. Having a meal tends to keep people seated rather than moving around the pub. Is this what Professor Staines is saying? Is it the case that so long as behaviour is changed and so long as people are seated and distant, then the meal is irrelevant? It is the behaviour that is important. Is that it?

Professor Anthony Staines

Largely, pubs have regulated themselves. There have been exceptions. There is an issue with several pubs in Ireland. We could adopt a model they have in Belgium. If there is misbehaviour in a pub there in respect of Covid-19, the pub is closed for 14 days and the owner of the pub is fined. Here, it depends on waiting for the next licensing sessions, which could easily be a year or two years away.

In fairness to some of the publicans, it is not always within their control how every person moves or behaves at a given time. Part of the effort is to try to keep people seated and stop them moving around, as they would have been used to doing behaviourally beforehand.

I wish to follow up on Deputy McAuliffe's questions. What is Professor Staines suggesting? Is the idea that if I live in Dublin, then I stay in Dublin unless I have an essential work or a care reason to go elsewhere? The idea is that I do not choose to go on holidays in Louth, Galway or anywhere. I make a choice to stay within my county or I am asked to stay within my county. Is that it? Are we essentially going back a stage to where we had been earlier, where people stayed within their area for reasons of managing localised restrictions? Is that it?

Professor Anthony Staines

Yes, essentially. The restriction would be at county level because that is easy to communicate. Obviously, some sense has to be applied for people who live close to the borders of counties and those who live close to the Border with Northern Ireland. Many people in the northern counties cross the Border both ways for work and family reasons.

That is one of the things we have done in the past that we might need to go back to.

I understand. To follow up on the Chairman's question, I still was not clear on what is being suggested by Professor Staines and his colleagues for the management of the Northern Ireland and Border issues. What do the witnesses specifically propose we do in monitoring that?

Professor Anthony Staines

What we do is work with Northern Ireland. When one looks at the figures, the large majority of visitors to the island of Ireland come through Dublin Airport. Even two thirds of the visitors from the United Kingdom come through-----

I am sorry to interrupt but time is short. I saw that detail in Professor Staines's opening statement but I am asking what he specifically proposes that we do in management terms about the fact that people cross the Border.

Professor Anthony Staines

We cannot close the Border. It is not possible so we will have to live with the system we find ourselves in. If we have clear messaging and responsible behaviour on the part of the people involved, we can deal with problems as they arise but there is no way to close the Border between the North and the South and it is most unlikely that it would be possible to close the border between the rest of the United Kingdom and Northern Ireland. I do not see that happening under any circumstance.

I totally agree and that is one of the practical problems with trying to implement something like this. It is a genuine practical issue that has always been the case. I want to ask about the section in Professor Staines's opening statement that refers to a vaccine. While there has been extremely interesting progress on finding a vaccine, we cannot rely on that or hope too much. Will Professor Staines talk to us about the advances we have seen in the treatment of Covid-19 and the effectiveness of same? Might that provide a countervailing balance of some kind to the development of a vaccine or to delays in the development of a vaccine?

Professor Anthony Staines

Treatment is not my specialist area but my understanding is that the treatment of people who are severely ill with Covid-19 has been substantially improved by the use of dexamethasone and proning, which essentially is the act of nursing someone face down. That improves the patient's ability to ventilate for reasons I do not understand.

I know Professor Staines said that is not his specialty but there have been some interesting studies carried out by Professor Paddy Mallon and others.

Professor Anthony Staines

Yes. They are fascinating but that does not address the question of long-term side effects. One of our real concerns about this virus is the increasing evidence of long-term side effects in people who have often not been seriously ill but who were left quite disabled afterwards.

That is something the committee has discussed in some detail with Dr. David Nabarro. Do I have much time left?

No, but the Deputy is free to come back in at the end. Our link is working and Professor Heneghan indicated he wanted to come in so we might go to him.

Professor Carl Heneghan

Can members hear me?

Yes, we can. Hallelujah.

Professor Carl Heneghan

There were some questions about different issues. We are talking about many more clear policies to get down to zero and then when there is a period of zero it is time to open up and that is what New Zealand's policy is. There are 30 or 40 other circulated pathogens at any one time. Respiratory pathogens are a complex issue. People are coming forward with simple proposals to say we will have a zero-Covid policy and that we can have non-essential travel, etc. If we go down that line, we have to be clear and the policies have to say we will follow a path to zero Covid. That is what people are talking about but the message cannot be fudged thereafter. Once anything else is allowed, it will be a question of mitigation.

The second issue relates to some of the evidence that has just been mentioned. For instance, admissions into intensive care units have gone down from 12% to 4%. The rate for people going on ventilators has gone down from 90% to 20% in England and survival has gone up from 50% to 80% so there has been a radical change in outcomes in the three-month period.

It is about being clear, and if one is clear that one wants elimination, one must have a clear hard-hitting policy to get to zero. If not, it is not elimination.

Professor Susan Michie

Could I come in to reply to the behavioural questions?

Yes, please.

Professor Susan Michie

The question was raised about meals versus no meals as well as other questions about behaviour in terms of non-essential travel and how people would respond to borders and test, trace and isolate. In all these situations three things need to be in place. People need to have the knowledge of what they are and are not allowed to do, and for that clear and consistent information must be provided. Secondly, they need to be motivated; I will come back to that. Thirdly, they need to have the opportunity, and use of environment is extremely helpful in terms of supporting behaviour change.

In terms of pubs, I mention meals versus no meals, absolutely, as was suggested. If people are sitting down and those seats are spaced then one is much more likely to have social distancing than if people are moving around. We know that alcohol disinhibits behaviour. We have seen with alcohol that even when people have good intentions or are motivated, after a couple of drinks they forget and hug each other, are near to each other and are face to face, etc. Eating food tends to reduce the amount of alcohol consumed and the impact of the alcohol on people's behaviour.

I agree with Professor Heneghan that in order to get to zero Covid there needs to be clear, specific, precise policies. The statement being presented today is about an idea and it needs to be followed up with a statement about what those policies will look like. However, in all the cases it is important to motivate people and to take the population with the Government, as I have said before.

One thing that has been shown to be effective in that regard is getting people to think not just about themselves but about their families, their communities and societies. We need to get people to think about the "we" and about other people. It is about using a moral leadership to motivate people to comply with adhering to the spirit as well as, if relevant, the law of what is essential travel. It is about getting tested when one suspects one is ill, giving contacts, which is often a tricky thing to do, and about isolating. These are difficult things to achieve and one needs public health expertise to achieve them.

Importantly, I said one needs to have knowledge and motivation but also, the opportunity. Isolation is key to this strategy, and test, trace and isolate is key to achieving zero Covid. We need to make sure that people are not disincentivised, that is, if a person is going to lose money because he or she cannot work then he or she should have financial compensation. If a person is unable to isolate at home, he or she should be offered alternative accommodation. This is being done in those countries that have successfully kept community transmission low, even quite poor countries like Vietnam and places like Kerala that have been outstanding in their achievements. They have made sure it is not just about people knowing and being motivated but about enabling and supporting them to do that. That is an important message to take into all the areas being considered.

I thank the witnesses for coming in. It has been extremely informative. I want to put a couple of questions to the experts about how we could leverage different types of testing to establish the green zones we are talking about which is more about finding out where the virus is not as opposed to where the virus is. The first of those questions will go to Professors Kearney and Staines. Has there been any consideration of the use of pool testing whereby we test large numbers of samples, perhaps 100 plus at any one time? That would exponentially increase the capacity for testing but it would also be relevant for something like international air travel where one might be able to test a full planeload at a time.

If one got an all-clear for that planeload, one would know that everyone on board was in the clear. It would also be useful for the meat industry to be able to test on a factory by factory basis. Has that been given any consideration as part of the zero-Covid plan?

A related matter, on which Professor Michie might be able to respond, is sewage epidemiology or wastewater testing on which a good deal of research has been done in universities, including in Newcastle, Bangor and Edinburgh. I am given to understand that it is possible to test for Covid-19 in wastewater systems and this may be able to give us an indication of prevalence. For example, in my home town of Tramore one could test and find there is no Covid with the sewage and wastewater system, which would allow the establishment of a green zone. One of the objectives Professor Staines is driving towards is establishing green zones and merging them as one finds and eradicates the virus from different settings. Would any of the experts like to give an opinion or view on those testing techniques and whether they have been used or might be relevant in an Irish context?

Professor Patricia Kearney

The testing needs to be part of the overall approach. This goes back a little bit to the specifics, which we will need to figure out. Once we agree that we are happy to adopt this strategy, we would then work with our population to figure out the various parts of this and the specific details of the different testing strategies. Professor Staines can speak to the question on sewage.

Professor Anthony Staines

There is a project on sewage epidemiology which is seeking funding at the moment. We believe it is technically feasible and we are waiting to hear if the reviewers think we are capable of doing it.

On pooled testing, there are technical issues about this which I only dimly understand. I gather that in many circumstances it is very useful. It does not always work and one would need to ask one of the testing experts further about that.

Can Professor Michie comment on the wastewater epidemiology given that it has been used in the UK?

Professor Susan Michie

I am sorry but as a behavioural scientist, this is not my area of expertise.

We will accept that answer.

In the time remaining, will Professor Staines outline how he would establish the green zones, in which the virus will have essentially been eliminated, when there is so much asymptomatic transmission? Are we talking about mass testing or is there a less invasive way of establishing green zones?

Professor Anthony Staines

Mass testing is not feasible. We do not have the resources to do it and it is an impractical step. We are stuck with identifying people who have symptoms. This will be very important because the tests we use are about 70% accurate. If someone has symptoms, even if the tests are negative, particularly now when influenza is rather low, we should be aggressive about saying that this person probably has Covid-19. My clinical colleagues tell me that the clinical picture is quite distinct. It is the speed of chasing the contacts of that person, identifying them, getting them to isolate and testing them that brings the rate to zero. We are doing this much faster than we were doing it but it is not yet fast enough. There are too many people where it is taking too long to trace the contacts. We are also having a problem where some contacts decline to engage with testing. That is partly about messaging and changing people’s behaviour. It is also partly about reassuring people, as Professor Michie articulated, that they will not lose money if they are tested and have to isolate. This is a real and very legitimate concern for many people.

I thank Deputy Ó Cathasaigh and Professor Staines. I call Deputy Duncan Smith.

I thank all the witnesses. I find this fascinating. I am instinctively positively predisposed towards this as a concept so any questions I have will come from that.

On the green zones, I know it is not mentioned but I think it is implicit that if we had a number of green zones merged together, illustrated in a newspaper or media article, that the other spaces would probably be shaded in red and would become red zones at some point. Would the witnesses have any concerns about the psychological impact on people who are living in areas that are not green zones? I was speaking with my colleague, Senator Wall, who lives in Kildare, about the experience of people who have gone back into lockdown in Kildare, Laois and Offaly. He was telling me that he had to get in touch with local services to reach out to older people and vulnerable people who found this quite a bracing and worrying experience. What impact do the witnesses think the green zones will have?

Professor Patricia Kearney

The disease has significant mental health implications. Part of the strategy we are proposing involves the idea of giving people a goal that they can work towards. While we recognise that there would be negative implications of being in a red zone, the idea is that we would all have a shared goal of getting to green. The other thing that we had not clarified is the idea that while these zones would be at county level, once one is in a green zone, one can then move to other green zones. Over time, Ireland as a whole will go from red to green. People who currently face the hardship of being in a red zone will at least see the steps that need to be put in place, which will be made clear, as something to work towards.

As well as green zones being divided county by county, would a city be classed as an entire county? If there is a cluster in Swords in north County Dublin, would that mean that Dundrum and Dún Laoghaire would be shut down too or how would it work?

Professor Patricia Kearney

At present, we are proposing that it would be at county level and that we would not get more granular than that. However, that might be something we would need to consider over time.

Is Dublin a county or is Fingal a county? A third of the population, more or less, lives in greater Dublin. Is County Dublin a county, or is it Fingal, Dún Laoghaire-Rathdown and Dublin city?

Professor Anthony Staines

From my perspective, it is Fingal, Rathdown, Dublin city and south Dublin. That is where we would start. We might well go quickly to north Dublin city and south Dublin city.

Are there any examples of how testing at airports is done well that could be applied here? How would the testing, tracking and tracing regime be put on a more permanent footing? Can Professor Staines give us a view on what that would look like? Would it involve call centres, officers and people going around in cars?

Professor Anthony Staines

If I may, I will answer the first question and pass the second to my colleague, Professor Kearney, who has done work in the tracing centres and is familiar with them. There are different regimes of testing at airports in different countries and I do not know which ones work best. A number of people in Ireland are real testing experts and I would look to them for further guidance on that.

Professor Patricia Kearney

On contact tracing, I ordinarily work full-time as an academic in UCC but I was seconded to the health service early in March to assist with the efforts. Some of my work in that regard was about contact tracing. It was literally a case of speaking to individuals as they tested positive and going through their movements over the previous two weeks to assess who they had been in contact with and who those contacts were.

To be clear, I understand how it has worked so far. Is it the intention that it would continue in that same style and structure or would it be a different style and structure going forward? That was my question. I was probably not clear enough in how I asked it.

Professor Patricia Kearney

I apologise. One of the things that has happened here is we have had to scale up the approach very rapidly and institute a national system. That has been implemented differently or at least it has been implemented locally. As such, we would need to think very carefully about what processes would be put in place to make sure we use all the expertise that exists within the individual departments of public health around the country and build on that expertise. The national system is excellent for the straightforward cases but a lot of the work with the more complex settings such as nursing homes is undertaken by the departments where the expertise exists. We need to build on that existing system.

I thank Professor Kearney and all the other witnesses.

Mr. O'Brien wanted to respond to that question.

Mr. Dan O'Brien

Professor Staines mentioned resources for testing. I will comment on the bang for buck, so to speak, of investing in testing. It seems from the medical experts here and elsewhere that testing and tracing is absolutely vital to defeating this. If that is the case and the cost of that is millions or even tens of millions, that needs to be put in the context of billions of euro for income support, tens of billions of euro in lost output and wealth creation and a public debt that is heading towards a €250 billion by the end of next year. There seems to be consensus among medical experts that testing and tracing is successful and vital. If that is the case, it is a very good investment and everything including the kitchen sink should be thrown at it.

How might this policy play out in ports and airports? I understand that the specifics have not been worked out but to date we have been issued with a green list and from what I can gather, at the moment 7% of people who fly into the country are contacted after that to see if they have isolated and only half of those answer the phone when contacted. Would a big part of this policy involve enhancing the test, trace and isolate capacity in airports? In the week after the green list was published, many of the countries on the list were quickly removed. Is it also important to have a red list and to ensure that people coming in from red list countries are tested, traced and isolated more than those from green list countries? Perhaps those are questions for Professor Kearney.

Professor Patricia Kearney

What we are proposing is that there would be no non-essential foreign travel in the first instance. Over time, the idea is that there would be travel from other zero-Covid countries. As to how this might be implemented, much work needs to be done to ensure that systems are put in place for people who will be arriving here on essential travel. Anecdotally, I understand that contact levels are pretty low but I do not think the appropriate structures or systems have been put in place yet. That would be a very important part of this approach.

Would the establishment of a red list help by allowing greater testing of those arriving on flights from red list countries than those arriving from green list countries?

Professor Patricia Kearney

That is really problematic. As we have seen with the green list, it is a bit of a moveable feast. Consequently, the strategy for us, as we have said, is the idea of zero transmission. As there is a risk of importation of positive cases from other places, what we need to focus on is having the appropriate structures in place to identify anyone who is positive coming in and to ensure there is no forward transmission from that person.

For anyone on the panel who wants to answer, what is the biggest barrier to achieving this zero-Covid island policy?

Professor Anthony Staines

I think Professor Michie has an answer for the Deputy.

Professor Susan Michie

My response will partly address the Deputy's last question and partly address the previous issue she raised. I want to speak to the issue of trust because there is a lot of evidence that trust is really important in getting people to adhere to any policy. Test, trace and isolate requires trust. This is because the trace part of it, the tracing and revealing of contacts, means giving information about contacts. In the UK we have two parallel systems at the moment.

One system is run by a national commercial organisation that has call centres, so people get phone calls from people they do not know. Under the other system, local public health officials contact people. The latter has shown to be much more effective and much of the reason for this is trust. People need to be able to trust where their data are going and that, if they provide information about contacts, that data will be respected and there will not be a punitive policy under which these contacts will be asked to quarantine without the necessary support. Achieving this requires an understanding of the communities. This is where local knowledge comes in. At airports, which do not have that local community feel, some kind of follow-up is important to ensure that people are quarantining. That is, in fact, important in all of this.

This should not be done in a punitive way but in a way that indicates how very important society thinks these measures are and which shows that society is prepared to put resources into follow-up. In countries in which this has been successful, the process has been based on shoe leather - going from door to door and knocking to see whether people are in and if they need any help to carry on isolating. That is the sort of approach that has been successful. This whole area requires a lot of consideration, thought and behavioural advice if one is to get it right.

May I ask a follow-up question on the issue of trust? We initially approached this with a view to flattening the curve. We accepted that it was going to spread through society but we hoped it would do so at a level that would not overwhelm our health service, which is more prone to being overwhelmed than those of other European states. We aimed to avoid scenes such as had been seen in the north of Italy and Madrid. We then moved towards a view that not everyone would get the virus and that we could protect everyone from it. We became more ambitious in our aims. In the view of the panel, does that shifting of the objective undermine trust? We had believed that everybody would come into contact with it. We did not aim for herd immunity but we believed that, sooner or later, everybody in the herd would come into contact with the disease, as they do with influenza or the common cold which, although I am not a scientist, I understand is a coronavirus.

Professor Susan Michie

I can certainly talk about the pattern of what happened in the UK. There were a couple of things that led to a real decrease in trust and an associated drop in adherence. One of these was the very mixed messaging with regard to opening up the economy, which focused on very vague ideas such as staying alert and controlling the virus. People got confused and a bit alienated as a result. In the UK, there were two or three days when people close to the scientists and politicians were mentioning the concept of herd immunity. That resulted in a real outcry because such a small percentage of the population would have had any kind of build-up of antibodies. We already know that it is about 6% which means that 94% do not have such antibodies. We do not know whether antibodies translate into immunity and, if they do, how much immunity and for how long. This is really not a viable strategy without tens of thousands of unnecessary deaths. This is why Independent SAGE, the Scottish Government and others are considering a zero-Covid strategy. I have heard the British Medical Association is also going to endorse it. In the UK, the lack of a strategy and the chopping and changing of advice to people is one of the reasons trust continues to be very low. Having an overarching strategy and measures therein which the population understand will engender trust. The population can be brought along with that, with clear leadership. In the absence of a strategy, we have confusion and the conspiracy theories which were alluded to at the beginning of the session.

I need to go shortly, but, from the perspective of Independent SAGE UK, I really commend this strategy to the committee, even though I understand that a lot of the details and nuts and bolts need to be worked out to implement it.

I thank the witnesses. I will direct the following question to Professors Kearney and Staines. We had representatives from the aviation sector in here two weeks ago to discuss the effect of Covid on the entire sector. Our two airlines are both haemorrhaging money and the one that used to be the national airline is in severe difficulty. The aviation sector represents approximately 9% of the economy. Would the witnesses be prepared to modify their plan to allow for random testing of airline passengers coming into the country? If a flight has 200 passengers, we could pick out ten or 20 to be tested and try to see what is the rate of infection in those, regardless of whether they are coming from green zones.

Professor Anthony Staines

I understand the point the Deputy makes and I thank him for the question. The problem with modern airline traffic is that one might have people on an aeroplane who are coming from 40 different places. They may all have got on an aeroplane in Birmingham but they could have come to Birmingham from literally the four corners of the world. There is a real challenge with bringing airline traffic up to its previous levels. Airline freight is a different story. Air crews are a manageable number but I do not see that there will be a return to the scale of passenger air traffic that we have been accustomed to for some time to come. Mr. O'Brien might have a better idea about that than I would.

It is possible to do random testing. The problem with it is that the test itself is about 70% reliable. Once one tests a sample of passengers on an aeroplane, for example, with an unreliable test, the reliability goes down another few notches in terms of answering the question of whether there is someone on the aeroplane who can transmit Covid. There is enormous work being done on Covid testing, which I only dimly understand, so I would expect that the quality of testing will go up and the price and speed of testing will go down. At the moment, with the tests we are currently using, I think most of us in public health would advocate testing everyone on the aeroplane. I appreciate the challenges that throws up for the industry.

I thank Professor Staines. He probably saw this morning that China has imposed an embargo on certain Brazilian products coming because Covid was found on frozen Brazilian chicken. Is the importation of frozen products something that we should be looking as well? Is there any chance of contamination of people in the sector who are handling it or the logistics people who are distributing it?

Professor Anthony Staines

I would have to defer that to someone who is an expert on the virus. It is possible to detect the virus long after it is dead. One can find a positive test for a virus with no living virus, and the place one is most likely to find that is somewhere cold. I really would have to ask somebody who is an expert in the areas of viral spread and viral survival what their thoughts are. I would not have thought it is a major contributor to our risks. It was suggested in the New Zealand outbreak of two days ago but the direction of the investigation there has now gone towards someone who broke the quarantine regulations and may have triggered the outbreak in Auckland by doing that.

I thank Professor Staines. I will ask Mr. O'Brien a question. He highlighted a pretty grim economic picture. Assuming that we continue on the path we are on - and that most European countries will probably do likewise - whereby we are trying to mitigate the disease, trace and put temporary lockdowns in place, what does he think is the path to the ECB unwinding support to European countries and in what timeframe? Where would Ireland be in the pecking order in terms of that support being removed?

Professor Anthony Staines

I suggest I take the first part of the question and pass the second part to Mr. O'Brien. The economic damage is driven by the virus and it is instructive to compare Sweden with Denmark. Both have had significant economic damage but Sweden has had more than Denmark. Sweden had no lockdown and very high death rates. Denmark had a lockdown, with much lower death rates. Studies within the United States and South Korea both suggest the same idea, that the regional economic damage was not driven by government and state response to infection but was driven very directly by the rate of infection itself. That needs to be the focus. As Professor Michie said, it is not the case that health and wealth are in opposition but instead they are really pushing in the same direction. Mr. O'Brien would know vastly more about this than I do.

Mr. Dan O'Brien

There is extreme uncertainty about the relationship between the measures that were taken and the economic impact. There is still much uncertainty around that.

In the general terms of the conversation, it is not clear to me there is quite the sense of how serious this is from an economic perspective. Recessions are extremely bad for countries. We know that in this country and we had a very bad one between 2008 and 2012. Recessions cause social, political, economic and health damage. This one also risks intergenerational conflict, as we should be absolutely clear that younger people are at a very low risk of death from this disease. It risks bringing out intergenerational conflict if younger people, who are always most severely damaged by recessions, end up in long-term mass unemployment because of what is happening.

There was a specific question about the European Central Bank. The existing pandemic purchase programme, which is effectively money printing for governments, is due to last into the spring of next year. It is very unlikely anything will happen to disrupt that so governments should be free to borrow and spend until that point. Thereafter, some divisions among member states may emerge in terms of the risk associated with money printing. We should be clear that if money printing was a way of making everybody rich, poverty would have disappeared 500 years ago with the invention of printing presses. It is an emergency measure that will not go on forever. We certainly would not want to bank on it for a long time past next spring. Unfortunately, Ireland is not in a fantastic position, given that we go into this with quite a high level of public debt already. There is big uncertainty around how long that central banking support will last.

I thank the witnesses for their presentation. I am from Offaly, one of the lockdown counties, and I represent Laois and Offaly. I completely disagree with the decision, and it was completely over the top to lock down three entire counties when there were clusters. We have all been told we must live with the virus but common sense must kick in very fast.

I want to take up a point raised about economic damage being done by the virus. It is not all done by the virus and in some cases it is done by very poor decision-making. In this case, economic damage is being done in my county of Offaly and Laois as well because of the very poor decision-making and the knee-jerk reaction to clusters in meat factories, which should have been handled much better. I said this earlier to representatives of organisations who attended the committee today.

This lockdown was presented to us in Laois, Offaly and Kildare as being done in the name of health. Many business people are very stressed at this time, and we all know stress affects health and causes different health problems. I would like the witnesses to take more consideration of that. Was the possibility of targeted lockdown in the specific areas affected by clusters not considered?

It has come to my attention that Tullamore and Portlaoise hospitals have remained clear of cases since the large-scale regional lockdown was announced.

I again say that it was unnecessary and I call for it to be reversed before more harm is done. I mean social and economic harm in that regard. What is happening here is totally unfair. Dr. Ronan Glynn stated earlier in the week that areas like Birr, Ferbane, Clara, Tullamore, Edenderry had cases of Covid but he did not specify the number. On one day this week, the number of cases for Laois and Offaly were not released. If there had been more than ten cases, we would know about it.

I want to know what is going on. People are becoming very frustrated. We need to exercise common sense. Was an impact study carried out before the decision was taken to lock down three counties? It was absurd nonsense and over the top. I have spoken to businesspeople who are very hurt by this. There was no consultation with any businessperson. There is much talk about us being in this together. We are not in this together. No consultation was held with businesspeople in my county. The Bridge House Hotel has 230 staff facing great uncertainty. It is unacceptable and we need to get our act together, but we need to do it in a way that protects public health and exercises common sense and consideration for people. I have consistently called for financial packages to be made available because people were wrongly punished by this decision. I hope financial packages will be made available.

Professor Staines mentioned the situation in nursing homes. I agree that not enough was done and I have raised that matter previously. What was done was reactionary. We need to be proactive in respect of nursing homes. Is Professor Staines confident that enough is being done now? What planning is being done? What policies are in place to ensure we can prevent deaths among the most vulnerable in our nursing homes?

Common sense needs to be exercised in the context of all decision-making. We have handfuls of cases rather than what is being incorrectly reported. It has done untold damage to three entire counties which was totally unnecessary.

Does anybody wish to comment on that? I assume Professor Kearney and Professor Staines agree with the approach adopted by New Zealand and the lockdown in Auckland in response to the cases there. Do they also agree with the approach of the lockdown in Kildare, Laois and Offaly?

Professor Patricia Kearney

I hear Deputy Nolan's frustration and understand the severely negative impacts of the lockdowns. Part of the Covid-zero approach and our call for a very clear elimination strategy is based on our clear will to try to avoid lockdowns. I absolutely agree that we need to be very proactive here. With making a decision to just live with the virus, as seems to be the case at present, the problem is that we are then exposing ourselves to these events where we will see these increases in cases and will take a reactionary approach to those. We are saying that we need to consider the implications this Covid-zero strategy.

As has been discussed, we need to build the trust with the population and think about the hard decisions that will need to be made and implemented. By implementing those and working together we can get to a point of these green zones where we can start to live normal lives. I absolutely agree that it makes no sense to think of health and wealth as being in opposition. We know that the economy is just a reflection of society and health. All those things go together.

Professor Kearney said that these types of lockdowns are an inevitable consequence of the strategies the Government has followed, but she also advocates a strategy similar to that in New Zealand, where there is a lockdown in place in Auckland in response to four cases.

Professor Patricia Kearney

To be clear, we are advocating an elimination strategy as was adopted in New Zealand. The outbreak of cases that occurred was due to problems with implementation of the strategy.

They have certainly introduced a lockdown very quickly and they had a very agile response. The likelihood is they are doing an outbreak investigation and in Auckland they will be able to return to normality as soon as possible. The rest of New Zealand has largely been able to continue with the normal lives they had been able to attain. To me, it is a very different lockdown than is happening here at present.

I thought the outbreak in Kildare, Laois and Offaly was equally a result of a failure to eliminate the virus. What is the difference?

Professor Patricia Kearney

The difference is that Ireland has said that it is going to live with this virus and continue to live with it until, hopefully, a vaccine is developed sometime next year. What we are saying is that we want to eliminate the virus. That is what is being done in New Zealand. As a result, there were 104 days when people in New Zealand were essentially able to return to normal, society was functioning and businesses were functioning. The difference in Ireland is that we have this lockdown in three counties, it is unclear how long that lockdown will last and it is unclear what the target is in terms of making the decisions. It was interesting that Deputy Nolan spoke to how the decision was made to implement the lockdown. With any of these lockdowns, the hard decision is implementing them but an even harder decision is when to lift those restrictions. What we are trying to convey with this elimination strategy is coming up with very clear targets about what we are trying to aim for and thinking about how we will respond in an agile way if some cases do emerge.

I thank each of the expert witnesses. It is great to have them here and to have their insights. I will start with a question for Professors Kearney and Staines. In presenting this zero-Covid strategy the witnesses have said it is backed by science, experience and extensive analysis. With regard to experience, are there examples of where this has been done? Is New Zealand an example or are there other places where it has been done successfully? In practical terms, what would be the implications for people in Ireland if we were to pursue this strategy? One of the aspects that received a lot of coverage was the nature of life in New Zealand, for example, where there are large gatherings of people. Would that be the case in Ireland if we pursued this successfully? For example, would pubs be allowed to reopen? Would we have large music events and that type of thing? How would life of on a practical basis be different for people in Ireland if we pursued this strategy successfully?

Professor Anthony Staines

If we succeed, life would return to normal except that if one travelled abroad and came back one would almost certainly have to be tested and isolate for a period of time. How long that would be would depend on the final decisions around how, when and how often a person gets tested. That would be the main thing that members of the public would notice. Pubs and restaurants would open, Croke Park would open, the GAA would come back, we could hold weddings and I could have my birthday party. All of this would come back to normal. That is the plan and that is the desire. Businesses would be able to function as normal. Businesses would not have the awful uncertainty of wondering if they would be locked down next week or the week after next. All of that would be gone away. Life would be substantially returned to normal but foreign travel would still not be normal for at least some significant period of time and probably until there is a vaccine. I suspect that will be the middle of next year or even towards the end of next year.

A point was raised by Mr. O'Brien earlier in argument to the approach. It is the argument we hear regularly in opposition to this approach, including from the former Taoiseach and now Tánaiste and Minister for Business, Enterprise and Innovation, Deputy Varadkar, which is that Ireland is not like New Zealand.

We are much closer physically, geographically and economically to our nearest neighbours, Europe and the United States. Our economy is a very different one from New Zealand's. How would the witnesses address the interconnected nature of Irish society and our economy compared with other places? Where does a zero-Covid policy end? Is it like everything else and must go on until a vaccine is found? I ask Professors Kearney and Staines to discuss the interconnected nature of the Irish economy.

Professor Anthony Staines

New Zealand's economy is quite different from ours. It is largely a primary producing country with a lot of agriculture. The Deputy is correct that it has some advantages, as Professor Heneghan has also pointed out. However, other countries, such as Vietnam, which has a long land border with China, have successfully brought Covid down to zero. Most parts of Australia have brought Covid down to zero. There is Covid in Victoria and New South Wales but it is pretty much at zero everywhere else in Australia. South Korea has largely brought Covid down to zero, though it has had a number of outbreaks which it has dealt with. China, which may not be a good example as it is a very different society, has brought Covid down to zero. It has had two large outbreaks, one in Beijing and one in a town whose name I cannot pronounce near the Russian border. This can be done. Our society is closely connected with Europe but that does not have to mean closely connected physically. The technologies for interaction at a distance have greatly improved over the past year. We are all becoming used to working-----

I thank Professor Staines. I will move on to my next question. I take it from Professor Heneghan's contributions that he has a different opinion on the zero-Covid approach. Given that he works in the Centre for Evidence-Based Medicine and has done a lot of work on evidence synthesis, does he advocate an alternative approach and what would that approach be?

Professor Carl Heneghan

Often, people try to make points and look for evidence. For instance, the committee just heard about Vietnam. It is a classic fallacy. The median age in Vietnam is 30.5 years. The temperature and humidity are radically different from here. We do not even know whether people in Vietnam have pre-existing infections, cross-reactively, from SARS-CoV-1, of which it had outbreaks. With these issues, people say "here is the evidence and because they did that, we are going to do this". I find that very difficult to understand from an evidence-based perspective.

Second, we have heard much about pubs. Pubs are interesting. People talk emotively about what we should do and say we should close the pubs. Ireland has 7,200 pubs while the UK has 47,600. In the UK, we have had fewer than ten outbreaks. Every pub is an outlier and it is an opportunity to study what is going on. When people break the rules there might be quarantine for two weeks. If they break the rules they should have to stop. However, we should have an evidence-based approach for some of them and sample what is going on. There has been a knee-jerk reaction of closing all pubs.

I reiterate that to go for a zero-Covid strategy, we need an effective vaccine in place now. Otherwise, we would need to follow the New Zealand approach to the letter of the law, which means locking down, having 14 days' quarantine, driving it out and not letting any people in. There are no fudge factors. The alternative is to look to countries like Sweden and Denmark, which are taking a much more sensible approach right now. Denmark is not mandating masks but is doing randomised controlled trials of masks, which are due to be published soon. Following this approach results in a very intelligent mitigation strategy.

I would look to the evidence of where we think significant transmission will happen before we have a vaccine. There is some preliminary evidence about that. I cannot go in to all of it now but I refer to things like mass events beyond the 1,500 people allowed, particularly indoors. We look for the areas where we can make a difference versus the knee-jerk reaction, which is what we have seen in the UK. A very good example of that would be, for instance, the recent lockdown in Leicester. I believe one of the Deputy's colleagues alluded to that. To be clear about what is happening, at the height of the pandemic, Leicester, which has a population of approximately 340,000, had 45 admissions. Since the city locked down in July, there have been seven admissions. While the number of detected cases was going up, and we must remember that is not the same as cases, the city had seven admissions in the whole of July, and we are working on this. What is happening with the disease, therefore, is not the same as what is happening when we detect cases. That strategy is to have a test and trace system and manage the cases.

When we think about lockdown, it is important that we think about the impact of Covid-19 on morbidity and mortality and not its impact on cases. At the moment, the number of detected cases is going up. That is not the same as cases but in terms of the impact of the disease, admissions, critical care units and deaths are at a historic low level. I would watch that information to drive the policy of the Deputy's country as opposed to detected cases, which are increasing.

I will tell the Deputy the reason the number of detected cases is going up, and this is my last point. The UK is picking up about 100 cases per 1,000 people. On a daily basis, therefore, we are getting about 1,000 people a day but the Office for National Statistics, ONS, survey data tell us that in terms of the background rates in the UK, between 2,000 and 8,000 people actually have the disease right now. Wherever more testing is done, one will pick out what is in the background. What one should not do is use that to get stressed and anxious and come up with a knee-jerk policy. It should be done to reflect on what is working and what is not working.

I thank Professor Heneghan for that response. I have a final question for Professor Kearney. There is a lot of agreement on the need for testing capacity to be improved and to have rapid and flexible testing. We currently have unused testing capacity. I am inclined to think that is an inappropriate position to be in but does Professor Kearney have a sense of the type of testing capacity that would be required and how frequently specific cohorts would require to be tested and retested?

Professor Patricia Kearney

One of the things it is important to consider when we are talking about testing capacity is the type of capacity because there are many different steps in the process of testing. We saw testing being rolled out in Croke Park, for example, in terms of actually taking the swabs but then it is a question of getting those swabs to the laboratories, the laboratories analysing them, the process of getting the results and acting appropriately on those. The important point for me, when we are thinking about ensuring that our testing capacity is appropriate, is making sure that we are paying attention across all of that.

That is not the case with the cases in a crèche in County Meath. I know people involved who had to wait more than a week to have the test and contract tracing done and to get results back. That is completely unsatisfactory in a relatively quiet time in terms of demand on the system. It is something we can all agree we need to improve. I thank the witnesses for their responses and contributions.

The last speaker before I put a couple of questions is Deputy Durkan.

It is appropriate that the last speaker should come from one of the affected counties. Where do we go from here? I am not being funny but I am reminded of the gentleman walking on a lonely country road in a town in the province of Munster who asked for directions to the next nearest town only to be told, "If I were going there, I wouldn't start from here". The problem is that the individualisation of the close-downs in particular counties is not as effective as they could or should be. They generate anger and distrust and identify a blame path. That is what is happening, and it is generating anger.

Anger has never solved a problem. We must consider more carefully the points raised by Professor Heneghan. For instance, he suggested that pubs could be opened. If they cannot comply, so be it, but those that can and are willing to open should be allowed to in opposition to the holding of house parties, an issue that is not controlled and has posed issues previously.

Where do we go from here? Do we continue with hand sanitisation, distancing, masks and all of the other things we are supposed to do or do we intensify those measures? Where would that leave Kildare, Laois and Offaly in two weeks' time, for example? The Chairman knows the extent of the concern and anger among the business community. We recognise the need for business to survive as well as people's health to be maintained. Will the experts give us some indication of where we need to go from this point? Should we intensify our methodology, which has been successful nationally, or should we continue isolating pockets as they arise, which would be against my own advice and would create further dissension and debate of a divisive nature within our society?

I wish to bring in Mr. O'Brien and then the experts. Mr. O'Brien wished to contribute in response to Deputy O'Rourke's questions.

Mr. Dan O'Brien

Regarding New Zealand, the International Monetary Fund, IMF, believes that New Zealand's economy will contract by more than Ireland's in 2020. That may prove to be incorrect, but it is the IMF's current forecast. Therefore, the painting of New Zealand as returning to complete normality may not be correct. For example, indicators right up to July pointed to further declines in consumer confidence in New Zealand. Although New Zealand's approach may turn out to be correct, we cannot be certain in any way that that will be the case. My hunch is that it will not.

On the Deputy's specific comments and questions, my hunch is that we need to follow a risk-based approach. People need to be advised by medics on how risky something is for them. Any of the medics present can correct me if I am wrong, but the risk of younger people of dying from this virus is tiny. In Ireland, not a single child or baby has died. No one under 15 years of age has died. I checked this with the CSO on Monday - eight people under 65 years of age and with no health issues have died. The majority of the population is under 65 years of age and has no health issues. We need to assess individually how great a risk we face from this virus and adapt our personal behaviours on the basis of that risk.

If we look back over the past 100 years, what had the greatest impact on human welfare holistically? Was it the Spanish flu, from which tens of millions of people died, or was it the Great Depression, which led to social and political upheaval and eventually war? I can say, as an economist, that we are on track for a Great Depression-type event. I have no idea how things will turn out, but we know what happened in the 20th century. Look at the history books. What event had a greater impact on human welfare, the Spanish flu or, ten years later, the Great Depression?

I thank Mr. O'Brien. Professor Heneghan is still on the line. I thank him for staying with us, notwithstanding the technical difficulties. Does he wish to comment on the last contributions?

Professor Carl Heneghan

It was a clear and fair point. It is important that everyone understand what the risks are by age and certain conditions. Unlike the flu, there is a stark difference in the risk for young people. For example, the risk for under 50s in England is minimal. It is slightly higher for over 50s because there seem to be some issues about ethnicity, but there are also higher rates of diabetes, cardiovascular disease and, in particular, obesity. That is one strategy which should be pursued.

The main threat now of Covid is the emerging threat of focusing unified on this single problem of Covid. There are many people who do not have experience in healthcare who have overnight become experts in respiratory pathogens in this outbreak. It has been astounding where they have all come from. They tend not to use an evidence-based approach but cherry-pick evidence to suit the argument. In the UK right now, we are looking at 200 excess non-Covid deaths. The current messaging means that 50% of people with a worsening health condition are not coming forward for healthcare and presenting as an emergency and that is leading to substantial problems with strokes and cardiovascular disease. For the past seven weeks in a row, we have had approaching 700 excess deaths in private homes that are not related to Covid whereas we have drastically reduced the excess deaths in care homes and hospitals. Overall, we are tending under, but we have got this huge burgeon now appearing that the public does not get where its risk is. If one examines the risk and looks at one's strategy and one takes an evidence-based approach to when one does things and what the evidence allows one to understand, one might get a more measured approach going forward.

I appreciate Professor Heneghan has to leave us in five minutes but I will go to Professors Kearney and Staines. I wish to ask a question at the very end. Do Professors Kearney and Staines wish to comment?

Professor Patricia Kearney

We started with the question: where do we go from here? We need a clear strategy now. I agree that it needs to be evidence based. I agree that we need to engage and debate this in public and come up with something that the Irish people trust, and that we can work together. I hear absolutely that there is a risk that people become angry and frustrated and that is not helpful. I agree that it is really important that our health service and our economy continue to function and they cannot only be about Covid. The reality is that if we move towards an elimination strategy, that will allow us, for example, to get back on board with matters such as our screening services.

I started today by talking about Covid being a serious and scary disease. I chose those words very carefully because part of the problem and the challenge we face with Covid is that scariness of it and the other impacts that it is having in what we have just heard from Professor Heneghan in terms of people not engaging with our health services. That is why it is important that we have clarity and leadership about how we approach this. That is, I suppose, back to the point of elimination.

Does Professor Staines want to add to that?

Professor Anthony Staines

Briefly, in terms of outcomes, there is increasing and increasingly-worrying evidence that this is not a benign disease in young people. It is absolutely true they seldom die, but death is not the only adverse outcome from an infection. We do not yet know, because this virus was really only identified in January of this year, how common these long-term effects are. We do not know how severe they are. We know from many other conditions - if this is the case for Covid the same will hold true - that the long-term effects of illness cost far more than the short-term effects. Somebody dying is a tragedy, but it is a cheap tragedy. It is a low-cost tragedy. Quite a number of people are left relatively disabled for a long period of time. We do not yet know how many. We do not yet have reliable figures.

Quite a number of people are left relatively disabled for a long periods of time after this illness and the cost of those people is enormously higher than the cost of either acute healthcare or the mortality which, as Professor Heneghan and Mr. O'Brien correctly observe, is heavily concentrated in the oldest segment in the population.

I thank Professor Staines. There is only one issue remaining. As we evolved through this, I remember sitting on the committee and hearing from a few members of National Public Health Emergency Team, NPHET. NPHET is our equivalent of the Scientific Advisory Group for Emergencies, SAGE. It was asked about face masks and the committee was told there was no evidence that face masks were beneficial.

At that time, the World Health Organization, WHO, had not recommended wearing face masks. Now there seems to be near universal acceptance that face masks are an essential component in the fight against Covid-19 in Ireland. They have been made compulsory in all indoor retail outlets.

The WHO has still not changed its guidance, which is to recommend the use of face masks by medics and in enclosed settings where 2 m cannot be achieved, but it does not recommend the use of face masks among the general population.

I will do a quick tour de table, starting with Professor Heneghan because I know he has to leave. Does he think the case for face masks has been proved and that there are benefits to the general population in wearing them?

Professor Carl Heneghan

Again, this is about the evidence. In 2010, at the height of the last pandemic, there were six published trials of about 4,000 people. Since then, we have not addressed the lack of evidence and closed that graph. In the intervening ten years, there have been about another six trials. If one looks at the 12 trials together, what they show in healthcare professionals is that masks, gloves and a combination of PPE reduces the risk of infection.

When one goes into the wider population, there is a small bit of evidence that shows that if one has influenza in one’s household - a child, for example - and if one wears a mask for one week in the house, one can reduce one’s risk of influenza or likely illness by about 10%. However, one has to completely adhere to mask wearing for the whole week. If one stops adhering to it, as 50% of people did, one loses all the effect. That is one of the problems.

The second issue is that the evidence comparing cloth masks to surgical masks or the N95s shows clearly that cloth masks are worse and may actually increase the risk of infection. Therefore, that is why they are not recommended in hospitals or in health professional settings.

What happens in these situations of uncertainty is that the opinion divides. Someone thinks mask are a good idea while someone else does not think they are and that people should not wear them. That is why we end up with people proposing them more and more. They say people should put them on in schools, pubs and shops. However, there is no clear evidence. They use observational data to inform their decision. If one looks at what has happened in the UK, for instance, it put masks in on 24 July. They were supposed to reduce the risk of infection by 40% over the next two weeks. In fact, infections detected have gone up. In effect, people are not looking at the evidence.

When Norway looked at this, it said that at low circulation, the public health consequences were so minimal that it was not clear they worked and, even if they did work, it reckoned about 200,000 people would have to wear a mask fully for a week to prevent one infection. That is how one has to think about the uncertainty. If one is going to put a policy in place, that is fine. What one cannot do, however, is say it is evidence-based because when people talk about the evidence, they have again cherry-picked low-quality, observational evidence to suit the argument. However, they have not picked further observational evidence. For instance, if one puts masks in, what is one expecting to happen to the case definitions and the reductions in the next two to four weeks to show it was a worthwhile policy to enact?

Professor Anthony Staines

One of Professor Heneghan’s colleagues, Professor Trisha Greenhalgh, has conducted a systematic review of the evidence for masks. Unlike Professor Heneghan, I make my living analysing and interpreting observational data. I am extremely familiar with what one can and cannot usefully do with it in public health. I am moderately convinced by the evidence.

The evidence that masks protect a person from infection, particularly this type of mask or the cloth masks some members are wearing, is very low but the evidence that they reduce spread from an infected person is much better.

In terms of evidence, as far as I know there are no clinical trials, although I am aware there is one in Denmark - Professor Heneghan mentioned it - that is proceeding. We may have more evidence later in the year. Anyway, it is noteworthy that in many of the countries where this virus has been most effectively controlled people wear masks for other reasons. The view in most of the public health community - the evidence as reviewed by Professor Heneghan's colleague supports the view - is that this is a worthwhile effort. It has a modest effect on the risk of a person spreading the virus to other people. That is desirable. Again, it is part of a spectrum of imperfect measures. It is by putting many imperfect measures together that we achieve positive results. That is my 2 cent.

Professor Patricia Kearney

I do not really have anything to add to that other than to say that "evidence" is one of those words that we throw around. Anyone can be selective in the evidence they choose to use. The reality is that this is a new disease. It has been with us for a fairly short period. We are learning all the time. We need to be able to adapt and change our responses as the evidence emerges.

To a certain extent, some of the suppression strategies were based on our knowledge of flu pandemics and the planning for them. As the evidence emerges, it is clear that we need to move more now towards elimination. I was a mask-sceptic at the outset of this based on the evidence that I was familiar with. However, like Professor Staines, I have looked at where they have been used at a population level. I have been convinced that it is part of the suites of things we need to do to address the virus.

Professor Heneghan wishes to come back in briefly.

Professor Carl Heneghan

I would like to correct the record. There was some inference that I do not have experience or expertise in observational evidence. I am a worldwide expert in the area. I have previously done systematic reviews for The Independent Medicines and Medical Devices Safety Review and people can look it up. I would not like it known on the record that somehow there was a deficiency in my understanding or experience.

Do you accept, Professor Heneghan, that there is no evidence that it protects the wearer but that is stops the wearer spreading it, if the wearer has Covid-19? The point is it diminishes the risk of the wearer spreading the disease to others.

Professor Carl Heneghan

Within our World Health Organization advisory role we are specifically looking at transmission dynamics, including aerosol, fomite, oral-faecal and vector transmission. The Chairman is talking about laboratory-based evidence to show that if a person puts a mask on perfectly and wears it, then it reduces the aerosol spread in a laboratory situation. Is there any real-world evidence of that? No, there is not. People should look at the evidence in a critical way. If we consider the way people wear masks and the type of masks they wear - there is emerging evidence that some are better than others - there is no real-world evidence, but there is laboratory-based evidence.

Thank you very much for taking the time to be with us and for staying with us notwithstanding the technological difficulties. I also thank Mr. O'Brien and Professor Staines for coming in and Professor Kearney for travelling from Cork to be with us.

With that, I will draw the session to a close. I wish to inform members before we formally adjourn that we will meet the Minister not next week but the week after. I think it suits some members of the committee and it also suits the Minister. We do not have a definite date yet but the secretariat will be in touch. My thanks to the secretariat for organising today and especially to our witnesses for taking the time to be with us and for staying with us for such a protracted period to answer our questions.

The committee adjourned at 5.55 p.m. sine die.