State Response to Recent Spike in Covid-19 Cases

I welcome to our meeting the witnesses from the HSE, joining us by video link from committee room 2, to examine the State's response to the recent spike in coronavirus detected cases. Mr. Paul Reid, chief executive officer, Ms Anne O’Connor, chief operations officer, Dr. Colm Henry, chief clinical officer, and Ms Niamh O'Beirne, lead for testing and tracing, are very welcome to our meeting this morning.

Before we commence the formal proceedings, I advise the witnesses that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to this committee. If they are directed by the committee to cease giving evidence in relation to a particular matter, they must respect that direction. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable.

I invite Mr. Reid to make his opening statement and ask that he please confine himself to five minutes to allow time for questions and answers.

Mr. Paul Reid

I thank the Chairman and members for the invitation to appear before the committee. I am joined by my colleagues from the HSE, Dr. Colm Henry, chief clinical officer, Ms Anne O'Connor, chief operations officer, and Ms Niamh O'Beirne, lead on testing and tracing.

Over the past few recent months, we have been focused on restoring various aspects of our health services that had to be suspended in the early phases of Covid-19. We have also been finalising plans to protect our patients, the public and our staff this coming winter and throughout 2021. As we have recently seen, we need continuously to assess these plans as we experience increased numbers of cases of the virus, major outbreaks and a requirement for significant serial testing, along with increased demands on testing and tracing. In the past 14 days, there have been 1,269 confirmed cases. For context, the equivalent number for the same two weeks in July was 264.

In respect of testing and contact tracing, the committee has requested specific engagement on the State's response to the recent spike in Covid-19 cases. In the past two weeks, we have triggered our resourcing escalation plan for testing and tracing. Serial testing is ongoing in meat and food processing plants and we have reintroduced serial testing programmes in nursing homes and long-term care settings for older people.

I wish to inform the committee of the current circumstances regarding testing and tracing. To date, we have completed more than 750,000 tests. Last week, we recorded our highest weekly number of tests since April, at 55,000, and we are recording similarly high numbers again this week. The previous weekly peak was in April, when we tested 60,000. The median end-to-end turnaround time over the past seven days is 2.2 days. Last week, we completed 4,949 contact tracing calls. These statistics give the committee a sense of the numbers we are contending with and the pace at which we are moving. Setting up these teams is complex and must be understood in the context of our need to make the best use of resources during peaks and troughs of the virus. It is important to re-emphasise that testing and tracing is a key tool to protect against transmission of the virus. However, the primary line of defence is the public health measures we must all take all the time.

We are finalising a new model of testing and tracing to set out a more permanent workforce and implement further processes and technology changes. In respect of outbreaks, testing and tracing works hand in glove with the work of our public health teams. Throughout this pandemic, our public health teams have adopted a rapid, robust and comprehensive response to prevent, identify and control outbreaks where they occur, utilising the best public health knowledge and science available. I pay special tribute to all our public health teams who have been working relentlessly for the past seven months.

The national standing oversight committee on cases and outbreaks of Covid-19 in high-risk settings was established by the HSE on 7 August and includes a broad range of cross-sectoral representation. Criteria for the assessment of meat plant outbreaks, to inform decisions regarding their closure and reopening, have been developed. This utilises a standard public health risk assessment model, emphasising that blanket measures may not be helpful. We have also worked with the Department of Education and Skills on similar criteria for responding to outbreaks in schools, which will be a key focus in the coming weeks and months. While institutional and workplace settings are receiving much attention, our public health departments are also responding to a large number of outbreaks in private households and among family, sporting and social groups. By 22 August, our public health teams had responded to a total of 2,580 outbreaks since the onset of the pandemic.

As for hospitalisations, while there has been an increase in the transmission of the virus, the indications are that our hospitals have not as yet been confronted with a similar increase in admissions. There are currently 23 patients admitted to hospital with Covid-19 and four in ICU, with three currently being ventilated. The lower rate of admission may be attributable to the lower age profile of patients that has characterised the resurgence of the disease in recent months. There is, however, no room for complacency and we have plans in place to deal with a surge in hospitalisations.

We are facing into a very difficult period in our health services. In an ideal world, the elimination of the virus would make our work somewhat more straightforward, but this is not our reality. We must live with this virus in a very new way and this requires a carefully balanced approach. The health services need a functioning economy and society. Shutting down the economy and society has implications for our health services.

Finally, I again pay special thanks to everyone working in healthcare. We have witnessed much of what is great about the people who work in it. We all now need to support them again.

I thank Mr. Reid, in particular for being so timely.

Generally, members are speaking for five minutes so I will indicate when they have reached four minutes and stop them at five because time is of the essence. The first speaker is Deputy Carroll MacNeill who has five minutes.

I thank the Chairman and thank Mr. Reid for coming in and for all of the work he is doing. I have a couple of quick questions on his statement. He talked about the median end-to-end turnaround time being 2.2 days. Does the complete turnaround time refer to all contacts contacted or contacted and tested? What does it mean exactly?

Mr. Paul Reid

The median end-to-end refers to completion of test, notification of test results and the contact of all contacts. It does not include the contacts' testing. Their testing is then scheduled. They are offered a test immediately; we encourage them all to come forward straight away for their test. So it is end-to-end to the contacts being contacted.

At an earlier point in this committee's work I recall reading that it must be done within 72 hours and I know that it was much longer when the HSE started so I want to congratulate Mr. Reid on getting to that point. Of course, there are outliers on both sides but it is important to acknowledge how far the work has come.

I wish to talk now about education, people going back to school this week and next week, and the HSE's engagement with the Department of Education and Skills. What is going to happen if and when there is an outbreak in a school with a child or a teacher? I ask Mr. Reid to talk me through what is going to happen. The Minister said last night that it would become a public health matter. What happens in such circumstances?

Mr. Paul Reid

I thank the Deputy for her comments. It has been a significant challenge to ramp up our resources to get to where we are. We want to continuously improve on testing and tracing and I want to reassure members of that-----

Mr. Paul Reid

On the specific question, we have had significant engagement with the Department at senior, ministerial and official levels. Our public health teams have been working collaboratively with departmental officials for the last while. Specifically in terms of what happens when cases emerge and outbreaks occur, I will pass over to my colleague Dr. Henry, who leads our public health teams, in just a moment but will make a couple of comments-----

Please, I only have five minutes-----

Mr. Paul Reid

Okay, I will just pass over to Dr. Colm Henry who will bring the Deputy through the steps when a case or an outbreak emerges.

Dr. Colm Henry

The emerging evidence is that child to child transmission in school settings is relatively uncommon. We are gaining more evidence on the behaviour of this virus in educational settings as schools open up in other countries. That said, it is inevitable that there will be suspect cases, cases and there may even be outbreaks. That is the price we must pay in order to open schools again, with all of the educational, health and welfare benefits this brings to children. Public health departments will apply the same principles as they do to outbreaks in other settings and will take a risk assessment approach. In any outbreak setting, they will look at the individual characteristics of the school, the rates of community transmission, the number of cases in the school and the number of serious illnesses that might emerge - which would be very uncommon and unusual in children - as well as hospitalised cases and ICU admissions. They will also look at the interplay with the community, the infrastructure of the school and the capability of the school to adhere to infection prevention and control measures. In some schools, for example, special needs areas may require more intimate connection between people, with unavoidable breaches of social distancing guidelines. It is not a tick-box exercise but an individual assessment based on a set of principles by public health consultants who have the expertise and experience to-----

I have some specific questions on what Dr. Henry has just said. Child to child transmission is very low, as Dr. Henry has said, but people are concerned about child to adult transmission and children bringing the virus back into the home or out into the community. I ask Dr. Henry to talk to us about that.

Dr. Colm Henry

Child to child transmission in educational settings according to the evidence is relatively low. In household settings, emerging evidence suggests that the likelihood of children being the source of primary infection appears to be lower than for adults.

When Dr. Henry speaks about the community transmission rate, is he referring to the rate on a localised basis, on a county by county basis or is it broader than that?

Dr. Colm Henry

I am talking generically here. In terms of the primary source of transmission, it appears that in educational and household settings children, particularly preschool and primary school children, carry a lower risk than adults.

On the timing, clearly the HSE has been working with sporting groups and in other settings where outbreaks have occurred. If this happens in a school in the next number of weeks, how quickly will the HSE be able to engage and respond? What is the nature of that response and how ready is the HSE? Obviously there are lots more schools with the potential for outbreaks relative to sporting situations and so on.

Dr. Colm Henry

The challenge we have is differentiating what may be Covid, which is unusual in children and presents in a different way, from non-Covid illnesses, which are much more common in children in education settings and involve upper respiratory symptoms, cough and other respiratory symptoms. We have developed an algorithm working with experts in paediatrics, general practice, primary care and public health. This algorithm and the pathway were discussed with almost 2,000 GPs in a webinar two nights ago. It describes the series of actions that will be taken once a suspect case emerges in a school. As was highlighted by my colleague, Dr. Mary Favier, the other night, it balances the need for continuity in education with the need to identify cases where they emerge with children. For example, children with sniffles or mild upper respiratory tract symptoms do not warrant testing and can continue to attend at school while those more specific symptoms such as cough, respiratory symptoms, loss of taste or loss of smell do merit isolation and testing. This algorithm is for GPs and will be communicated clearly to principals in schools to enable them to take the appropriate set of actions should there be a suspect case in school.

Witnesses in committee room 2 are having difficulty hearing us so I ask everyone to speak loudly and clearly.

From the diaphragm.

I thank all the members of the HSE. I have only five minutes and want to run through a number of questions. On the National Treatment Purchase Fund, NTPF, will the HSE be encouraging or recommending that patients who are travelling to the North for appointments or operations should continue to do so? What advice is the HSE explicitly giving to those patients?

Mr. Paul Reid

As I understand the question, we are continuing to work through scheduled NTPF appointments. We have stepped up our services over the last while, which includes NTPF-funded appointments. Obviously, we are monitoring this as we progress through the current uptick in the virus. We have started the approach of stepping up all our services, which includes the NTPF services. I hope that answers the Deputy's question.

That is fine. Given the unpredictable yet devastating impacts of the Covid pandemic, is the HSE considering a backup plan for the winter months in the event of a second wave so as to allow services to resume as close to normal as possible? Linked to that question and specifically in respect of cancer patients, if there are future outbreaks of Covid-19 that might be worsened at the height of the winter months, is there any plan to continue cancer services as normal?

Mr. Paul Reid

On the first question, we have been working through a plan which is to see us through the winter and 2021. We are looking at this plan very differently now because it is not just about a winter plan and what we would normally have to do in winter. It is about how we and our services cope, how we protect the public, our patients and our staff with Covid virus, and about the level the virus reaches at different stages. We have done two things. We have significant funding already in place which is supporting a number of initiatives that we put in place in the early stages of Covid. We are also finalising plans with the board of the HSE and through Government for a set of funding to see us through the winter and through 2021. This will involve a range of significant, different approaches aiming to keep people out of hospitals, including the likes of the community assessment hubs that we used during Covid in a very different way to treat respiratory illnesses, to try to filter out the number of people who will need to come to a hospital setting, the number of outpatients that we can have in place outside of a hospital and in our community services, and a range of investments which are the traditional investments in home care packages and our community service and community intervention teams, and the Covid response teams. This is a range of initiatives that strengthen our community services, reduce the impacts on our acute services but also significantly increase our capacity in the community services. One further aspect of that response will be our engagement with and utilisation of the private hospitals, as took place throughout the first phase, but in a very different way.

I am happy to go through how that may look in the future. It is another support that we would have throughout winter and into next year.

My final question relates to testing in respect of meat processing plants and direct provision centres. The latest update provided by the HSE is that this process has commenced. Can Mr. Reid confirm that the process is under way and, if so, can he provide further details on it?

Mr. Paul Reid

I can confirm that it has commenced. We completed significant mass testing in the meat plants over the past few weeks, and in the first phase when there were outbreaks in meat plants. Serial testing at meat plants recommenced last Friday. We completed testing at three meat plants over the last day or so, involving a total of 2,254 workers and some 823 swabs were completed. That was across the three counties. The primary focus of the serial testing in terms of meat plants is specifically related to plants that have 50 plus employees. We will be working through more than 50,000 employees over the coming phases as part of that serial testing.

On serial testing of those in direct provision centres, we are working through that process with the Department of Justice and Equality and its agencies in terms of the data and so on that we will need in advance of scheduling that process. In terms of serial testing in direct provision centres, there are more than 8,000 people to be tested, comprising approximately 7,500 residents and the remaining being employees. There is serial testing across 50,000 people in meat plants, 8,000 in direct provision and, also, approximately 30,000 staff and healthcare workers in our nursing homes, which has been ongoing for the past few weeks, with a current phase recently completed. There is serial testing across those three areas.

The next speaker is Deputy Cullinane who has ten minutes.

I welcome Mr. Reid and I again thank him, his team and all of the front-line healthcare workers for their service. I have a number of questions to put to Mr. Reid in respect of which I have only ten minutes so Mr. Reid will appreciate that if his answers are as succinct as possible it will allow me to put many of those questions. My first question relates to the number of weekly tests being carried out. Mr. Reid said that the HSE recorded the highest weekly tests since April at 55,000, which we should welcome. On 26 April, Mr. Reid said that there were confirmed plans to ramp up testing for Covid-19 to 100,000 tests per week and that it was expected that the 100,000 weekly test rate would be reached by the third week in May. Can Mr. Reid give me the figure for the number of tests carried out in the third week of May? How is it that we are at only 55,000 and not the 100,000 that Mr. Reid promised on 26 April we would be at now?

Mr. Paul Reid

I will be succinct but as the Deputy will appreciate I could say more. Specifically, what I said was that we were ramping up capacity to have a capacity to test 100,000. That is exactly what we did. In terms of the determination of what we test, how we approach testing and what areas are serial tested, three things drive outturn, namely, the targeted approach of symptoms that we would be targeting for testing, the level of spread in the community and our approach on serial or mass testing, which is determined by NPHET. What I did commit - I want to be very clear on this - is that we would be ramping up the capacity to have 100,000, which we have done.

Sorry, I have Mr. Reid's direct quote. What he said was that it is expected that the 100,000 weekly test rate would be reached, not the capacity to do it but the actual number of tests. I am not sure whether Mr. Reid misspoke then or whether we just have not reached our target, but given that we had a number of counties in semi lockdown, one of which still remains in lockdown, and that we have higher levels of contraction not just for meat plants but in terms of clusters in some parts of the country I think people would expect to be hitting higher targets. The 55,000 is down from a high of 60,000. I am not judging Mr. Reid on my figures because it would be irresponsible of politicians to make up figures, rather I am putting to him what was reported widely in all of the newspapers, namely, that the figure would be 100,000 and it would be the number of tests that would be carried out.

Mr. Paul Reid

I am being very clear. What we were asked to do, targeted by NPHET and overall Government policy, was to develop a capacity for 100,000, which we have done.

We have built up our lab capacity from one lab in the State for the Covid-19, the National Virus Reference Laboratory, NVRL, to 46 labs. We have built capacity across our swabbing centres and across our contact tracers. The determination of volume is a function of the cases being brought forward, what the cases determine of the testing. The HSE are guided by the approach on testing and the recommendations by NPHET based on its information and assessment.

I wish to unpack the median end-to-end turnaround time, which, thankfully, is down to 2.2. Regarding what that actually means, what is the difference between the average turnaround time for a community sample as opposed to a sample in a hospital or some other setting, which I imagine would have a much more rapid turnaround time? What is the average median turnaround time for a community sample?

Mr. Paul Reid

I will be brief, respecting the Deputy's time, and will pass the question to Ms O'Beirne. Obviously, in a community hospital setting it is rapid with a much more quick turnaround. In most hospital cases, it is less than a day, 0.8 -----

What is the median turnaround time for a community case?

Mr. Paul Reid

I will ask Ms O'Beirne to give the exact details on both.

Ms Niamh O'Beirne

There is no referral time in a hospital setting. The statistics we produce show a referral time, which is the period between a GP referral and someone showing up at a swabbing site. That referral is the difference between community and hospital. Second -----

No, I know all that. I just need the answer to the question: what is the median end-to-end turnaround time for a community test? I understand it is different, which is why I made that point, I just need the figure if Ms O'Beirne has it.

Ms Niamh O'Beirne

One would reduce it by one day, which is the referral time.

Is the 2.2 days inclusive of negative samples?

Ms Niamh O'Beirne

Yes, it is inclusive of negative and positive samples.

Is there a difference between the turnaround time for positive and negative samples?

Ms Niamh O'Beirne

The only difference is that positive cases go into contact tracing whereas negative results do not.

I will return to Mr. Reid on another important issue, namely childcare for front-line healthcare workers. I will not give the name but I will put to him the content of an email I received from two front-line workers who work in a hospital in Galway. They have two children, who were in a crèche. Its opening times and their working hours, as front-line healthcare workers, have left them with no option but to remove their children from paid childcare and that they now have no choice but to leave their children with their grandparents, which is not ideal. They state: "Why is there still no childcare options for front-line healthcare workers that actually work?" Can Mr. Reid tell them, and others, why we still do not have a childcare solution that they believe works?

Mr. Paul Reid

It would be unfair for me to refer to that specific case as I do not have the details but I have no doubt its authenticity. From the start, the HSE has encouraged and directed local management to be as supportive as they can, first, through revised rosters to accommodate people in a different way. Second, we put out a clear call to husbands, partners and spouses of healthcare workers, and to organisations and businesses, that they would work at home and support our healthcare workers getting to work. We have put practices in place where, if we can find alternative work for our workforce, we will do so and we have done that on occasions. Obviously, front-line healthcare workers are key for us and we have shown the greatest flexibility we can. I have been clear throughout this process from the start of Covid that we will demonstrate the greatest flexibility we can. There is a wider issue in terms of what Government supports may or may not be there at different stages but we have been very clear to give whatever -----

Does Mr. Reid accept that many front-line workers still do not believe there is a solution in place that works for them? Does he agree that childcare remains a problem for many front-line healthcare workers?

Mr. Paul Reid

The trade unions have represented that point to us throughout this. That is why we are aiming to be as flexible as we can.

Will free car parking for front-line healthcare workers continue?

Mr. Paul Reid

There is some issue with Dublin city, which has been well aired and communicated on publicly.

A solution has been found to that issue and we have continued the process we started with in terms of car parking facilities for healthcare workers.

I want to deal with one more issue. I have a number of questions on screening services. Before I ask them, I want to point out that I completely understand that a cancer diagnosis comes from going to a GP and being referred on. However, we also know that screening is important for detection and, therefore, helps. What is the situation with CervicalCheck, BreastCheck and BowelScreen? What capacity are they currently operating under in comparison with pre-Covid times? My understanding is that BreastCheck is still not up and running, whereas some of the other screening services may be operating again. At what capacity are they operating and how do we ratchet up that capacity? What additional investment and supports are needed, whether it is physical infrastructure or more diagnostics in the community? How will we increase capacity in the time ahead?

Mr. Paul Reid

I will make three quick comments before asking my colleague, Dr. Henry, to give specific details. We launched a plan a few weeks ago to ramp up capacity in our four cancer screening services. We did this to reassure the public and to encourage anyone with symptoms and a referral from a GP to come forward for screening. Our services have remained open during the period of Covid-19. Our key focus for these services is to protect the public and our staff. Some of the cancer screening programmes are more difficult in that regard. We have launched a plan which steps up capacity in all of them. I ask Dr. Henry to provide some specific detail.

Dr. Colm Henry

As we announced before, the cervical cancer screening programme resumed in the first week of July with invitations issued in a phased and incremental way. We expect that all invitations suspended until that time will have been caught up on by the end of October and that any cases delayed during 2020 will be caught up on by March 2021.

Capacity in all three screening programmes depends on where the screening is done, the nature of the test and how or if it may facilitate transmission of Covid, and the dependencies. For example, in the BowelScreen programme the test is done at home but the main dependency is the availability of a colonoscopy. A colonoscopy is a procedure and a service that has a reduced capacity for delivery because of the infection prevention and control measures that are necessary in the Covid environment. We are aiming to resume that screening programme at the end of September, as with BreastCheck. BreastCheck was supporting symptomatic breast care services during the first phase of the pandemic and it will be resuming all services at the end of September. Some 70% of BreastCheck screenings are delivered through mobile vans. These require repurposing to bring them into line with the infection prevention and control measures required for the delivery of healthcare in a Covid environment.

Will Dr. Henry provide Deputy Cullinane with a written reply to his additional questions?

What capacity are the screening services operating at in comparison with pre-Covid times? I want the actual numbers, figures and percentages, in writing if possible.

Dr. Colm Henry

We can provide the Deputy with specific figures later-----

I am sorry but I have to move on to the next speaker. I appreciate that Dr. Henry has the details to hand so we may be able to return to that matter later.

It would be helpful if Dr. Henry could email those details to me and to all members today.

Mr. Reid has a fine record of transparency and accountability since taking up his post and I welcome all the work he and his organisation have been doing. However, a serious issue has arisen in my constituency as a result of a significant number of deaths in Dealgan House Nursing Home. The difference between these 23 deaths and all the other deaths in nursing homes around the country is that Dealgan House is the first nursing home which the HSE, through the RCSI hospitals group, took over. The families are extremely distressed, having lost so many of their loved ones, but they are also extremely angry that they are not getting accountability from their requests to find out on what grounds the HSE intervened to take over the nursing home. They will not have closure until they have all the facts. They have spent hundreds of euro on freedom of information requests to the HSE, HIQA and others. Will Mr. Reid meet these families to ensure they are fully advised of the reasons the HSE went into Dealgan House Nursing Home?

The families are looking for a separate independent inquiry, but it would help greatly, given those facts which Mr. Reid's organisation has and its record in transparency, if he would meet with them.

Mr. Paul Reid

I understand and empathise completely with the distress that deaths in nursing homes have caused to families all over the country. Regarding Dealgan House specifically, the Deputy is correct concerning the approach taken by the RCSI hospitals group. That approach was taken for a range of reasons. I am not personally familiar with the direct request to meet, but I will arrange some discussions with local management, in the first instance, through the RCSI hospitals group.

If I can interrupt-----

Mr. Paul Reid

I will certainly have to talk with the-----

They have got no information from the HSE in response to a freedom of information request. Mr. Reid said he is aware of some reasons the RCSI hospitals group went in there. I think Mr. Reid owes it to the families to make sure he contacts them following this meeting. I want him to meet with the families. I believe that he should meet with them and that Mr. Reid has to be accountable. This was the only nursing home in the country that the HSE went into. I do not want to harangue Mr. Reid, and I do not intend to be rude in any way, but I think he must meet with the families. They must get closure. It is unacceptable what is happening to these families.

Mr. Paul Reid

I do not take the Deputy's contribution as haranguing me or anything like that. I respect fully his role as an elected representative in the Oireachtas and I do not take his comment like that whatsoever. I will, in the first instance, have to talk with the RCSI hospitals group. I ask Ms O'Connor if she has any further information that she can add.

Ms Anne O'Connor

The circumstances in Dealgan House were such that we worked closely through our National Ambulance Service and sought to deploy staff there. The nursing home experienced such a loss of staff in the facility that, given the concerns at the time regarding maintaining safe levels of care, it was deemed appropriate for the RCSI hospitals group to go in and be able to staff up the facilities. The staff that went in were deployed.

I do not deny that or disagree with Ms O'Connor. I agree that is what happened. The families, however, have not been told and have not been given the facts around that decision. Their freedom of information request has not given them the facts which the HSE obviously has. The families need to be given these facts because the HSE has to be accountable and they have to get closure. I will leave that point with Ms O'Connor and Mr. Reid.

I have a different question now concerning testing. We were told in July that there were 1,300 people in all, I think, who had been identified as needing a test for Covid-19 but who had refused to go for such a test. The intention of the HSE was to follow that up. Can we be given the result of that follow-up? What has happened since? How many people have now refused testing and what has been the outcome of all that action?

Mr. Paul Reid

I will comment briefly and I will then ask Ms O'Beirne to comment further, as we have some facts and figures to hand. What I was referring to then, and which is still a factor that we strongly encourage and it has got better, was where we make contacts of positive cases. We now organise a test for them on what is called "day 0", their first test, and then another test on day 7. What we saw originally was some people not coming forward for their tests. We obviously try relentlessly to make contact with them and set up appointments for them. Equally, we do that on day 7. We have seen an improvement and also regarding those coming forward for the day 7 tests, but it is part of our contact tracing resources.

What are the figures? I welcome the facts.

Mr. Paul Reid

I ask Ms O'Beirne to comment. She has some figures that we can give to the Deputy.

Ms Niamh O'Beirne

We refer people for day 0 tests and day 7 tests. Somewhere between 70% and 80% of people will show up for day 0 tests, and on occasion it gets closer to 85%. On the day 7 tests, it is closer to 50%. Looking at the age profiles, the cohorts who have the most difficulty tend to be the very young and the more elderly. We are looking at different tests for children, such as saliva tests, to make it an easier appointment to attend. We have done further campaigns and several press conferences to encourage people to show up for their day 0 tests.

I thank Deputy O'Dowd.

My time is very short. I just did not hear the figures that Ms O'Beirne mentioned. I am not suggesting that she is keeping them from me, I just did not hear them because Ms O'Beirne's voice is just a little bit low for my ears. Could I please get those figures?

The last part of my question concerns social stigma, which is a reason that some people are not showing up.

Is the HSE going to address that issue?

I ask that Ms O'Beirne provide an answer to the question regarding social stigma - I am sure she has the answers and figures - to Deputy O'Dowd by email as soon as reasonably possible.

Is the HSE considering saliva tests for schoolchildren? When will that be done? It is so important for children in particular. I ask Mr. Reid to revert to the committee with a timescale for that to be done. As he knows, children are going back to school. We do not wish to be back here in four months' time and the HSE to still be considering that measure. It is important that Mr. Reid revert to the committee on that very important issue.

On testing, I dealt with a particular case involving an elderly lady who rang her doctor last week. The doctor advised that she needed to be tested. The woman was referred on Tuesday. She could not go to Kilkenny. The testing centre in Tinryland, County Carlow, which is in CHO 5, has been closed. Will the testing centres in Limerick and elsewhere that have been closed be reopened? The woman was tested at 1 o'clock on Friday. Today is Wednesday and she has not received her results. I am aware of other similar cases. This is what is happening on the ground. People are being tested. If the members of a family are tested, they must isolate and stay inside. They cannot go to work. It is unacceptable that people are waiting six days to receive results.

I was contacted by a business in County Carlow. One of its employees contracted Covid and the business did not know what to do. I rang the Minister for Health. A person working on the business premises was diagnosed with Covid and had to isolate for 14 days. The owners did not know whether the business should close or remain open. They decided to close because they wished to be fair to people. There are no guidelines to cover such circumstances. The business was closed for 14 days. No urgent system of testing was put in place for its employees. The employees were out of work for two weeks because the business had to close when one employee got Covid.

I refer to counties which border counties Laois, Offaly or Kildare. I live in Graiguecullen in Carlow town. There are restrictions in place but the county is not in lockdown. However, businesses in Graiguecullen and elsewhere in County Carlow, including a hotel, had to close. There was significant confusion regarding the local lockdowns. I acknowledge and respect that the witnesses are doing their jobs as best they can, but proper guidance must be given. People have contacted my office seeking guidance and I had to try to get answers that I could not get.

Mr. Paul Reid

I will ask Dr. Henry to address the question on saliva testing. On the testing centres, we have scaled up the number of centres across the country. We were dealing with an average of ten cases per day or 50 cases per week and had 29 centres, originally 48 centres, across the country. We must adapt our centres based on where the virus is and the volume of transmission. We have stepped back up to 28 operational centres across the country because we have gone from 50 positive cases per week to 600 cases. That is where we had to step up. We installed pop-up centres through the National Ambulance Service in recent weeks to directly target communities where the transmission of the virus is potentially high. We have scaled up our centres in that regard across the country. The Deputy will appreciate that when we are dealing with maybe ten centres per day, having 48 centres across the country is not the best use of our teams as we try to get services back up. We must scale services up or down in accordance with the rate of transmission of the virus.

I ask Dr. Henry to address the issue of saliva testing and Ms O'Beirne to deal with the Deputy's comments regarding turnaround.

Dr. Colm Henry

Briefly, the Deputy is absolutely right regarding the saliva test. It is a more acceptable and easier test, particularly for younger children, including those in preschool or primary school. A group of paediatricians and GPs has examined the issue and recommended it as a preferred test. The question is whether it is sensitive enough to be applied. That is being considered by the expert advisory group of NPHET chaired by my colleague, Dr. Cillian De Gascun. I expect the group to issue a decision on the matter next week.

I ask that written answers be provided to my other questions, particularly that relating to the timescale for testing. It is becoming a significant concern. Many Deputies are being contacted regarding cases where this is an issue. It is so important. Testing and tracing is the only solution to deal with the spikes that are occurring, particularly in light of the fact that children are going back to school.

It is important that we have testing and tracing and that the witnesses come back to us on exactly how long people are waiting for that. I thank the witnesses.

Mr. Paul Reid

Our data are published daily and we generally present them at a weekly media press conference and at the NPHET update media conference, which, at this stage, is happening twice a week. We can give the Deputy some specific figures now, if she would like.

We need to do a lot more testing. My concern would be that we are not doing enough testing. I thank the witnesses and I will raise my concerns again at the next session.

I thank the witnesses for their attendance today and their submissions to the committee. I thank their team and all the HSE staff for their huge work effort over the past six months.

I have a question on the reopening of health services. It was expected that the health services roadmap would be published before now. Has that happened and is there a full service in place yet for outpatients, inpatients, acute, elective and emergency care, and community help? If not, when will full services return?

Mr. Paul Reid

I thank the Deputy for his opening comments. They are appreciated, as are those of other Deputies.

On the reopening, we published our plan a few weeks ago, at the end of July, which was for the reopening of all services. The document, which is on our website, steps through the various services and the timeframes for their opening, service by service, throughout this period and through the winter and onwards. I am happy to share that document again with the committee, if it is useful, but it has been published on our site.

I appreciate that. A colour-coded alert system is meant to replace the plan for the phased reopening of the economy. How will this affect the health service? Will services need to be shut down or scaled back if we move to a stricter colour-coded alert process?

Mr. Paul Reid

I know that the coded alert system, as the Deputy describes, is being worked on by NPHET and the Minister has been communicating on it. That is still in the process of dialogue. Ultimately, however, as we have seen over the past few weeks in particular, while everybody had predominantly been talking about when we might see a second surge, I think the reality is that what we are seeing in the country right now is probably what we are going to be living with for the future with this virus. We are going to see significant peaks and, we hope, significant troughs very soon and those changes may not always be national. They could be regional and, in some cases, local. That is the new reality for us in terms of living with this virus and the transmission we have seen to date. Therefore, our plans are now not so much around a second surge and a mass scaling up or scaling down. The focus now is around agility, how we adapt, scale up and scale down, and how we try to get back our services, which I referenced a while ago. We were very strong in our document that it is all dependent on the transmission of the virus at any particular given time. We are constantly focused, every week, on where is the level of transmission of the virus and what services we need to adapt. The focus is not always on the acute services. In fact, at this time, the services we have had to step up are primarily in community services and particularly in public health teams. The situation is not quite as black and white as we might have expected at the start of this, where we expected to see surges. It is probably the case that what we are seeing right now is going to be the reality.

If we have a localised cluster in a school or another location, particularly in rural areas or locations that are distant from test centres, are there mobile units that can be deployed and, if so, how quickly can that be done to reduce the amount of travel time for people going to test centres?

Mr. Paul Reid

Where the need arises, we have three responses. One, we would open some of our traditional swabbing centres. Two, we would deploy pop-up centres from the national ambulance service, which has been done a significant number of times throughout the country. Three, we would deploy the national ambulance service into a specific organisation or area, as needed, with paramedics carrying out the testing and swabbing for us. A combination of those three measures would be our rapid response.

I thank Mr. Reid. In terms of the target turnaround time for testing of 2.2 days or one day less than in a hospital setting, is there any part of the process we could improve to reduce that time of 2.2 days, either in terms of the collection time, treatment time or the process of communicating the test results? Is any work being done to decrease that time?

Mr. Paul Reid

It is a good question. I will try to be brief. I have always described what we put in place at the start as a rapid-fire wartime model. We have modified it significantly over the past weeks and months in terms of automation of the process. An example is the automation of the negative test results that we put in place and that carries on. Second, there is an automation between our labs and our contact tracing teams with both systems interfacing. That took 24 hours off the process of handovers to different systems.

Ms O'Beirne is working with us on what I described in the opening statement as a future model. We are now looking at a more standardized and permanently recruited workforce, both for our contact tracing and our swabbing. Part of that will be looking at the logistics and the transportation of the swabs from various parts of the country to a lab in order that we can turn them around more quickly. We are looking at elements of automation, logistics, transportation and a permanent workforce.

I thank Mr. Reid and the Cathaoirleach.

I have a quick follow-up to Deputy Matthew's question. The median turnaround time is 2.2 days. What is the average time? Second, does the HSE have an average and median time for testing alone, that is, the time between when somebody seeks a test and when they get the result?

Mr. Paul Reid

The median measures we generally are using are ones the WHO and the ECDC recommend. I ask Ms Ó'Beirne to comment on averages.

Ms Niamh O'Beirne

The average is 2.4 days and the median is 2.2.

Could Ms O'Beirne provide it in writing at the end of the meeting rather than taking time now? I could not hear her response.

Ms Niamh O'Beirne

It is 2.4. That is the average and 2.2 is the median.

Is that from when somebody seeks a test to when they get a result, leaving out the contact tracing?

Ms Niamh O'Beirne

No, that includes contact tracing.

What is the figure without contact tracing, from when one seeks the test to when one gets a result? If I suspect I have Covid-19 and look for a test, what is the average time to get a result?

Mr. Paul Reid

In an acute hospital setting, it is generally less than a day. In the community setting, it is 1.2 days from swab to lab result.

How long is it outside of an acute hospital setting?

Mr. Paul Reid

Primarily it is less than a day, 0.8.

That is in an acute hospital setting but what is it in a general community setting?

Mr. Paul Reid

In a general community setting, it is 1.2 days from swab to lab result.

I thank Mr. Reid and call Deputy Smith.

I thank the Chairman and I thank the witnesses for their submissions and for coming before the committee. During the summer, patients in private hospitals began to be charged for Covid tests. Can the witnesses confirm whether those tests are processed in labs within those private hospitals, or are they sent to labs commissioned by the HSE? If so, are those tests processed in the same manner as tests that come from public hospitals or are they given any priority based on the fact that a patient has paid for them?

Mr. Paul Reid

It is a good question. Any tests carried out in private hospitals are generally processed in the private labs. We are focussed on protecting the capacity we have developed in the public system for 100,000 tests. We significantly protect that all the time.

On getting prepared for the winter, can Mr. Reid give us any update on the winter service plan? Will primary care centres in communities be used? He may have commented on this earlier but I did not hear. In what capacity can these centres be used?

Every year, there is a push for staff in the HSE, particularly front-line staff, to have the flu vaccination. Given the winter we are facing, what are the plans to increase take-up of the flu vaccine? Have mandatory flu vaccinations for front-line staff been ruled in or out?

Mr. Paul Reid

I will take the second question and briefly address the first. Then I will ask my colleague, Ms O'Connor, to give some specifics on our community responses.

On the flu vaccine, we are anxious to make a significant increase in numbers. Last year, it was about 60% overall across the system in terms of flu vaccine uptake by healthcare workers. However, there is significant variation in that, both on a geographical basis and between hospitals and community settings. There is a mixed variance in all of that. That is not a sustainable position as we head into dealing with Covid. We have discussed this significantly and we will be in dialogue with the trade unions, as well.

Vaccination is not just good to have at this time, but absolutely necessary in terms of managing Covid. Some countries have opted for legislation to make it mandatory, but we do not believe such a process would happen quickly enough for us. Instead, our approach would be a risk-based assessment. If a local service manager determined that the risk was such that people needed to have the vaccine, it would be deemed a risk factor for the staff to have the vaccine. Obviously, there will be minor exceptions, but that is the situation we would like to see.

Vaccination at this time is not just good to have, but absolutely necessary in terms of managing with Covid. Some countries have opted for legislation to make it mandatory, but such a process would not happen quickly enough for us. We would take the approach of a risk-based assessment, for example, a local service manager determining that the risk is such that people need to have the vaccine. There would obviously be minor exceptions, but that is what we would like to see. I have been clear that we need a significant ramping up of vaccinations this year.

What we are referring to for this year is not a winter plan. Rather, it is largely about managing our services with Covid through winter and into next year. It will not stop. We want to put in place approaches that are sustainable into 2021 beyond just February. I ask Ms O'Connor to touch on these approaches briefly.

Ms Anne O'Connor

The primary care centres will be central to how we approach winter and the coming year. The specific initiatives we are considering relate to supporting people in avoiding admissions to hospital and in having timely discharges, for example, our integrated care people for older people and our programme for chronic disease for people who need to attend our community nursing services, occupational therapists, physios, etc. We are also considering primary care centres in terms of the development of our community health networks. This core element has been in existence for a while and we are looking to roll it our further. Having better and more localised integrated care available to the population will involve GPs, community nursing and other allied health disciplines in the community. Our primary care centres are also key for our community intervention teams and many centres have mental health services working out of them. The centres will be at the core of what we are trying to do this winter.

I have a final question, but I am unsure as to how much time I have left.

Thirty seconds.

Testing in meat plants, schools and direct provision centres has been referenced and I thank the witnesses for their answers. Have there been further discussions with the Dublin Airport Authority, DAA, on testing at our airports?

Mr. Paul Reid

I will make two brief responses. The e-locator form, the development of which we have been working on from the HSE's perspective, is now ready to go live, if not today or tomorrow, then shortly. It will allow people to put in their details before travelling. Regarding testing at airports, we are working on reaching a decision with NPHET. It will be a question of the prioritisation of resources, but we are working through the process with NPHET in terms of timing and how and where testing would be done.

I thank Mr. Reid.

I wish to start with the question of testing and tracing, which are some of the key tools in our living with the virus. It would be helpful if the witnesses were up front with the committee on the reasons the HSE is not using the full capacity of 100,000 tests per day. What is the main threat to having that kind of rapid and agile testing and tracing service in place? Is it a staffing problem? Is it a funding problem? What is preventing the HSE from operating a very active, proactive and reactive testing and tracing system?

My second question is on testing in meat plants. Who is paying for the 50,000 tests?

My third question relates to the flu vaccine and drops for children. What are the arrangements for administering that programme?

My fourth question is on the creation of additional capacity in private hospitals. How does the HSE propose to go about doing that?

Mr. Paul Reid

The Deputy has been a strong advocate of testing and tracing and has in-depth knowledge of the matter, so I will answer her questions as openly as I can, which I always try to do. Our approach has been to build a capacity of 100,000 in terms of our swabbing centres, labs and contact tracers. This is determined by the transmission of the virus, the case definition and the resources.

I appreciate that, but will Mr. Reid be specific about what the main threat to utilising that full potential is?

Mr. Paul Reid

Our approach to deciding where to carry out serial testing and mass testing is guided by the recommendations of the National Public Health Emergency Team. That body has in-depth knowledge of the transmission and impact of the disease.

Are there staffing issues?

Mr. Paul Reid

No. We have provided whatever staffing resources are needed and we will continue to provide those resources. We have assigned even more staff to contact tracing in the last week, going from 60 to 120. We will reach 150 by the end of this week and go beyond that next week if the virus makes that necessary.

I thank Mr Reid. We will pursue that matter with NPHET.

Mr. Paul Reid

Very well. I will ask Dr. Henry to comment on the vaccine. All of the serial testing and mass testing at meat plants to date has been funded directly by the State via the HSE. I would like to make one point on serial testing for the committee's information. Serial testing provides the public with a lot of reassurance. I fully respect that and we will need to continue with serial testing in various settings. It represents a very significant cost. For example, I refer to the serial testing of healthcare workers and in nursing homes during the first phase of the response. We completed 99,750 tests in a four-week period. The rate of positive results was 0.13%. It is a very significant cost and absorbs a lot of resources. I appreciate that it gives the public a lot of reassurance, but it is not the major tool with which we can protect the public. I want to state that very clearly. The major tools are the public health measures we can all take. I know serial testing provides reassurance to the public but the positivity rate from such testing is low.

It is critical, however, that the HSE is geared up to respond rapidly if there is an outbreak.

Mr. Paul Reid

Regarding the meat plants-----

I would like to ask about the flu vaccine for children.

Mr. Paul Reid

Dr. Henry will address that. I would like to comment on the status of private hospitals. There are three parts to my response on this topic. First, I note that as we have terminated the last agreement, we have put a bridging fund in place to see us through until the conclusion of a further agreement. That is a €25 million fund which has been approved by the Government. That is being drawn on by various hospital groups for services they provide.

Second, we have issued a tender to all private hospital groups. It has two aspects in that it is a tender for diagnostics and services. We are working out our services plan for the winter and for next year in order to determine the funding we will need for that purpose.

Third, we are directly engaging with the private hospital groups on their role and the services we will make use of if we experience a massive surge like the initial outbreak. The private hospital groups have asked us to engage with them and we are doing so. I am confident they will do the right thing if such an outbreak occurs.

Is the HSE discussing cost per item?

Mr. Paul Reid

Yes. It will be a very different model from our initial approach.

Will this mean requisitioning beds, etc.?

Mr. Paul Reid

The current tender features activity-based pricing for services. As we see it, our preparations for the next phase should not be based on what we experienced previously. The first phase concerned capacity across the board. This phase of the response will be targeted. We will have to allocate resources to different regions at different times.

I would like to hear about the flu vaccine for children.

Dr. Colm Henry

Some 600,000 doses of the vaccine have been ordered for children aged between two and 12. Delivery is expected in the latter half of October. Training information and a communications campaign have been developed for healthcare workers who will be administering the vaccine.

In regard to administration, I note that the primary care division of the HSE is negotiating with the Irish Medical Organisation, IMO, on the fee payable for the administration of this vaccine by GPs. That negotiation is not yet complete but will come to a close shortly. That will hopefully come to a successful conclusion which will allow us to carry out the plan.

I thank Dr. Henry and Deputy Shortall.

I have some questions for Mr. Reid. I would like to ask about the situation concerning schools, but first I will ask some questions about quarantine. The European Commissioner travelled to this State from a non-green list country. He has justified breaking the 14-day quarantine on the ground of having received a negative Covid-19 test result.

I think the answer to this question is probably fairly obvious but it is important that we hear it from the chief of the HSE. The question is this: did he break HSE guidelines by doing so?

Mr. Paul Reid

I will come back briefly and I will ask my colleague, Dr. Colm Henry, to deal with the specific guidelines. Obviously, as a public servant, I am not going to encroach into the area of any kind of political comment. What I will say is that our guidelines and guidance are very clear on the HSE site and, indeed, there is more in-depth guidance on the HPSC site, which would be the go-to site in terms of information on both travel and testing negative. I ask Dr. Henry to clarify that.

Dr. Colm Henry

The advice from the HPSC is clear in this regard that people coming to Ireland from non-green list countries restrict their movements for 14 days, and that is irrespective of tests that are performed either abroad or here.

My other point on that, before I get to my main points on the schools, is that The Irish Times this morning reports comments from two women who were in the K Club between-----

The Kerins judgment is very clear that we have to stay within our terms of reference and I do not think this comes within our terms of reference. That is my view, although I am happy to come back to this point. The HSE will be in before us again and we can take a legal opinion on this. As Chairman of the committee, I am tasked with keeping us within the terms of reference and I intend to try to do that.

Let me put it this way. If someone were to be staying in a hotel complex with apartments within the timeframe of a 14-day quarantine, and they were to stay in that complex but to dine in a public restaurant and other public places within that complex, would that constitute a breach of the 14-day quarantine?

I do not think it is fair to say we are talking in generalities here because we are not, given the first question. If this is within our terms of reference, I am happy to have it discussed, but I am very keen that we remain within our terms of reference.

I would like an answer to the question. I am not naming any individual. I am saying that if someone were to be within a hotel complex or an apartment within a 14-day quarantine-----

It is clear Deputy Barry is asking this question in the context of a political controversy that is ongoing.

Mr. Paul Reid

All of our guidance is on our website. I am happy to circulate it again to the committee but it is very clear on our site.

It is a question of where to find it. At one point, I went to find it and it was remarkably difficult to find the guidance. I am not suggesting for a moment it is not on the HSE website but where is it? The guidance changes as the medical advice changes in response to what is a changing scenario. Where is it available on the HSE website?

Mr. Paul Reid

It is readily available.

I am conscious of the fact Deputy Barry has two minutes left so I will let him finish and come back to that point.

On the “Six One" news last night, there was a news item about the return to school which featured a school in County Carlow. It showed an assembly where, I think, prayers were being conducted, with more than 150 students spaced about 1 m apart. Would the witnesses be prepared to comment on that situation, not with regard to that specific school, but in a general sense. Do they think it is best practice not to have assemblies of that type?

Mr. Paul Reid

Again, I will not comment on that particular issue because the news report is all I have heard on it. On the guidance to schools, in fairness to the Department of Education and Skills and the school principals, they are working through a very difficult situation. The absolute guidance, as they have repeated themselves and as the Minister said last night, is to aim for a 2 m distance throughout the whole school setting. What I have seen so far is a really strong engagement by principals and schools to implement that. Obviously, it is very challenging in some schools versus others. Our guidance would absolutely be to avoid mass gatherings where possible.

The new president of the ASTI went public the other day and said there was an issue which she described as an issue of life or death for some of her members, namely, people who are categorised according to the guidelines as high risk, including people who have had cancer, heart conditions, diabetes and so on, being denied the right to work from home and being asked to report for duty in the schools. One such teacher, who is affected by acute leukaemia, type II diabetes, asthma, anaemia and an autoimmune disorder, said: “I feel like a turkey waiting for Christmas.”

Should teachers who are at high risk as opposed to very high risk be forced to report for duty in schools as opposed to being allowed to work from home?

Mr. Paul Reid

The Deputy is quoting generalities and all I can say is that our public health guidance is very clear on the approach for vulnerable groups. It is the guidance that all work organisations have available to them, including schools. I cannot comment on specific cases or a particular teacher or particular vulnerability a person may have. It is an issue for all work organisations to implement, as per our guidelines.

I thank the witnesses. My first questions are for Mr. Reid. I have previously raised with the committee the issue of serial testing in healthcare. Are there plans to consider random testing or temperature testing of hospital care workers? As I have said previously, these protocols are in place in factories. I am not sure why they cannot be implemented randomly in the HSE.

My next question is on congregated settings, particularly in the meat industry. We have heard about the issue of foreign workers being domiciled together. The HSA told us it was not within its remit but that it was a public health issue. Does the HSE have any intention of looking at it or engaging with the meat industry to see how it might be ameliorated?

Mr. Paul Reid

The first serial testing that was completed was targeted in nursing homes in particular on healthcare workers. In some cases we also tested some of the residents.

With regard to the question on meat plants, the national standing oversight committee has been established and I referenced it briefly in my opening comments. There is multi-agency representation on it, looking at the various aspects that have arisen from our assessments of meat plants. A number of State agencies are involved and I will not go through them here. They have examined and assessed a wide range of issues that emerged with regard to the organisation of plants, and how social distancing spacing can be operated. The industry has engaged quite well and very responsibly with us. There are also issues with regard to shared transport to work and shared accommodation. In some cases, there is shared accommodation and shared transport involving multiple plants. The national standing oversight committee is looking at a range of issues. One of its specific terms of reference is to look at the basis of legislation for the various agencies with regard to enforcement. This is progressing quite well.

I ask Mr. Reid to come back to me as my first question was on community hospitals and not residential care settings. I know it was covered previously but perhaps the thinking has changed. Can the random testing of healthcare workers in community hospitals be considered?

With regard to diagnostic tests, a number of weeks ago, representatives of the DAA and the Department with responsibility for transport were before the committee. The Department suggested looking at a protocol whereby people would get a Covid test before they flew into Ireland. The suggestion was that diagnostic testing is available outside of Ireland that could be done within a matter of days. Is Mr. Reid aware of these tests? Will he update the committee on other diagnostic tests that are being looked at outside of the PCR test? The saliva test was mentioned. Are there others?

Mr. Paul Reid

I will ask Dr. Colm Henry to answer this.

Dr. Colm Henry

In broad terms there are three modes of testing, all of which are determined by the expert advisory group, and HIQA has input through its own assessments.

The PCR test is determined to be the most sensitive and real time of the three broad categories. Antigen testing does not hold as much promise at present. As more evidence emerges, we know that antibody testing is more useful in determining population exposure or the exposure of particular risk groups but not the current level of infection. The mode of the PCR test is a nasopharyngeal swab which, of the different types of swabbing available, presents the most sensitive measure.

As was alluded to earlier by one of the Deputy's colleagues, we are looking at the version of this that would be easier for children, which is salivary retesting. That has to be determined by the expert advisory group.

On NPHET, the expert advisory group is always considering new and emerging evidence from other healthcare systems on modes of testing in the three broad categories mentioned and the mode of carrying out tests. At this point in time, August 2020, PCR by nasopharyngeal swabbing is our preferred mode of testing as is the case throughout most healthcare systems in the West. We are constantly monitoring new evidence and proposals that are coming to us from other healthcare systems.

I have three questions I would like answered in writing.

Yes, as long as they can be answered in writing.

Is the use of plasma and ultraviolet systems for infection control being encouraged in hospitals?

On the proposed service agreements that might be reached with private hospitals, I am aware of patients who have been waiting for diagnostic tests in public hospitals. They have been sent to private hospitals without having been tested for Covid and have been sent back to await a Covid test. Can a protocol be put in place for such situations?

My third question concerns masks in national schools. Some states in America are now talking about children in national schools wearing masks. Is any of the evidence they are looking at being examined?

I would like to move onto the next speaker. I would appreciate if the witnesses could provide answers in writing to Deputy Shanahan. The next speaker is from the Rural Independent Group, Deputy Mattie McGrath, who has five minutes.

I thank the witnesses for coming before the committee. In March and April, the focus was rightly on flattening the curve. Everybody co-operated with that. At the height of the pandemic, there were 879 patients in hospital,160 of whom were in ICU. It appears that great work was done by everyone. I sympathise with anyone who lost their life and the trauma people went through.

However, our objective now is confusing. We do not know where we are. As of 8 p.m. yesterday there were 23 cases of Covid-19 in 29 acute hospitals.

According to the information in the opening statements, there were 22 cases.

Sorry, 22 cases. There were four confirmed cases of Covid-19 in ICU beds.

There are 22 cases in hospital and six in ICU. In any event, the figures are lower than in April.

I thank the Chairman. That is better again. People are rightly concerned as to why we have a lockdown, in particular in one county. The pub industry has been closed down, despite it having no part to play in spreading the virus. There has been damage to the economy and mental health as well as other side effects, such as people who are waiting for a plethora of procedures. Can we now have a clear timeline or roadmap out of the current situation to try to help our economy to recover, address people's mental health, assist those going back to school and all the other issues? I ask for some clarity around that.

Mr. Paul Reid

I will answer the Deputy's questions as succinctly as I can. He referenced the number of hospital cases being low, thankfully, and we want to keep it that way. We now face uncertainty as we have seen a rapid increase in the transmission of the virus among those below the age of 45. I understand that 75% or, in some cases, 80% of the positive cases are now in those aged under 45. Our concern is community transmission and the impact on other groups.

I would make the point that nobody is immune to the virus and some of its impacts. Younger people may think they will not suffer from it. There are extreme cases where people had really bad illnesses as a result of Covid. Our specific concern is the spread of transmission further in the community and among vulnerable groups, particularly older people. We want to protect our hospitals in that regard.

Our colleagues in NPHET will come before the committee later. The measures taken at different stages are recommended by NPHET, based on the best knowledge it has at the time and which it has communicated to Government. From our perspective, I understand the concern. From a health service perspective, the impact of lockdown is key and we know it is significant. It has a significant impact on the health service and recovery, as well as on the public in terms of our services being constrained or, in some cases, shut down. Some of the mental health impacts can be very significant.

I think we are all trying to find an approach that keeps the economy and our society going and can keep our health services going and, equally, protect our public. As I said in my opening statement, that is important not only for the health service and for us in protecting it but also for the way we are seeing the virus transmit at the moment.

I wish to speak about another situation that gives mixed messages. I compliment the community in Golden, in my county, where an incident broke out two weeks ago in Walsh Mushrooms. I got a phone call from Kate Killeen of the HSE, whom I thank and who kept me informed. The Army, the Garda, the Ambulance Service and everybody else rolled in and did the testing on a parish site. This can be contrasted with the rumours abounding about a plant in Cahir for weeks, finally admitted last week, and then testing being done privately. Now Mr. Reid has just told another Deputy that the tests are being paid for by the HSE. We could get no information on this, and there was no phone call from the HSE. It had no information. We could get no information yesterday or all weekend on the number of tests. A number of shops, including excellent ones in our wonderful town of Cahir, had to issue statements to deny rumours of incidents on their premises. There were huge mixed messages, and the treatment of a community in Tipperary was different from that of a big business there. We value those businesses, but the question is of special treatment, and now we find that the HSE is paying for the tests anyway. Was there control over those tests? How come we could not get the answers until very late?

I wish to ask briefly about St. Brigid's in Carrick-on-Suir, a wonderful community hospital that was taken over to deal with Covid. When will it go back to its former use? There are three hospice beds there for elderly people and people in their last days. They need those beds. They are not being used. I would like a definite date for when it will go back to its former use.

Why were the meetings ceased? At the start of this outbreak we all, party and group leaders, were briefed once a week by the HSE. We have not had a meeting for two months. Why the secrecy, and why are we not being engaged with? We are expected to support the HSE in all the work it does, and we have done so, but we need a quid pro quo. We have to have information.

Could Mr. Reid perhaps give Deputy McGrath just a very brief answer?

Mr. Paul Reid

May I respond to just one point briefly? To clarify, what I said earlier is that the mass testing and serial testing completed by the HSE is paid for by the HSE. Other private testing carried out through private testing systems is not paid for by the HSE. I just want to make that distinction.

Perhaps Mr. Reid could reply in writing to Deputy McGrath on the issue of the hospitals he outlined-----

Mr. Paul Reid

Sure.

-----as soon as is practicable rather than now. If there is another question-----

We all, leaders of groups and parties, had weekly briefings with NPHET, the Taoiseach and the Tánaiste. They have stopped as of two months ago at least. While many of them were not hugely useful, we need to be kept abreast at least. All our groups, meaning the representatives of the people, need to know what is going on.

Mr. Paul Reid

We have made ourselves available on every occasion and will continue to do so at the request of the Oireachtas and the Oireachtas committee. We have put forward a wide range of our teams and staff throughout the past few weeks and will continue to do so. We do our preparation for such engagements and give the committee the best information we can give.

Perhaps the question would be best directed at the political leadership. The Minister for Health will come before us later this afternoon. I wish to point out also that the HSE did make itself available for a meeting two weeks ago when we asked it. We did not proceed with the meeting but the HSE did make itself available.

I accept that. I am talking about the briefings for the party and group leaders. They were held weekly and we all attended. They suddenly stopped, way before the summer recess. They have not resumed. Perhaps it is a political question.

The HSE's position is that it is available for briefings if and when required.

Mr. Paul Reid

As I said, we will make ourselves available as requested by the Oireachtas. We have done so throughout Committee Stage of the relevant legislation. We do media briefings, which I know are not Oireachtas events, but we have made ourselves available as requested. The Oireachtas committee was established and, again, we have presented here regularly and as often as requested and will continue to do so.

That is noted and appreciated. I thank Mr. Reid.

I will ask a very quick follow-up question to Deputy McGrath's point. He pointed out that there are 22 people admitted to hospital as of today and there were 800 people in hospital at the peak of the pandemic. I notice that in Mr. Reid's introductory statement he said, "This lower rate of admission may be attributable to the lower age profile of patients that has characterised the resurgence in the disease in recent months."

It is, however, also an international phenomenon that has been experienced in the United Kingdom and right across the western world. Is it being studied or are there any other explanations for it other than it may be attributable? Is the HSE happy to attribute it to the lower age profile or is this being studied?

Dr. Colm Henry

I might take that question. There has been much observation internationally, as the Chairman points out, of the lower rate of hospitalisation and some suggests this represents a change in behaviour of the virus, but the virus has been sequenced in Swiss studies and the overall diversity of the virus has not changed. There is no new variant and there is no development of some less severe mutation. The most likely explanation for this trend we are seeing internationally is as follows: we know the virus has a steep age-dependent rate of illness and mortality. The more testing one does, particularly in younger people, it will result in an imbalance between tests and hospitalisation. We have seen in this country, as in other countries, a predominant shift towards positivity in younger age groups. The CEO referenced that 71% of cases in the past two weeks are aged under 45. It may also reflect that older people are behaving more cautiously and as such are less prone to the illness as they were when we knew less about asymptomatic transition, the mode of transmission of the virus some months ago. Nevertheless, the big caveat and warning at the end of all that is that there is a lag time between seeding within the community - between open outbreaks in the community such as in some counties or where there is high levels of transmission - and inevitable community transmission leading to older people and vulnerable groups getting the disease.

What is that lag time?

Dr. Colm Henry

The incubation period of the disease is seven to 14 days.

We have seen this increase in testing for longer than seven days now.

Dr. Colm Henry

Yes.

I refer to the spike in detected cases. I suppose we can never know what the transmission rate in society is; we can only know what is detected. The increase is much longer than seven days and it has not been accompanied, thankfully, yet at least, by any increase in admissions and deaths.

Dr. Colm Henry

Yes. As I pointed out, the evidence does not show a change in the behaviour of the virus. There is no new mutation. The most ready explanation is that predominant rate of positivity among younger people and perhaps the behaviours of older people in terms of avoiding risk.

I thank Dr. Henry for that and I thank Deputy Mattie McGrath. Going back to Fine Gael, the next speaker is Deputy Colm Burke. Is he taking five minutes?

There will be five minutes for Deputy Durkan then.

I thank Mr. Reid and all HSE staff for their work over a difficult six months.

I will follow up on what the Chairman asked in relation to the people identified. Confirmed cases numbered 1,269 over the past 14 days and reference was made earlier to the reduction in hospital admissions. How many of the 1,269 cases were aged over 65? It would be interesting to know what numbers are over 65. I know Mr. Reid cannot give it to me today but he might come back to me on it.

I have a series of questions on the nursing homes issue. When the outbreaks occurred in nursing homes, there was considerable engagement between the HSE and nursing homes. My understanding is that the level of engagement between Nursing Homes Ireland and the HSE has not been maintained. Can I get some clarification as to whether that engagement can recommence?

I refer to temporary assistance payments to nursing homes. As Mr. Reid will be aware, Covid has resulted in considerable additional costs for nursing homes The Government put in place the temporary assistance payment until September. Has the HSE made recommendations to the Minister about the continuation of that payment in view of the fact that nursing home payments under the fair deal scheme have not been reviewed for four or five years but they now face additional costs?

The Covid expert panel made recommendations on the entitlement of residents with medical cards in nursing homes to community and medical healthcare services. Has the HSE currently capacity to deal with that issue?

One complaint was there was not the access to the supports that nursing homes required when they needed it urgently at the time. Has that now been revisited?

What is the current procedure when a person in a nursing home needs to attend an outpatient clinic? What additional precautions have been put in place? What changes have been made? I have a view, which I expressed on a number of occasions, that rather than people from nursing homes coming into outpatient clinics, a member of HSE staff would visit the nursing home, perhaps on a monthly basis, to deal with all the issues arising. Will the witnesses come back to me on those issues?

Mr. Paul Reid

I will come back on some of the points and I will ask my colleague, Ms O'Connor, to respond to the temporary system payment, the procedure in nursing homes with regard to outpatient attendance and the expert panel.

The Nursing Homes Ireland engagement has not ceased at all. In fact it has probably increased in the last few weeks with the HSE specifically. We talk with Tadhg Daly, who is actively involved, and with Nursing Homes Ireland. The individual nursing homes have been very involved in scheduling and organising the serial testing all across nursing homes. Tadhg is on calls with our teams and with Ms Niamh O'Beirne who leads the testing process. I am on a call with Tadhg tomorrow and our colleagues on the community side are regularly in contact with Tadhg. I would say that the engagement has not ceased and has in fact probably increased over the last while. I am happy for it to continue. I will now ask Ms O'Connor to comment on some of Deputy Burke's other points.

Ms Anne O'Connor

On nursing homes, the statutory, or the assistance scheme is, as the Deputy has said, administered by the HSE. In the work we have been doing to support nursing homes the Deputy will be aware that we established the Covid-19 response teams early in the pandemic and we look to continue those from now on. It became apparent that the support relates to the clinical oversight in nursing homes and how we support people who require that clinical governance. It is something we are actively working on and this aspect features in the report we got last week. The first meeting for the oversight of the implementation of the report happened yesterday. From our perspective, with regard to people attending outpatient appointments there are agreements around testing for people accessing any of our services in hospitals prior to attendance. Our priority, however, is to be able to ensure we can provide support to people in nursing homes as they need it. Building on the learning over the last couple of months and building on the experience of the Covid-19 response teams, which have been proven to be extremely positive, we will continue that to see how we can provide more comprehensive support.

I thank Ms O'Connor and Deputy Burke. Perhaps the witnesses could reply to the other questions in writing.

Can I get an answer to my query on the support to nursing homes providing community services and healthcare services to people who hold medical cards but are in nursing homes? Up to this they have not really been able to access community healthcare services because they were deemed to be in nursing homes. What changes have been made in that regard? The witnesses might come back on that.

Ms Anne O'Connor

We are examining all of that in the context of how we provide better clinical supports to people in nursing homes. As the Deputy said, there are many people in nursing homes who have medical cards. I think the experience differs around the country in what people can access at a local level. We are looking at that in the context of our work.

I thank Ms O'Connor. Ms O'Connor might supply more detail for Deputy Burke in writing, including when it is anticipated that people might be able to access the normal range of services provided with the medical card.

The next speaker is from Fianna Fáil. Will it be Deputy McAuliffe or Deputy Lawless?

I will take five minutes and give the remaining five minutes to Deputy Lawless. The Chairman might assist me in indicating when the five minutes is up.

I appreciate Mr. Reid and his team coming to us again today. I will take us back to the first days in March when there was an outbreak in a local school in my constituency. Some of the communications around the early stages were possible because there was a small number of incidents. Given the reopening of schools taking place, has the HSE looked at the communication strategy for what will happen when an outbreak takes place, as it inevitably will, in a school?

In my experience, there was much confusion, particularly because of social media and because the information was able to travel so quickly. In the absence of any statutory decisions on what would happen, all sorts of confusion emerged. If an outbreak takes place in a school, will all the children have to self-isolate? Will brothers and sisters have to self-isolate? Will team members of a local soccer or GAA group have to self-isolate if cases emerge there? We need to be really clear because a strong communications strategy is really necessary, alongside the public health strategy.

Mr. Paul Reid

I will answer two parts of the Deputy's question and I might ask my colleague Dr. Henry to comment also. In the first instance, as the Deputy quite rightly noted, as the virus emerged in February and March the country was scared. I thank the Deputy and other local elected representatives for their support during that process. We at the HSE went out publicly and met parents and teams at various schools. The Deputy is correct to ask how we can manage that situation if there are schools with cases or potential outbreaks in the next few weeks. The first thing to say is we should plan on the basis that there will be positive cases and that it is likely there will be outbreaks throughout the country in different schools. That is the most likely scenario we have to work towards and it is the one on which we have been working with the Department of Education and Skills. We have given the Department clear guidance on its role, on communicating with parents and on our role, which is primarily led by our public health teams.

I will finish with a brief comment because Dr. Henry covered a bit of this earlier. I know that people have the urge to get a kind of checklist of what will happen in various situations, where boxes can be ticked, but our public health teams largely go in and assess each school, in this case, or organisation on its individual drivers of the transmission of the virus and various other factors. The primary driver of our communications will be through local public health teams, in conjunction with the Department of Education and Skills and local schools in how they communicate to parents. The public health approach involves, exactly as Dr. Henry outlined, a range of factors, including the numbers of cases, how rapid is the spread of cases, the impacts of the cases in terms of hospitalisations, what is happening in the community, what is the response of the local management of the school, and how we get reassurance of what measures were taken or are having an effect. All of that is geared towards not getting to a scenario of shutdowns. We will be driving a range of processes, public health led by our public health experts, but communication will be directly from the Department of Education and Skills and local schools to parents.

Dr. Colm Henry

To reiterate, it is unrealistic to expect we can eradicate risk; we cannot. I recall the committee meeting at the beginning of March when we communicated that clearly. Viral upper-respiratory tract symptoms are very common in primary school children and the vast majority are due to more common ailments. In communicating this to parents, principals, teachers and wider society, we are trying to strike a balance between the significant health and well-being benefits for children in education, that is, the opportunities this presents to health, such as vaccines and screening for vision, hearing and so on, versus the risk of transmission of the virus. As I said earlier, the emerging evidence is that child-to-child transmission in a school setting occurs at a lower frequency and is rarer than we initially thought. What we have to have in place is clear communication to GPs, a clear definition of cases, insofar as we can when one considers all the other illnesses children get at that time of the year, and a rapid testing strategy for those who are funnelled through to testing as determined by a general practitioner. As I said, we have been working this week with primary care and public health teams to create an algorithm for this purpose.

I call Deputy Carthy, who has five minutes.

We will go round the room and come back to the Deputy.

To be clear, I had ten minutes on this slot. Fianna Fáil has not-----

No, it is ten minutes at the start and then five-minute slots thereafter.

Yes, but the Chairman might remember that at the beginning, Fine Gael-----

The Deputy is using time. I am going to-----

Sorry, Chairman. Fine Gael and Sinn Féin each had ten minutes at the beginning. Fianna Fáil has not had a ten-minute block for the entire session.

Fianna Fáil has now had 15 minutes. This is eating into Deputy Lawless's time, because I have to eat into somebody's time and it is only fair.

This is incredibly unfair.

The first Fianna Fáil speaker was Deputy Pádraig O'Sullivan, who had five minutes. The second was Deputy Murnane O'Connor, who had five minutes. The third was Deputy McAuliffe, who had five minutes, and the fourth, Deputy Lawless, will also have five minutes.

We have not had a block of ten minutes.

You had the option of taking a block of ten minutes at the start, as does everybody else.

I thought I cleared that with you earlier. Obviously, I was wrong.

I am being as fair as I can. I am sorry. Will Deputy Carthy start again please?

I want to focus on food processing plants and meat factories. It is fair to say, unless our guests want to contradict me, that outside of healthcare and residential settings, food processing plants are by far the most likely workplace in which Covid-19 clusters emerge.

I have two questions. On what basis does testing currently take place in these types of factories? In other words, is testing random, routine or does it only take place where a case is suspected or confirmed? Whose responsibility is it to inform the public when confirmed cases emerge from these factory settings?

Mr. Paul Reid

On the process for food processing plants and meat plants in general, what happens is the testing process is determined and the public health team guides whether it is mass testing. It is kind of similar to what I just relayed around the criteria for schools. It would assess it based on the transmission of the virus, the seriousness of the cases emerging from the virus, how local management has adapted to the requests for implementation of certain measures, the capacity of the plant to implement the measures and the capacity of the workforce in complying with the implementation of the measures. Our public health teams then assess all of that and the nature of the transmission from and into the community. They address all those factors and determine the testing approach and whether that is mass testing. We would then assess both in terms of serial testing in conjunction with NPHET. We have done a combination of both. We have done mass testing in plants where outbreaks emerged-----

I asked what the current basis is. Whose responsibility is it to inform of confirmed cases within factories?

Mr. Paul Reid

I will ask Ms O'Beirne to respond.

Ms Niamh O'Beirne

At the moment we are doing what we call serial testing. It started last Friday. We are covering all the primary meat processing factories in the three counties and some food processing companies also. That is taking place this week. The results go back to the individual in all circumstances. That is the best-----

Whose responsibility is it to inform the public when a positive case emerges in a factory setting?

Ms Niamh O'Beirne

The HSE communicates to the individual. Our accountability is to the individual.

These questions are important because we know these centres are the source of considerable outbreaks that arguably led to more restrictions being put in place. Earlier this week, for example, it emerged that two workers from the ABP factory in Clones had contracted and tested positive for Covid-19. It then emerged those cases had been confirmed ten days ago but testing was only taking place this week. Throughout all that period the factory has been operational.

A similar situation occurred in Cahir on County Tipperary where it emerged this morning that as well as the initial cases, there have been 22 further Covid-19 cases. One can appreciate the absolute anxiety occurring within the counties in which these sites are located because of the experience of Kildare and other counties.

When it emerges that a positive case has been detected in a meat factory, does the HSE consider itself under any obligation to inform the public?

Mr. Paul Reid

I will make a couple of quick comments on that. On a daily basis-----

I do not want quick comments. I just want a "Yes" or "No" from the CEO.

Mr. Paul Reid

I am sorry, it is not a "Yes" or "No" answer. I need to give the Deputy the detail of it, specifically regarding daily cases that emerge. They are published on the HPSC website in terms of the local electoral district area and are communicated by NPHET at its weekly conferences. We also communicate them. That is on the website and I am happy to share the links. I urge a word of caution in terms-----

I apologise to the CEO because my time is running short. As well as asking whether Mr. Reid considers it important to inform the public, I will also ask him why testing is being carried out at the plants I mentioned by private companies. Why is the HSE paying for it?

Did the meat factories request that the public would pick up the bill for that?

Mr. Paul Reid

In response to the question, as I clarified earlier on, where we carry out the testing we fund it. If it is carried out privately by the meat plants, they fund it. That is the approach. I would urge a word of caution and I know that NPHET has communicated on that-----

Can I ask-----

Mr. Paul Reid

Can I just finish my point?

Can I have a response in writing on the funding aspect of all of this-----

Mr. Paul Reid

Can I just finish, briefly-----

-----and the language used. All of the information we are getting in respect of the meat plants is coming from the meat factories themselves and I do not trust them, to be quite frank about it. They are saying that testing has been carried out by private companies in conjunction with the HSE. I want to know who is actually paying for that and if it is the public purse, why is the public paying for this provision given that every other business in the country has to cover the cost of Covid-----

I think Mr. Reid has been clear on that but I will ask him to confirm-----

Mr. Paul Reid

If I can, one last time, confirm-----

-----that the HSE pays for the testing it carries out and the plants pay for testing carried out by private companies.

One can see where the language-----

I will allow Mr. Reid to answer but very briefly.

Mr. Paul Reid

I can confirm that where it is carried out by a private organisation, where a meat plant carries out the testing privately, it pays for it. Where it is mass testing carried out by the HSE, we fund it.

Thank you Mr. Reid.

Mr. Paul Reid

Can I just make one very brief point? I wish to urge caution from the public's perspective. There was a really interesting study from the ESRI released this morning. What we are seeing in the transmission of the virus is that it is not just in meat plants. In fact, a high prominence of transmission is in various workplaces and largely community, social and home settings. The ESRI report made a very good point regarding the public's perception of blame in terms of transmission. I would just put it in the round. The transmission we are seeing, as NPHET and Professor Philip Nolan will outline later, is quite wide ranging. Transmission of the virus is across a whole range of sectors and settings.

I do not propose to get into that now as we are under pressure with time. The next speaker from Fine Gael is Deputy Durkan who has five minutes.

Initially we must all acknowledge the Herculean work done by the HSE in dealing with this virus nationally and locally. The executive is to be commended on its work and the efforts made by its front-line and other staff. My questions relate to the lessons to be learned in respect of County Kildare and the adjoining counties which were put under the first lockdown and County Kildare which is now under a second one. What were the most important lessons learned and what action has taken place as a result? To what extent has the HSE identified entirely the sources of the upsurge in Kildare and its causes? Have they been forensically examined with a view to addressing the issues arising? To what extent have responses to the issues arising from any investigation been implemented and to what extent are they in place at the present time? My last question relates to how the lessons to be learned from Kildare can be applied nationally. Are those lessons being applied nationally? Particularly in the context of the reopening of the schools, is it possible to apply a formula nationally based on the lessons learned from the Kildare and adjoining counties situation?

Mr. Paul Reid

I thank Deputy Durkan for his questions. I will make some brief comments and then ask my colleague, Dr. Henry, to respond. On the issue of lessons, the NPHET delegation including Dr. Ronan Glynn and Professor Philip Nolan will give the committee some insights later on but in terms of the transmission of the virus and the actions taken, largely what we were seeing was a mass transmission into the community. The actions taken and the approaches recommended by Government were directly related to what the analysis was demonstrating in terms of transmission. One key lesson is that the public health measures are absolutely key. We have spent a lot of time today talking about testing and tracing and rightly so but I feel the need to really emphasise that the public health measures are our 80% factor in terms of suppressing this virus and mitigating against further transmission. Testing and tracing can be a 15% to 20% factor; an important one but not the major factor. The big lesson is and remains the role of the public health measures. In terms of actions and their impact, I may have picked up the Deputy's question incorrectly but I think it related to specific actions that we would have implemented in the context of the mass testing that we carried out in meat plants and food processing plants.

Our public health teams will be overseeing the implementation of those actions and the national standing oversight committee would be assessing the whole sector in terms of responsiveness to some of the measures we would have to put in place specifically in respect of that. I ask Dr. Henry to describe any wider lessons.

Dr. Colm Henry

The experience in the three counties and particularly in Kildare shows the lesson we have already learned, not just in this country but abroad. Even though we may change, the virus has not. As I said earlier, the evidence is that the virus has not changed. It is not less vicious or transmissible. In an uncontrolled setting the doubling time is a matter of days. A small number of cases can lead to a rapid escalation if uncontrolled and unmitigated. What we saw in Kildare and the other counties to a lesser extent was the hazardous effect of open clusters and how they can seed out into the community, hence the measures that have been continued in Kildare. With an incidence rate over 14 days of 180 per 100,000, that presents a real and immediate threat to widespread community transmission, which is a huge threat to safety, health and well-being and to the continuation of health and education services in Kildare and beyond. Allowing for the fact that counties are not enclosed structures in themselves, it presents hazards to contiguous counties including Dublin. The virus has not changed. It is very transmissible. Outbreaks whether in meat plants, workplace settings or elsewhere, can seed out into the community. That is where it is important to emphasise that for a virus for which there is no treatment and no vaccine, those measures which we all know by heart by now are the first and primary line of defence. When we have outbreaks, rapid identification, isolation of cases and contact tracing represent the second line of defence. That is the work of our public health colleagues and I pay tribute to their diligence in Kildare and beyond.

I am sorry to have to cut Dr. Henry short but we are running out of time. The witnesses might provide written replies to the additional questions that Deputy Durkan raised. I have to move on to the next speaker.

I thank Mr. Reid personally as I have been following his Twitter during the pandemic and it has been very informative, and I thank all of his team right down to local level. The HSE staff in Kildare I have been dealing with have been very professional and committed. They have made sacrifices themselves and have been very much on top of all this. I represent Kildare, which is in lockdown again. It is effectively the third lockdown because we had the original lockdown like everybody else, a second lockdown and then a third, unlike other counties. Would it be reasonable to deduce that Kildare has the highest rate of transmission or incidence per 100,000 of population in the country? It seems to be the most acute hub of incidence right now according to the advice and the fact that we are under lockdown again. In that context it is reasonable that every effort be made to ramp up testing, to make it available at all corners and to remove any barriers to doing so. I was made aware recently of an issue arising if a suspect case presents out of hours in Kildare. A constituent of mine presented last Saturday to the only out of hours health service available in Kildare, which is KDOC. Unless patients have a medical card, they have to pay a €50 consultation fee. I confirmed with the Minister for Health on Saturday that the HSE's position is that Covid testing is free of charge. No barriers should be put in front of anybody presenting for a test. The principle applies across the country but it is particularly acute when Kildare is the only county in a third period of lockdown and appears to be the epicentre of Covid in Ireland. I have had extensive conversations with KDOC's management team and they advised me they are aware of the HSE guidance. My understanding is that there is an operational agreement yet to be entered into or signed off on. Time is not a luxury that we can enjoy here. We are into our third lockdown and have ten days. The clock is ticking to see if we can escape from that. We do not know how many more cases are transmitting or about to be identified in the community.

If people are being turned away from test centres because there is a €50 charge for the test and they cannot afford it, that is not good enough. I can see both sides of the story but heads need to be banged together to get this matter resolved. I hope Mr. Reid can advise us of good news on the matter this morning.

Mr. Paul Reid

I thank the Deputy for his opening comments which, I am sure, our teams around the country and all Deputies will appreciate. On the question regarding testing in Kildare, I agree with the Deputy. We have put in significant resources, including the installation of pop-up centres throughout the weekend of the emerging outbreaks, the national ambulance service, home visits and extended opening hours of a range of centres in the county and outside of the county.

On the specific out-of-hours issue, I was in dialogue with the Minister on it. I understand the Minister engaged with the Deputy on the issue over the weekend. There should not be a charge for out-of-hours services for Covid referrals. There is a national agreement. The agreement was due to expire but it has been extended and is under discussion in terms of a further extension. It is expected that will happen. It is applicable all across the country. I will ask my colleagues to get under the bonnet in regard to KDoc to find out exactly what the issue is. At a national level, we have extended the agreement to all out-of-hours services and there should not be a charge. We have to close out whatever the issue is in that regard.

I appreciate the response. It is an issue of the utmost urgency because, as things stand, if a patient presents to KDoc out-of-hours services this evening he or she will be charged. I do not believe that is good enough. The Minister for Health, Deputy Harris, and Mr. Reid also do not believe it is good enough. That dialogue has to take place with KDoc. In fairness to KDoc it has put forward operations and lack of agreement as the issues arising. This issue needs to be addressed as a matter of utmost urgency and I would appreciate if it could be tackled today.

Mr. Reid might liaise with Deputy Lawless following the meeting. The next speaker is Deputy Louise O'Reilly.

I welcome our guests. I join with others in commending the work that the men and women from every grade, group and category in the HSE and the broader health service have been doing over the past number of months and continue to do now.

My questions are, as ever, fairly simple. I ask Mr. Reid to outline how the HSE and the contact tracing personnel communicate with the Border Management Unit in regard to people who travel here through our airports and sea ports in terms of follow-up, which all of the available evidence suggests is scant and rarely happens. Does the HSE communicate with the Border Management Unit with regard to contact tracing, follow-up or additional testing that might be required?

Mr. Paul Reid

I thank the Deputy for her comments. On the issue of tracing and border management we are clear in terms of the HSE's role, which is tracing and follow-through. The matter of where people are staying and if they are where they declared they would be is one for a separate agency-body and it is carried out through a separate process. I will ask Ms O'Beirne to confirm the dialogue and process in that regard.

I ask Ms O'Beirne to be brief as time is tight.

Ms Niamh O'Beirne

We do communicate. We seek manifests from the flights, which give us details of people on those flights and their contact details when we are doing a trace of a particular flight.

Beyond that, there would not be any dialogue between the HSE and the Border Management Unit? In other words, the unit does not keep the HSE informed of numbers or let it know how many people have been followed up, if any.

Ms Niamh O'Beirne

It does not come directly to the HSE with that information.

Would the HSE not think of asking for that information? Is it not important?

Ms Niamh O'Beirne

What is important is that once there is a confirmed case on a flight we do detailed contact tracing of that flight and that individual and refer those individuals for testing. That is what we do within the contact tracing centre.

With regard to contact tracing, how many people are full-time employed in that regard? I am seeking not just any number but the whole-time equivalent, WTE, as of today. How many people are working on it today?

Ms Niamh O'Beirne

There are 100 people working full-time today.

I thank Ms O'Beirne. How many people are currently in Citywest?

Ms Anne O'Connor

We have about 100 for self-isolation and we had about 60 healthcare workers.

There are 60 healthcare workers in the field hospital.

Ms Anne O'Connor

No, the field hospitals are all part of the self-isolation facility. In the self-isolation facility we provide two different types of accommodation, one of which is for people in general who need to self-isolate and are referred through public health, their GP or acute hospitals. The second cohort is healthcare workers who need self-isolation as they are returning to Ireland to work. The care facility does not have residents. We use it for initiatives such as the drive-through glaucoma testing. We are working with Children's Health Ireland on other initiatives such as accessing allergy testing for children.

There are 130 people on trolleys today. Could none of those be accommodated in Citywest?

Ms Anne O'Connor

No, not in its current format.

That is regrettable. The last time representatives of workers in the meat processing industry were before the committee, they informed us that there was a delay in receiving test results of up to four days. In the intervening time, a person who was tested went back to work and the line that person was working on subsequently became infected. I note the figures relating to the median but we also know they are skewed by the healthcare workers who have a very tight and fast turnaround time.

When we spoke to representatives of workers in the meat and food processing industry, I was struck by the lack of information available to workers in their own language. We know this is a migrant workforce. Is that information now available or was it always available and somehow magically never made it to the floor of the factories? If that information is available, in what languages is it available? How does it get into the hands of the workers who need it? A person who was tested went back to work, which is obviously not the advice. I am trying to ascertain how that happened.

Dr. Colm Henry

Dr. Mai Mannix is a public health specialist who has led out on this nationally. Part of our response is to provide information and advice in multiple languages to workers in meat plants. We can come back with a specific figure on the number of languages.

I would also like to know the number of leaflets that have been distributed. They are no use if they are sitting in boxes in Dr. Steevens' Hospital. They have to make their way into the hands of the people who need them. Will Dr. Henry provide the committee with information on how many were distributed and the distribution channels so that we can confirm they are getting to those who are supposed to get them?

Ms Niamh O'Beirne

We agreed yesterday with the meat plants. They gave us the languages and we agreed to start with Polish and Lithuanian. We will continue with a series of other languages for the documents on serial testing.

I have some brief questions before we conclude. There has been much talk about the travel locator form. The Dublin Airport Authority, DAA, has been contracted to follow up with people who come into the country. Was that agreed by the HSE or another Department or Government agency?

Mr. Paul Reid

The Department of Health is ultimately the data processor and lead on the data privacy impact assessment, DPIA, and so on. We are a sub-processor so we carry out some processes for it. The Department is the lead on the agreement the HSE has developed, the e-locator form and the technology for it. The agreement with the DAA relates to the contacts and a call centre which makes contact.

Was it the HSE which contracted the DAA to do that?

Mr. Paul Reid

No, it was directly contracted from the Department of Health.

I will raise that with the Department later.

I congratulate the HSE on sourcing so much PPE. There was a major challenge in sourcing sufficient PPE on the world market at the start of the pandemic. I have seen some of the PPE the HSE sourced and has stockpiled in the event that is necessary. I will not get into the issue of nursing homes as we will have a separate session on that later, save to ask whether the HSE will provide PPE to nursing homes in the event they are unable to obtain it on the open market if there is an outbreak? They say they are still unable to do so.

Mr. Paul Reid

We are still very focused on procuring PPE for the rest of the year and through to March 2021. We have secured orders that would see us through to March next year. Some 59 million items arrived this week and 10 million items will arrive next week. The distribution of those will continue as before, primarily large supports to nursing homes provided by the State. That will continue.

We have received good reductions in price in the area of procurement based on what has happened in the market.

It is strategically important that we have PPE in the event of a further outbreak of Covid-19 or of a future pandemic and there is an issue around Brexit. Is there a strategic plan for this going forward? The HSE has done what it had to do, and it has done well in obtaining the amount of PPE required. Is there a plan in place to have a stockpile of PPE or to manufacture PPE to provide long-term sustainability of supply?

Mr. Paul Reid

We have two immediate stockpiles in both of our major warehouses. Separately, our strategic plan at the start of this was to work with other Government agencies and Departments to scale up existing indigenous industries to transition them towards PPE manufacture. We have had some good successes with that in certain line items of PPE, particularly masks, gowns and some gloves. We are working with other Departments and agencies to scale up Irish industry capacity to produce PPE. That is where we would like to see our efforts focused but we will be guided by public procurement requirements.

Hospital overcrowding is a recipe for disaster if it is accompanied by an increase in transmission of Covid-19 in the community. University Hospital Limerick is consistently the most overcrowded hospital in Ireland. I was informed by the previous Minister for Health, Deputy Harris, and by Mr. Liam Woods, a senior member of Mr. Reid's team, that there were plans to scale up the services being provided in tier 2 hospitals to alleviate overcrowding in University Hospital Limerick. We have not seen any sign of that yet. Where are those plans? When will we see an increase in the number of procedures being carried out in tier 2 hospitals such as Nenagh General Hospital, St. John's Hospital and Ennis General Hospital to alleviate the numbers presenting at University Hospital Limerick?

Mr. Paul Reid

I will ask my colleague, Ms O'Connor, to talk about our plans for the coming weeks and months as well as the capacity in University Hospital Limerick and services distribution.

Ms Anne O'Connor

The Chairman correctly pointed out that we have been challenged in recent years, not just during the Covid-19 pandemic, with regard to capacity in the mid-west. We have been working closely with the various sites to scale up capacity. It is important to note that in University Hospital Limerick, in particular, we have new capacity coming on stream. We have the sports arena that opened for a short-term bridging period but we have additional beds opening on the site of the main hospital over the coming months. That will make a significant difference to that area. As part of our planning for winter and for next year, we have done an extensive modelling exercise that shows the impact of all of the different proposed investments. The beds that are coming on stream are expected to make a significant difference in that area. Clinicians in the area are also committed to looking at what initiatives can be driven in a more integrated way. That part of the country could be used as an example for good integrated working between community and acute services.

When will we see an increase in the number of procedures being carried out in the tier 2 hospitals? We were told that would happen.

Ms Anne O'Connor

I would have to look at that. I do not know the dates but work is ongoing on that.

Can Ms O'Connor provide that information to me in writing?

Ms Anne O'Connor

We can look at that.

I appreciate that. Mr. Reid might also revert to me in writing about how the plan to scale up indigenous production is coming along. I have been looking through the HSE website and I do not see advice for incoming travellers, although I see a link to other advice. I might raise that matter with the witnesses after the session because there is no point in all of us looking at mobile phones to find out where exactly the link is.

I thank the witnesses for coming in and answering all our questions. I congratulate the HSE on its response to date. It has not been perfect but it has been enormous and perfection is not attainable in this life or in this world.

Sitting suspended at 12.15 p.m. and resumed at 12.45 p.m.