State Response to Recent Spike in Covid-19 Cases (Resumed)

I apologise to our witnesses for starting slightly later than anticipated. I can see they are taking their seats. I welcome Dr. Ronan Glynn, acting Chief Medical Officer, CMO, and head of the National Public Health Emergency Team, NPHET, and Professor Philip Nolan, chair of the NPHET Irish Epidemiological Modelling Advisory Group.

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 ask everybody to confine their speaking slot strictly to five minutes because there are many questions and time is limited. I ask Dr. Glynn to make his opening statement.

Dr. Ronan Glynn

I thank the Chair and members of the committee. The public health response to Covid-19 to date has been guided by public health data and expertise and international best practice, and has been underpinned by ethical principles, including the minimisation of harm, proportionality, solidarity, fairness and privacy. The central focus of our response has been to control the spread of the virus in so far as possible to protect those who are most vulnerable from infection, as well as protecting against causes, situations, circumstances and behaviours that can lead to the spread of Covid-19.

In the absence of a vaccine or treatment at present, the key to controlling Covid-19 is to adopt a proportionate, dynamic and stepwise response tailored to the evolving epidemiological situation and the wider public health and health service context. The foundation underpinning this approach has been the wide acceptance of, and buy-in to, the basic but essential public health protective measures, including hand hygiene, respiratory etiquette, social distancing, avoidance of crowds and the use of face coverings, where appropriate, by the Irish public. People in Ireland have shown that they are willing to follow public health advice to protect themselves and others. We have seen tremendous solidarity and co-operation across society and across sectors in response to this pandemic.

It has now been nearly eight months since the world first became aware of this new coronavirus. Worldwide, there have been more than 23 million cases, and 810,000 people have sadly died as a result of this virus. In Europe, while the situation had stabilised in early summer, many countries are now seeing an increase in cases and have had to reintroduce public health measures.

Here, our own public health approach proved effective and by 24 June our five-day average was just six new cases per day. However, since the beginning of July there has been a gradual change in our epidemiological situation, and by the end of July a large number of cases emerged rapidly in Kildare, Laois and Offaly. These cases were initially predominantly linked to several large clusters in food processing plants in the region. There were also several linked clusters in direct provision centres.

As the committee is aware, NPHET was monitoring the situation in that region closely and made related recommendations on 30 July and 4 and 6 August regarding the protection of vulnerable groups living in congregated settings; the mitigation of risk in high-risk workplaces; and the continued enhancement and strengthening of the public health, testing and contact-tracing functions in the HSE. On 7 August, NPHET recommended to the Government that a series of enhanced public health measures should be introduced in the three counties for a two-week period to bring the situation under control and prevent widespread transmission.

The NPHET reviewed the situation on 20 August and advised the Government that the position in Laois and Offaly had improved and the measures did not need to be extended. The situation in Kildare was different. While there was a certain level of stabilisation, a high number of cases continued to be reported daily, with cases widely distributed across the county and with incidence rates at several multiples of the national average. Several facilities were still undergoing mass testing as a result of recent cases and there was evidence of some increasing community transmission in the county. For that reason, NPHET recommended that the measures in Kildare should be extended until 6 September.

Separately, on 17 August, NPHET considered the deteriorating epidemiological situation across the country and recommended several public health measures to apply nationwide until 13 September to mitigate against any further increase in cases.

I am fully aware of how disappointing and frustrating recent events have been. As a country, we have demonstrated so much resilience, solidarity and resolve throughout this pandemic. We have set aside our plans and put our lives on hold for many months to suppress this virus. As a society, we have done that incredibly effectively. Although we have taken a step backwards, this is not irreversible. With the continued support and collective effort of people in Ireland, we can stop the rise in cases and protect what must be our three priorities in the coming months: the protection of the most vulnerable in society, the resumption of healthcare services and the return to education for children and young people.

This is a marathon and I know people are tired. I acknowledge the enormous and ongoing effort and sacrifice by people in Ireland to help protect each other during this pandemic and I ask them to continue to stay the course with us. By continuing to work together, by building on the individual and collective action which has characterised our response to date and by supporting each other, we will navigate our way together through the months ahead.

I invite Professor Nolan to deliver his introductory remarks and ask that he limit them to five minutes.

Professor Philip Nolan

I am glad to have the opportunity to update the committee on the work of the Irish Epidemiological Modelling Advisory Group, IEMAG, and, in particular, to offer some perspectives on the recent increase in the incidence of Covid-19. We need to be aware at all times that statistical analyses and mathematical models provide very useful insights but have important limitations. As such, our input has always been and must always be contextualised within the wider public health expertise available within NPHET.

The strict public health measures put in place between March and June 2020 brought the pandemic under control. As of 18 June 2020, the date of phase 3 reopening, we were detecting, on average, 13 cases of Covid-19 per day and had a 14–day cumulative incidence of 5.2 per 100,000 population. Thereafter, the level of disease continued to decline for one to two weeks such that at the end of June and in early July the average number of new cases per day was ten and the 14-day cumulative incidence was 3.2 per 100,000. We estimated at that point that fewer than one in 30,000 people in the population had an active infection.

However, from late June onwards, we began to see an increase in incidence. This appears to have had three components. First, an increase in viral transmission seems to have begun soon after 18 June, leading to a small, slow increase in cases over the period from 7 July to 20 July. This is understandable and, to a certain extent, was expected. As people increased their numbers of contacts and perhaps began to relax a little with regard to hygiene and physical distancing measures, the virus transmitted more easily. This was associated with an increase in the reproduction number above 1.0, which was clearly flagged to the public in early July. The public seems to have responded by taking added precautions, as case numbers and the reproduction number decreased again towards the end of July.

Second, a number of large outbreaks in counties Kildare, Laois and Offaly, as alluded to by the acting Chief Medical Officer, developed in the week beginning 27 July 2020. These outbreaks were quite explosive, with the virus entering and spreading rapidly within specific workplace settings. Epidemiologically, this acted as an amplifying event and significantly increased the overall burden of disease in the country as a whole and in counties Kildare, Laois and Offaly in particular. The outbreaks were controlled, and significant community transmission prevented, by the outbreak management actions of public health teams, as well as population level public health measures applied in those three counties, as Dr. Glynn mentioned.

Third, since early August and in parallel with these events, we have seen a wide variety of smaller outbreaks with modest levels of community transmission. The cases associated with the major outbreaks to which I referred seeded further outbreaks in households and extended families, but separately, and much more widely within the country, sporadic cases led to household and workplace outbreaks which spread between households and in a variety of workplace, social and sporting settings and, hence, more widely within the community.

The most recent set of public health restrictions to limit indoor and outdoor congregation and mixing between households is specifically aimed at minimising this inter-household spread and keeping community prevalence and transmission to a minimum. It is my evaluation that these challenges were anticipated and detected quickly and that the responses were timely, specific, proportionate and, in so far as we can tell at this time, effective. It should be noted, as Dr. Glynn has done, that similar patterns of resurgent disease have been seen in other jurisdictions in recent weeks.

We are at an important juncture. The next few weeks will show whether we, as a society, are capable of resuming the most important of our social, economic, educational, healthcare, cultural and sporting activities without spreading the virus between households and into our communities to any significant extent. They will show whether we are, as the acting Chief Medical Officer has put it, capable of "protecting our priorities while living with the threat of this virus and keeping it at bay". I would like to record again my appreciation of the team of academic and public service colleagues who support the work of the modelling advisory group, the public health colleagues who work tirelessly to protect us from this virus and, at the same time, provide us with the information that informs our analyses and understanding of the disease, and, like Dr. Glynn, my appreciation of the general public, whose fortitude and solidarity in the face of this crisis are inspirational. I am happy to answer any questions members may have.

I am sharing time with Deputy Lawless. I pay tribute to all our health professionals, as I did during the earlier session with the witnesses from the HSE. It has been a very trying time during which the focus has been on protecting lives. We, as Members of the Oireachtas, have to be very careful that we put people's health and lives first. As we head into the cold and flu season, there is some confusion as to whether we are going into a second wave of Covid infections. The witnesses may have heard the discussion on the radio this morning where we were told that people are not aware that they can ring their doctor free of charge to get information about Covid symptoms and what they need to do if they have them.

I have been dealing with the concerns of local businesspeople over the past few months. The witnesses referred to the restrictions in counties Kildare, Laois and Offaly. I live in the Graiguecullen area of Carlow town, which is half in Carlow and half in Laois. Some businesses in the area have had to close, which was very hard given that we are so far away from the outbreaks in Laois. I spoke to the Minister about their situation and asked for a buffer to be applied. If something like this ever happens again, which I hope it never does, there must be better communication with the businesses and people affected. There are housing estates in Graiguecullen that are half in Carlow and half in Laois and there was huge confusion among the people living there. When information is given on these types of restrictions, there needs to be clarity on where exactly they apply and consideration should be given to a buffer zone.

My next question relates to testing. We saw last week that 13,000 tests were done in one day, which, months into the crisis, was the highest number of tests done in a single day. Are we going to see a ramping up of testing as the schools reopen? Recent infections seem to be happening in clusters, including in meat factories and direct provision centres. What is being done in regard to that pattern of infections? I have had several telephone calls from people asking about what testing is being done at airports, which is a huge concern for me. I am not aware of any definite cases but my understanding is that people coming in from red zone countries are not self-isolating for 14 days.

I am also concerned about whether we have enough personal protective equipment, PPE, particularly in view of the spike in cases and as schools and hospital services reopen. It is vital that we have adequate supplies of PPE for front-line service staff.

The most pressing question I have concerns wet pubs. Like all of us here, I have been contacted by owners of wet pubs who say they will be able to control their environment. Their businesses are the only ones that have not reopened and many of them do not know whether they will be allowed to open. In addition, there was huge confusion last week among owners of dance studios and theatres regarding the reduction in permitted indoor numbers from 15 to six. Several dance studio owners contacted me to say that this new restriction will see them lose their livelihood. I understand that the witnesses must put people's health first but where we are talking about a controlled environment in which the guidelines can be followed, why was the decision made not to open wet pubs and not to allow dance studios and other businesses to have 15 people instead of six?

Perhaps Dr. Glynn will respond to those questions. I realise there are a lot of them.

Dr. Ronan Glynn

I thank the Deputy. Her key question is whether we are on the cusp of a second wave. I hope we are not but there is no doubt we have seen a deteriorating situation over the past couple of months, if we are being honest, since the start of July. It is no surprise that we have seen more cases as we have eased restrictions and that we have seen a greater proportion and a greater number of cases in younger people. All of that is normal and I will take this opportunity to counter the narrative of blame that has been taken up around younger people. Younger people go out to work. They run our health service and our education service. They keep society going and so they come into contact with other people. By the nature of their lives, we will see more cases in younger people.

That said, we have grown increasingly concerned, overall, at the number of cases we are seeing. That led to the recommendation of the additional measures last week for the country. I know there has been some confusion around those measures but, at its heart, we are asking people to cut down their discretionary social contacts. We understand that is difficult for people but if we do not cut down the number of people that each of us comes into contact with, there is no doubt but that, unfortunately, the number of cases will continue to rise. If the number of cases continues to rise, it will inevitably lead to more cases in older people and those who are medically vulnerable. They have to be our central focus in this. All over Europe we are seeing an increase in cases. So far, all over Europe we are seeing an increase in cases in younger people without a concomitant increase in hospitalisations in ICU but there is no guarantee that will continue. If our number of cases continues to rise, we would be concerned about the impact that will have in terms of hospitalisation, admissions to critical care and mortality.

In relation to-----

Sorry, I have to cut Dr. Glynn short. He may want to provide a further reply in writing to Deputy Murnane O'Connor. The next speaker is Deputy Ó Laoghaire. He is taking six minutes, which is unusual.

I thank Professor Nolan and Dr. Glynn for their efforts to date in fighting this pandemic, which have been extraordinary. I know the people of this country are grateful as well. I have six minutes and that is to include answers so, as much as I appreciate public health and epidemiology are complex and do not lend themselves to brief answers, I would appreciate it if the witnesses could be as brief as possible.

I will be focussing on schools and education, which is one of the biggest issues the public is concerned about at the moment. We have an underfunded and overcrowded education system. An example of that is the grotesque sight of an isolation room in a national school in Athlone in a garden shed. I do not put the blame on the school but on Department of Education and Skills underfunding. I know the witnesses cannot comment on that. Because of overcrowded school estates, social distancing is simply not possible in some schools due to a lack of space. That is the reality at this time. The implied message from the Department seems to be to carry on regardless. That is what I am picking up. If a school cannot achieve social distancing, is it safe for it to reopen? I ask Dr. Glynn to answer that question.

Dr. Ronan Glynn

I thank the Deputy. The guidance around the need for social distancing and the differential needs for social distancing by age group was produced a couple of months ago. I cannot speak to individual educational institutions but, in short, we understand and internationally it is recognised that, for younger children, social distancing is impracticable. That should not preclude younger kids going back to school. We expect and hope from a public health perspective that the vast majority of older children in national school and certainly all children in secondary school should maintain a distance of 1 m from one another.

I have been contacted by many school staff and parents regarding the difference between those at high risk and those at very high risk. Many school staff in particular have been concerned. They have been certified by Medmark as fit to return to work as they are only high risk. They are upset and worried by this and they feel compromised. They are also unhappy at the relative lack of recourse. To be classified very high risk seems to be quite a high bar. On the other hand, the high risk category is quite broad and it seems to take in everything from mild asthma to cases of leukemia.

These people have been categorised as high risk and, therefore, are obliged to work. Should a more differential approach be taken to high-risk individuals in the context of schools? Is it safe for all those categorised as high risk to mix with dozens of people every day? Should the high risk bracket be expanded to encompass more students and teachers who are vulnerable?

Dr. Ronan Glynn

Regardless of what categorisation or bracket obtains, each individual who has a concern needs to be treated as an individual with his or her own specific set of circumstances. If 40 people are in the outpatient department of any hospital in this country for an ear, nose and throat clinic or a respiratory clinic, each of them will be treated individually and differently based on his or her individual circumstances. This must be the approach to children, teachers and carers who have underlying health issues. It is not possible for me to make an overall proclamation. It is a matter between the individual and his or her GP and the occupational health service.

That is a useful insight because, from speaking with school staff, children and their families, this issue requires a more tailored approach.

Dr. Glynn may have seen the Minister for Education and Skills, Deputy Foley, last night on "Prime Time". She outlined what would happen in an instance of a symptomatic child or staff member in a school. Many of the answers pivoted on the GP being informed, after which the issue would fall on what she termed "public health". Parents would prefer to have a much clearer idea, though. Dr. Glynn could give a detailed response, so perhaps he will provide a written answer on who should isolate and what the considerations are.

For now, I will ask a more direct question. If a child receives a negative test result, is it safe for him or her to return to school immediately? According to Dr. Mary Favier, if a child has sniffles or is sneezing and is otherwise well, he or she can attend. Coughing was not commented on, though. Many children are asthmatic or have other respiratory illnesses and coughing occurs frequently outside of Covid cases. Where children are frequently coughing, should they refrain from attending school and isolate? Greater publicity for some of these issues is needed. These are the kinds of question to which parents want answers.

Dr. Ronan Glynn

To answer briefly, if a child has a test and the test is negative, he or she should be able to return 48 hours after the end of the symptoms, but it depends on the precise nature of the circumstances. I will provide an overall written answer.

Dr. Favier commented on the issue of coughing at least in the press conference the other evening. There will be children with coughs as part of underlying conditions, but at issue is the onset of a new cough. On any given day over the next number of months, if a parent or carer has a particular concern, he or she needs to act with an abundance of caution in the first instance and keep his or her child at home. If concerned, he or she should contact the GP. That will lead to busy GP practices, but it is better to be sure and safe, keep the child at home in the first instance and have clarity and confidence before sending him or her into school.

Fine Gael is next. Deputy O'Dowd is going first. Is he taking five or ten minutes?

Cúig nóiméad.

I welcome the witnesses and commend them on their commitment and dedication to the work. I assure them that the whole country is listening and learning from the way they present the facts.

I wish to ask some questions about the number of people not turning up for testing. This morning, the HSE told us:

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%.

Some 50% of people not turning up is a high figure. We were not given it in July when I asked the same question. Will the witnesses comment on this, please? I acknowledge that 98% of all tests are negative, which is reassuring, but it is also a reason to ensure that those who do not turn up actually are tested.

Dr. Ronan Glynn

This is a particularly important question in the context of recent public commentary. The reason it is of particular important is that, of course, we are proponents of testing and want people to turn up for their day 0 and day 7 tests. That is absolutely vital. We are looking at alternative testing modalities that might be less uncomfortable than the traditional test we are using at the moment, particularly for the day 7 test. However, the result of that test does not change what people need to do. If someone is a close contact of a confirmed case, he or she needs to restrict his or her movement for 14 days. We want more people to come forward for testing. What is more important than anything is that if people have symptoms, they must not take the traditional approach of waiting to see how it goes for a couple of days but, instead, come forward immediately, put their hands up, contact a GP, identify themselves as having symptoms and get a test. That is the way in the first instance that we will control the spread of this disease and protect individuals and their families.

There has been commentary from some doctors in the media about people who presented to them with symptoms but did not go for the test even though they were recommended to do so. What happens in such cases? How are they followed up? Is this group different from those who have been in close contact with a confirmed case? Are there two different figures for these cohorts?

Dr. Ronan Glynn

People are offered day 0 and day 7 tests if they are identified as close contacts of a confirmed case. I believe the information given this morning was that 80% of the people identified as close contacts come forward for the day 0 test, but just 50% come forward for the day 7 test. My message is that a negative test result does not mean a patient does not have the virus. It simply means the virus was not detected at the time the test was taken. The test is merely one additional tool in our armoury to control the spread. It does not change the clinical outcome or change what individuals need to do.

What analysis is carried out on the cohort who acquire the illness after a negative first result? I understood from earlier comments that the HSE was trying to identify these people. Does it correspond to a particular cohort?

I have spoken to someone involved in contact tracing. This person is aware of a small number of people who do not turn up because their presence in the country might not be regularised. I want to stress that it is a small number. Does the Department have any evidence of that?

Dr. Ronan Glynn

I misunderstood the Deputy's question. Our public health colleagues in the HSE have identified two trends. The first is that younger people and, conversely, much older people are less likely to come forward for the day 7 test. Second, there is a cohort of people who do not want to come forward for testing because of the potential economic implications for them. We made specific recommendations in that regard through NPHET a number of weeks ago.

To respond to an earlier question, the test and consultation are free. Beyond that, we must ensure anyone who has to self-isolate or any contacts of confirmed cases who must restrict their movements have no fear for their employment after the 14 days and, indeed, that they will be given adequate compensation for the 14 days they are off work. Economic circumstances simply should not be a barrier to people coming forward and getting tested.

I thank the witnesses. I also thank Dr. Glynn for the attention he has given to Kildare. We have had a few conference calls in the past few weeks.

Of course, Professor Philip Nolan is well known to me as president of the local university.

I represent Kildare, which is in its third lockdown, given the initial lockdown, the localised lockdown and now the second localised lockdown. That has had a devastating effect on the local economy but also on the public at large. Confidence and morale is at a significant low at the moment as people try to grapple with the effects of this, and it is psychological as well as economic. People are prepared to get on with it and to do with the right thing once they can understand it, buy into it and support it.

I have listened to the testimony of both witnesses and they have both spoken about the importance of the workplaces and the clusters that have emerged in recent weeks. One of the questions that I, as a public representative in the county, have been asked repeatedly and will be asked again this evening when I meet with the Kilcock business association, given Kilcock has had just one case in two months, is why the entire county is in lockdown when it appears to be confined to a few workplaces. I have asked this question of many people, including the acting CMO at a conference call last week, and on many other occasions during the last few weeks. The answer I was given, which I believe because I believe the public health advice, is that the entire county has incidences, there are cases everywhere and it has spread beyond those initial workplaces or clusters. However, we really need to demonstrate that to drive buy-in and get public support and acceptance for the measures. People will follow the logic and follow the evidence for themselves if they have it.

We need to make that data available. This is something I have called for, as did the Taoiseach in yesterday's radio interview when he agreed it should be made available. We should make available microdata at electoral district, ED, level, while ensuring it is not low enough to embarrass anybody in terms of GDPR but is high enough for people to understand whether it is in their town or townland. A set of figures was made available on 12 August and that was the first set of localised figures since June, so there was a two-month gap, and ED level figures have not been made available since 12 August. Effectively, if we go back as far as June, we have one date for which localised figures are available, and nothing before or since. This is a live issue, not an academic issue, an esoteric issue or something we can resolve in a fortnight's time. Kildare is in lockdown today, businesses are struggling today, the people are struggling today and we do not have figures for today, for yesterday or for tomorrow. I understand the Government is in entire agreement. The Taoiseach confirmed that to me and also confirmed it in a radio interview yesterday, and I do not think there is anyone who disagrees, yet the information is not there.

I am not sure who is best placed to answer that question, perhaps Dr. Glynn. However, can the data be made available as a matter of urgency? I believe it would drive public support for these measures if people could see what the situation is in their own towns.

Dr. Ronan Glynn

First, the dashboard is due to be updated before the end of this week. On the Deputy's point, the figures for Kildare have been given every single day over the past number of weeks and for Laois and Offaly for the two weeks in particular. What I would caution is that for many EDs there have been fewer than five cases, and many of those cases are families, extended families and family clusters, so we need to be careful about what we give out at a point in time.

More broadly, it is accurate that the number of cases in Kildare in particular was driven by these clusters in meat processing facilities but the people who work in those meat processing facilities live, socialise, travel and interact with people all over the county. I have said previously that the county boundary is crude but we had to take some crude measure. As we heard earlier, the cases were not confined to Kildare and we have seen cases in Carlow and Wexford, for example, linked to the issues in Kildare, thankfully at a lower level. However, in broad terms, we had to pick a geography.

As we said previously, and as the WHO has said, at times we have to move fast at the enemy at the cost of perfection. I would put my hands up and say that but, in saying that, when we make these decisions, we have a set of data in front of us at a point of time and we have to make recommendations and decisions based on the potential for what might happen over the following days.

To go back to our meeting on 7 August where I made those recommendations, on that day there had been 150 cases in Kildare in the previous 14 days but 128 of those had arisen in the previous seven days, so we were very justified at that point in moving quickly to prevent community transmission.

To echo the Deputy's words, I acknowledge in particular the work and buy-in of the people in Kildare, notwithstanding their anger and frustration about what has happened. Their actions have prevented widespread community transmission and the situation there continues to improve. I will ask Professor Nolan if he wants to come in on this.

I am afraid that if he does, it will have to be a reply in writing as I must move onto the next speaker to keep with the time.

I thank the witnesses for being here today to answer questions. My first question is for Dr. Glynn. Many people with underlying conditions and parents of children with underlying conditions have contacted me. They are worried about being constantly left out of the roadmap and other announcements. In particular, I am thinking about a mother from Athy whose daughter has Wolf-Hirschhorn syndrome and two of whose sons are on the autism spectrum. They are not alone in feeling left out. Can we have an assurance that a section of each roadmap or announcement of changes will consider-----

I ask Deputy Ryan to speak more into the microphone. I am told it is a general problem, including with me, and not just with her. We all need to speak into the microphones so we can be heard in the committee room.

I apologise. Can we have an assurance that a section of each roadmap and announcement of changes will consider the needs of, and include a section directed specifically at, people with underlying conditions? Obviously they are in a very bad situation at present.

My next question is also for Dr. Glynn. Many parents in Kildare are fearful of sending their children back to school this week, during the county-wide restrictions. They feel their children are being used as part of a big experiment. They want to see how things go. I agree that children need to return to school. Will Dr. Glynn comment on the likely effect of the return to school on case numbers? What can he say to assure parents that their children will be safe? They need reassurance.

My next question is for a Professor Nolan. Many people in Kildare are very angry at being unable to leave the county. They accept that it is for essential reasons but they are angry that the food processing plants have reopened. They feel they are being punished for what they see as the sins of the meat factories. What measures are in place to ensure the food processing plants do not jeopardise Kildare as its emerges from the current restrictions on 6 September?

Dr. Ronan Glynn

I thank the Deputy. I do not believe there has been any set of recommendations that NPHET has made or a set of measures that has not specifically referenced those who are older and those who are medically vulnerable. In relation to Kildare, Laois and Offaly, I made specific reference to this group the day before we met to consider the measures because I wanted those children and adults to take particular care. Last week, a similar set of statements was made about the country more generally.

With regard to children, I fully understand there is anxiety and concern among parents nationally and, of course, in particular in Kildare given the set of circumstances but, as I answered earlier, thankfully we have not seen a greater level of community transmission in Kildare than we have in the rest of the country. The profile is very similar to the rest of the country. The wider profile of Kildare has improved again over recent days. International evidence suggests that children spreading Covid to other children in schools is relatively uncommon and that schools are not a key driver of community transmission of this disease. We know from our own data in Ireland that to date fewer than 3% of children in the country under 14 years of age have been diagnosed with Covid and of these, only 42 have been hospitalised to date. Of course there will be cases, and these cases have arisen in recent weeks throughout the country, but the key to minimising the harm that comes out of these cases is for us all to act together and quickly. To come back to my earlier point, if people have concerns, they should keep their child at home and contact their GP in the first instance. I will hand over to Professor Nolan, given the time.

Just one second-----

I am afraid the Deputy is out of time. Perhaps another Sinn Féin speaker will come in at the end. I need to keep this moving.

I welcome the witnesses and thank them for their tremendous effort to date in containing the virus. Have any particular lessons been learned from the spike in Kildare and the adjoining counties, for example early detection of the sources of the virus? Have all cases been sufficiently identified in order that there can be a rapid reaction in the event of recurrence? Given that schools are reopening, are the witnesses satisfied that adequate measures are in place to deal with any matters arising in the event of there being an upsurge in any particular location or in general?

My last question concerns the country at large. There was a huge, and very worrying, surge in Kildare between the first and second week of the lockdown in Kildare and the immediate area. Have the causes of that been identified? Have measures been, or are they likely to be, put in place in order to deal with that in a manner that can be replicated nationwide?

Dr. Ronan Glynn

I might let Professor Nolan take this first, if that is okay.

Professor Philip Nolan

It is fair to say that important lessons have been learned. The two lessons that have been learned are that if we react quickly we can bring the disease back under control. That is what the Kildare, Laois and Offaly outbreaks showed. The second thing they show is that if there is a very large outbreak the risk of diffusion into households and communities is higher than if there are smaller outbreaks. There was a greater volume of cases and spread into household settings in Kildare than in Laois and Offaly. In response to an earlier question, this could have happened in any county in the country. Most counties in the country have the kind of workplace settings that are capable of amplifying this disease. Quite a lot has been learned within those settings.

For the reasons Dr. Glynn alluded to earlier, in terms of the reopening schools there is a level of assurance. It is very unlikely that if a child were to bring a disease into a school he or she would spread it to another child. It is then unlikely that the child would bring the virus home and spread it back into his or her home. We need to remember that adults moving around in society, in workplaces and other settings, are more likely to transmit it between households via adult-to-adult transmission. In no way is it is an experiment. It is a carefully judged prioritisation of what we need to get back to, having done a very detailed risk assessment. On data and what we have learned, an integral case may be indexed to a particular address, such as a home or work address, but people move around. They live in one place and work in another. They have family and extended family quite widely distributed. Even though there may be two, three or four cases in a given electoral district, they are connected. The pattern of this disease was quite diffuse across Kildare and in its spread across the borders and into neighbouring counties. An electoral district map tells us something. It tells us one location that each case is associated with, but the reality is that each case is associated with multiple locations. We do most of what we do within our counties. That would not reveal the much wider influence of the disease within a given county.

I compliment NPHET on its tremendous work so far and wish its members well in their efforts. Naturally, we have a special interest in the situation in Kildare because it is the location in which we reside. In order to ensure that public confidence remains at a high level, can Professor Nolan give us an indication that the systems that are in place are adequate and ready to react quickly to any suspected upsurge in any area, in schools or anywhere else, over the next few days?

Could that be a very short answer, please?

Professor Philip Nolan

I think the past few weeks have shown us that the systems are in place. At one point, at the peak, there was a little strain on the tracing system but, aside from that, the system stood up extremely well to what was a very sudden and quite large challenge.

I thank Dr. Glynn and Professor Nolan for their efforts to date, which the whole country appreciates. My first question is directed to Professor Nolan. We saw the significant outbreaks in food processing plants, particularly meat factories, over the summer. What other sectors, workplaces or venues is NPHET monitoring particularly closely for potential outbreaks of the virus? It seems to me that we may have other workplaces or social settings where there is particular danger of an outbreak occurring due to the nature of human contact in those settings. It would be good to know where those dangers lie.

Professor Philip Nolan

I will make a very brief comment. I think Dr. Glynn, as a public health specialist, would be better placed to comment on some of that. There are particular circumstances that apply in industrial settings, where there might be chilling, high airflow and so on. Leaving those factors aside, any high-contact workplace, as one might call them, represents a risk of transmission. We have seen and continue to see smaller outbreaks - smaller because the workplace settings are smaller - in a very wide variety of settings. It is simply a matter of emphasis. Public health colleagues would concentrate on the fact that any workplace where people are required to come together and work closely represents a risk of transmission. Therefore, if an index case appears in such a setting, they move quickly to try to understand whether transmission has occurred within that setting. The short answer to the Deputy's question is that public health colleagues have a very clear picture in their heads as to which workplace settings are higher-risk and which are lower-risk.

I wish to make one other brief comment, though, which is that there are also high-traffic situations, such as in the hospitality and service industries, where people are not necessarily congregating but the staff are exposed to a high traffic of people past them. This is a situation in which not only do we want to watch for transmission but the employees need to be very careful in their preventative measures, and the patrons of those services need to respect the fact that those staff are also front-line staff. The patrons needs to be exceptionally careful not to transmit the virus in attending a restaurant, bar, hotel or whatever else.

I thank Professor Nolan for that. I have three questions for Dr. Glynn, but perhaps he could also address the one about particular workplaces that might be vulnerable. I will go through the three questions and he can take them all together.

There is a particular risk of outbreaks in congregated settings such as schools and meat factories. As NPHET considers the broad use of low-sensitivity, low-cost, rapid, frequent antigen testing, does Dr. Glynn accept that frequency and rapidity of testing may be more important factors in outbreak detection than high sensitivity? Should blood plasma from recovered coronavirus patients be considered as a treatment for infected people who have been hospitalised? Third, the latest Government advice is that people should avoid using public transport where possible. According to the Garda, road fatalities have increased by 9% over the past year, and 27% of those who died were walking or cycling. Has NPHET weighed up the costs to society of more deaths through road collisions and increased air pollution, as more people are encouraged to drive, against the benefits of increased isolation?

Dr. Ronan Glynn

To respond to the Deputy's first question about high-risk settings or places, my background is in public health medicine, and one of the reasons we get into public health medicine is to level up and help those in society who are most vulnerable. If a pandemic does anything, it shines a light on those in our society who are most vulnerable, and this pandemic is no different. The work my colleagues in the HSE and public health are doing now is just on a greater scale in respect of vulnerable groups: Roma, the Travelling community, those living in direct provision and those living in residential care facilities. Infectious diseases impact these groups disproportionately, and we need to continue to do all we can to ensure that these groups in particular are protected as we navigate our way through the coming months. That is why at all times when I talk about where we are going with this, I say this is one of the three priorities on which we must focus.

As a society, we all have a role to play as individuals in keeping transmission of this disease low so that those who are less fortunate than ourselves are protected from community transmission and the effects it will have on them if they become infected.

In relation to antigen testing and blood plasma, I would say that all new technologies and interventions, including testing and diagnostic screening treatments, are being kept under review. We are open to all of them. At present we are looking at new forms of testing to complement our existing nasopharyngeal swab and polymerase chain reaction, PCR, tests and we will continue to do that. We are constantly looking to improve our surveillance, whether through waste-water surveillance or other methods. This is an evolving situation. We are learning, but we do not want to rush something through that is not ready or will have unintended detrimental consequences in terms of our ability to manage this. We are absolutely open to learning, changing and evolving, but we need to do that in a considered way.

In relation to the avoidance of public transport where possible, the effect on air pollution is not one of our considerations in the first instance given that we have recommended this for such a short period of time and that wider use of transport more generally would have been down so much for such a prolonged period of time. Of course, I understand that our recommendations have an impact, but when we make recommendations the intention is that if those recommendations are effective, they will only be implemented for a short and targeted period of time to protect public health in the first instance.

I thank Dr. Glynn and Deputy Leddin. The next speaker is Deputy Smith from the Labour Party.

I thank Dr. Glynn and Professor Nolan for coming today, but also for all the work they are doing day in, day out to try to keep the country safe. It is very much appreciated. They have the toughest job in the country and it is not going unnoticed.

My first question is to Dr. Glynn. I have been in regular communication with my colleague, Senator Wall, and, indeed, residents from Kildare. Can Dr. Glynn envisage any scenario over the next couple of days, if the numbers continue to go down in Kildare, that prior to this weekend there could be a lifting of the restrictions in Kildare? I understand there were five new cases yesterday. Can Dr. Glynn envisage that happening or will they continue until 6 September?

Dr. Ronan Glynn

We indicated last week that we would keep it under review and we will keep it under review. If a point comes where we feel we can lift them, we certainly will lift them. We are fully cognisant of the impact of these measures. What we really want to do is get Kildare back aligned with the rest of the country so that we have one set of measures for the country as a whole, with one set of messages that everyone can adhere to nationally with a common set of aims and objectives. As soon as we can, we will.

I thank Dr. Glynn. As Dr. Glynn stated recently, and as Mr. Paul Reid said in the first session this morning, we will be living with this virus for a time to come and we will have to come to terms with how we will deal with that. What work is NPHET doing in relation to the restrictions on air travel at present? I speak as someone who represents a constituency with many airport workers who are fearful for their jobs. I suppose what came to light this week in the public consciousness is that those who travel into the country, even if they have a negative test, must still restrict their movements for 14 days. Where do we go from here? It is unsustainable. What systems can be brought into place to bring travel back to some kind of normality? Can Dr. Glynn give any hope to the industry in that regard?

Dr. Ronan Glynn

I am always conscious that I speak on behalf of NPHET. We have a particular lens through which we view these matters. I fully accept that the Government needs to make decisions based on a wider set of priorities. From my perspective, I do not see a scenario where we will have widespread travel over the coming months. Of course, NPHET will continue to evolve and look at the situation. We are looking at the situation but over the past 14 days alone, we have had 69 travel-related cases in this country. Every one of those cases can lead to further cases. For now, unfortunately, our message remains the same.

I know it is not a message that people will welcome or want to hear but it does remain the same: everyone should avoid non-essential travel.

I and others have made calls over the last months for testing at airports and ports. If this was to be implemented would it be useful in any way in changing the advice or is a person just as well getting a test at a local test centre as opposed to the airport?

Professor Philip Nolan

The test we have is an excellent diagnostic test when used under clinical supervision where one has a high suspicion that a person has the disease, with a one in 100 chance or a one in 500 chance of having the disease. When one gets down to screening, however, it is a very poor test. It will miss a lot of cases and will come up with a lot of false positives if there is only a one in 20,000 chance or one in 10,000 chance that the person has the disease. This shows the limitations of testing. A negative test does not necessarily prove the person does not have the disease. If the risk is low, sometimes a positive test can be false. We need better testing technologies and better testing regimes. Certainly, from the research and literature on what we know, strict self-isolation or restricted movements will always be part of a travel regimen. This is what protects from the spread of the disease. We may be able to improve testing regimens that can shorten the time or change the nature of the time but realistically, in the long term, we are going to be living with restrictions on movement, perhaps alleviated somewhat by a better testing regimen. Right now we are not in that place.

I have just one more question, if I can squeeze it in. Is NPHET aware of, or does it have any understanding of, the worries of many pregnant women around the public health advice and messaging for Covid-19 and its impact on women in pregnancy?

Dr. Ronan Glynn

We are absolutely aware of that. There is no group that has not been impacted by this. I know that maternity hospitals in particular have had to bring in measures that significantly impact on the experience of pregnant women and their partners. Of course we are conscious of it. Again, the key to alleviating the impact on pregnant women, or on any other group in our society, is for everyone to do their bit to keep this low. The lower we can keep this disease in our society the greater the level of freedom we can all enjoy and, hopefully, the less the level of worry and anxiety that will pervade amongst us.

I thank the witnesses.

I have a brief follow-up question to Deputy Smith's question on travel. Last week the deputy chief scientist of the European Centre for Disease Prevention and Control spoke on RTÉ Radio One. Having analysed the data he was getting from various member states he said that movement between the countries does not seem to play a major role in transmission. He stressed the need for local measures around testing and tracing. Do the witnesses disagree with his assessment?

Dr. Ronan Glynn

I will point to an article I read this morning about Germany, which is seeing an increase in cases. There were more than 2,000 cases on Saturday and 40% of their cases in recent days have been attributed to travel abroad. While Germany is in a different position, and this is based on an article from this morning, we can only speak about our own national experience. At one stage during the summer, when numbers had gotten really low, 20% of our cases were travel related. Currently it is 5% with 70 cases. To my mind the numbers speak for themselves.

Dr. Glynn said that 40% of the cases in Germany are now travel related. Is that correct?

Dr. Ronan Glynn

This is according to one article this morning. I am not suggesting it is definitive. It is one article I read this morning.

It will be interesting to hear from the German authorities. The figure of 40% is incredibly high and one would expect Germany could be sealed off pretty quickly in that instance.

I welcome both our guests. I frequently struggle to try to figure out what our national strategy is with Covid-19. There are calls for different approaches and so on, but I assume there is a general approach that is about minimising the rate of the virus. Clearly, the whole test and tracing regime is a key element of that.

We discussed that earlier with representatives of the HSE. In the early months, we spent a long time trying to get the testing and tracing system to capacity. By the time it was at capacity of 100,000 per week, the case numbers were very low. It seems there is now a certain degree of struggling to ramp up testing again to meet the increased numbers. I asked Mr. Paul Reid this morning about the approach that is being taken and why, if there is a capacity of 100,000, the HSE is not using that full capacity for both reactive and proactive testing. He informed me that the HSE's approach to testing is determined by NPHET. Perhaps Dr. Glynn will answer the question as to why it is that NPHET is not seeking to maximise the capacity that is currently there. Intuitively, one would think that is the right step to take.

My second question concerns the availability of data. It is unsatisfactory that we have to keep asking for data, all of which should be open source. I refer in particular to the electoral division figures, that is, the rates per electoral division. NPHET released figures on 12 August and the previous occasion was 12 June, although many of us had to battle to try to get our hands on those figures. Why is NPHET not releasing those figures regularly and in real time, rather than an accumulative figure that causes a great deal of hassle for people trying to work out the current figure and the current rate per electoral division?

My third question relates to travel. I have been tracking the figures that NPHET has been citing in its letters and I have noted the point it has been making about raising alarm bells about the fact that there are significant numbers of travel-related cases relative to those of actual travel cases, which might result in the passing on of the virus to family groups and other settings. NPHET seemed to be ringing loud alarm bells in that regard for a period but in its recent letters, it has made virtually no reference to figures for travel or cases indirectly related to travel. Why is that the case?

Dr. Ronan Glynn

To answer the Deputy's third question first, recent letters have not unduly focused on travel because they have focused on the particular issues that have arisen in the country over the past couple of weeks, and travel has been just a small component of that. That said, we have on a number of occasions reiterated our recommendations and I think our position is very clear in respect of travel. To the Deputy's specific question, of the 69 cases that were travel related over the past 14 days, 20 were imported cases, with the remainder having been acquired through contact with imported cases in the country.

To respond to the Deputy's second question, I fully accept that the dashboard needs to be updated more regularly. Significant work is ongoing in that regard and from the end of this week, it will be updated and will continue to be updated much more regularly, including by giving a breakdown by county for the previous 14 days, as opposed to just a total figure overall for the pandemic to date-----

Sorry to interrupt but is it possible to get those figures on an electoral division basis by week?

Dr. Ronan Glynn

I do not think it will be, for the simple reason that in the vast majority of electoral divisions, the number of cases in a week or a fortnight will be lower than five. We are precluded from giving information at that level for instances of five cases and under. The Deputy will appreciate that in many electoral divisions or areas throughout the country at the moment, there are household clusters. There will be electoral divisions where there is a household cluster and we have to be very careful about giving out that information - indeed, we are precluded from giving some of it.

That said, I am more than happy to look at how we can provide more information. I fully agree that the key to maintaining public acceptance and buy-in to this is information and data. The more we can give, the more we will give. I will commit to that. Professor Nolan might wish to come in on that point.

Professor Philip Nolan

We need more sophisticated data than case by electoral division.

We need to know what those electoral divisions are connected to. That will take some time. In the interim, we can give what can be given but there is probably a more sophisticated map of the country we could develop which would not just show cases, but connections.

Can Professor Nolan answer the question I asked about the testing and tracing strategy? What are the priorities there and why are we not using the full 100,000 capacity?

Professor Philip Nolan

There is no point in testing where there is not some advance signal that the disease is present. There is both active testing, in other words, people who come forward because they are symptomatic, and proactive testing, that is, tracking down the contacts of those people and being proactive in terms of screening in areas where we think there is a risk of disease or a risk of major consequences if the disease breaks out. Even though it may reassure people, it is pointless and a waste of resources to start using the testing capacity in some broad-brush sense. Testing capacity ramps up as disease ramps up and ramps down, quite frankly, as disease ramps down.

I appreciate that but perhaps Professor Nolan could tell us exactly what the strategy is now in terms of targeting the high-risk settings.

Dr. Ronan Glynn

In broad terms, for anyone who is symptomatic, anyone who is a contact of a case, anyone who lives in a congregated setting for direct provision or is homeless or a member of the Roma community living in a congregated setting, that set of testing is due to begin next week. This includes all healthcare workers in nursing homes and, as I am sure the Deputy heard this morning, all workers in high-risk meat processing facilities around the country. That is a level of proactive testing very few, if any, countries in the world are currently undertaking. That notwithstanding, we have a capacity over and above that and that capacity will be vital over the coming weeks and months. It is vital also that it is protected and ready to go when it is needed for those who are symptomatic, parents who are concerned and children who have symptoms and need to be tested. Let us be clear, the 100,000 capacity will be required over the coming months but there is no benefit in using it for the sake of it at this point.

I am not suggesting that but Dr. Glynn is saying that testing in direct provision will start. Why are we not doing it now? That is the point.

I am sorry but I am moving on to the next speaker. Will Dr. Glynn reply in writing to Deputy Shortall? The next speaker is from Solidarity-People Before Profit. Deputy Kenny has five minutes.

I have a number of questions for Dr. Glynn on the reopening of schools. Over the next few weeks, almost 1 million people will return to some sort of educational setting. That is a huge logistical headache for everybody involved.

My first question is on a comment made my Dr. Michael Ryan of the WHO, who said that school reopening should not become a political football. On purely medical grounds, is Dr. Glynn confident, as the acting Chief Medical Officer, to facilitate the full reopening of all schools in the context of the current figures?

Dr. Ronan Glynn

That does not mean there will not be cases. That does not mean there will not be clusters and that we will not have issues over the coming weeks. However, after six months of children having no schooling and all the societal, social, mental and well-being impacts that has had on them, weighing that up against our experience with children in Ireland to date, the experience internationally where schools have reopened, all the measures schools in Ireland have put in place to protect our children, the work that teachers and principals have done around the country, and the ability of parents individually to make choices and to act responsibly over the coming months, we are fully supportive of our education system fully reopening at this point.

My next question is on the rise of transmissions among children in recent weeks, which is obviously concerning. In that context, does that set off alarm bells regarding the settings to which young people will return?

Dr. Ronan Glynn

What we have seen over the past number of weeks is a rise in the number of cases generally in our communities around the country, the vast majority of which have been in households.

It is no surprise that children living in households where there is a case have themselves being identified as cases and that is entirely consistent with the picture internationally. The key reassuring point to make to parents and carers who are particularly worried is that the vast, vast, vast majority of children who are diagnosed with Covid-19 will have mild, if any, symptoms and our experience in Ireland to date bears that out. We have had 274 cases in children up to four years of age and 507 cases in children up to 14 years of age to date. Just 42 have been hospitalised and thankfully just two have been admitted to critical care units and again, thankfully, we have no deaths. I am not saying that some children have not had a negative outcome or a negative course as a result of this but again, we need to weigh up all of the risks and benefits when we make recommendations and decisions around this.

I thank Dr. Glynn. My last question relates to other countries. As mentioned earlier, some schools in Germany, specifically in Berlin, had to close because of outbreaks. Teachers, pupils and parents want to be assured that if there is an outbreak here, as happened in certain countries in Europe - hopefully it will not happen here - we will have no hesitation in shutting schools down in accordance with public health guidelines.

Professor Philip Nolan

I want to say something and Dr. Glynn may want to expand on it. We have seen an increase in cases in children, not transmissions. Children are getting it from adults but there is very little evidence of child to adult transmission outside of the household, where it does occur, and very little evidence of child to child transmission. We had 100 cases last week in children. We will see 100 cases next week and the week after and they will be back in school. It is really important not to overreact when cases are detected in school. It is really important that we give public health colleagues the space and respect to allow them to manage any given school cluster or outbreak differently. In no other walk of life and no other branch of medicine does one expect the full plan to be set out in advance. We do not ask cardiologists what the plan will be if I have a heart attack next week. It depends on the type of heart attack and it depends on a whole lot of co-morbidities. It is exactly the same with schools. The appropriate reaction to an outbreak in a school depends on the nature of the outbreak and the setting. We simply have to trust public health colleagues, because they have not let us down before, to properly manage those outbreaks rather than ask them for a specific, precise protocol in advance. There are broad protocols and principles there but we cannot say what is going to happen in any given setting this week. We just do not know.

I thank Professor Nolan and Deputy Gino Kenny. The next speaker, from the Regional Group, is Deputy Matt Shanahan.

I thank the Chairman. I thank Dr. Glynn and Professor Nolan for their attendance here today. My first question is for Professor Nolan and relates to the testing that was done in the meat factories, which was akin to screening and which turned up a high level of asymptomatic cases. Were these, in fact, false positives that were recorded as asymptomatic cases?

Professor Philip Nolan

No, I have no concern that they were false positives because the setting they are in is a high-prevalence setting. The disease was clearly there and that gives one confidence that the positives were true positives. It is only when one is screening large numbers of people who are very unlikely to have the disease that there is a concern about false positives. The proportion of asymptomatic people, which was 59%, mirrors the experience internationally. When one goes in and tests everybody in a large workplace setting, one finds that at least half of the cases are asymptomatic. That was the case in the recent set of outbreaks in meat factories, with 41% symptomatic and 59% asymptomatic.

We spoke previously at this committee about the idea of regionalisation and the potential for certain areas to be considered differently in the context of a possible opening up. I am specifically referencing the rural wet pubs, some of which are in areas where there is absolutely no evidence of Covid around and yet they are locked down.

Is there anything on the horizon or can Dr. Glynn offer any hope or support to those businesses that they might have some regional reopening policy?

Dr. Ronan Glynn

In the first instance, we need to reiterate that unfortunately we had to recommend a set of measures for the country last week. We recommended those measures because as of yesterday, we have seen cases in all bar one county over the past 14 days. As Professor Nolan alluded to earlier, within counties and within a particular community area, people work, travel and socialise. It is difficult to say that any one region in the country is devoid of disease and even if it is today, it may not be tomorrow. On the pubs, as I have said previously, we absolutely recognise the impact this has had on small family businesses around the country and on communities that rely on their local pubs as a key social point of contact for people. However, we have to be clear about what our priorities are. For the next few weeks at least, our priority has to be the reopening of our education system, ensuring that goes smoothly in the context of a set of measures that are already in place for the country around reducing congregation. I absolutely commit to keeping it under review both nationally and on a regional basis. I reiterate that we are fully cognisant of the impact this is having on the industry.

Dr. Glynn has made his thoughts known in terms of the aviation sector and where travel might happen in the future. On the travel cases he referenced a few minutes ago, are any of them related to the 30,000 movements across the Border that are happening per day?

Dr. Ronan Glynn

I am afraid I do not have those data to hand. If there is information available on that, we will get it to the Deputy.

The media is reporting that up to nine potential vaccines are currently at the front of a race to be approved. Has NPHET engaged in any way with the pharmaceutical companies involved or some of the promoters to see that if these vaccines get past phase 3 trials and achieve early approval, we will be able to get some of them for the Irish population?

Dr. Ronan Glynn

I am sorry. As I reflect on the Deputy's previous question, I think I probably misunderstood it. When I speak about imported or travel-related cases, I speak about cases that have come from overseas, not travel across the Border. None of the 69 cases I referenced would be directly related to that.

On vaccines, we have been actively involved in a process at European level for a number of months. There were some announcements around that last week. As part of the European process, we are actively engaged with a number of manufacturers around vaccines. Ultimately, of course I am the first person to want a vaccine and vaccines so we can move on from this but we need safe and effective vaccines. Speed cannot trump safety or effectiveness. We are engaged so that when a safe and effective vaccine becomes available we will be able to procure it. Precisely when that will be remains a little bit uncertain. I would agree with the Deputy in that given the unprecedented level of research and work that is ongoing, I would be optimistic and hopeful that we will have news on vaccines over the coming months.

On a quick point of clarification, are England, Scotland and Wales considered overseas? A lot of people will be coming from England, Scotland and Wales via Northern Ireland. Are they classed as overseas for the purposes of the statistics?

Dr. Ronan Glynn

If they are identified in contact tracing as having come from England, Scotland or Wales, they would be identified as a travel-related case.

Overseas?

Dr. Ronan Glynn

Yes.

Regardless of whether they came across the land Border or arrived by air, it is the same classification.

Dr. Ronan Glynn

If a person has been in England, Scotland or Wales and is subsequently identified as a case in the Republic of Ireland, he or she will be categorised as a travel-related case.

Is Dr. Glynn saying that a person who travels here from Belfast and is subsequently identified as a case in the Republic of Ireland is not categorised as a travel-related case?

Dr. Ronan Glynn

Precisely.

Okay, that is reasonably clear. The next speaker is Deputy Mattie McGrath.

I thank the witnesses for their attendance. There have been a lot of illogical situations in terms of our handling of the Covid-19 crisis. I earlier mentioned that we set out to flatten the curve, and we did. Why is NPHET victimising one particular segment of our economy, namely, pubs, without any evidence? Who came up with the guideline that if a person has a €9 meal, he or she is safe for 90 minutes? It is totally unfair.

On the return to school, many of our national and secondary schools reopened today and leaving certificate students will get their results this weekend. Our children have been through an awful time and we all want them to return to school. How is it logical that national and second level students up to 18 years of age can sit together in a classroom for six or seven hours while the Dáil is required to meet in the Convention Centre at an enormous cost of €25,000 plus per day? I have had this debate with the Ceann Comhairle and the Business Committee. We have asked that the Dáil be allowed to return to its Chamber. The advice is that we could do so at a 1 m distance but NPHET is insisting on a 2 m distance. Where is the logic in that? There are many things that do not make any sense. I wish Dr. Holohan and his family well. I understand that some time ago his advice was that mask wearing was of little benefit and that there were question marks around it, yet we are now enforcing the wearing of masks. There is no logic to what is being done, from start to finish.

I know of a young man who was out last Saturday night fortnight and met a person who had attended a party the previous night at which there were a number of people who were infected with the virus. I am speaking about a cluster area in Cashel in Tipperary. The young man rang his employer on Monday morning and his employer told him to stay at home and to go to his doctor to get a referral for a test. He was tested on Monday at 4 p.m. but he did not get the results until 5 p.m. on Friday. As I said, the area in question is a hotspot. This young man was not asked for details in regard to the other people at the party and, as such, there was no contact tracing. The process is a mess in many ways.

Reference was made to a specific number of tests and contact tracing. It is not happening. The system is not fit for purpose. The mixed messages are unfair. It was unfair that the young man I mentioned had to miss a week's work and it was unfair to his employer as well. There was no follow-up, by telephone or otherwise, in regard to the people he met who were infected. There are some very dubious issues around the process. We need clarity but we are not getting it. We also need a roadmap in regard to what we are aiming to do. I know we are aiming to beat the virus. Flattening the curve was the big objective and we did that.

I support an earlier speaker who said that we have taken the focus way from hand-washing and hygiene to mask-wearing. Mask-wearing was supposed to be not safe. It was frowned upon at the start. Why do we keep changing the goalposts? How are we to get the public to keep supporting us in this situation, including the continued lockdown of pubs? I thank the Minister, Deputy Donnelly, for not imposing a lockdown on Tipperary, as happened in Kildare and so on. We cannot afford it. It cannot be sustained.

As I said, there are too many mixed messages and illogical decisions, including, as I mentioned earlier, the €9 sandwich which allows a person to drink in a pub while wet pubs cannot open. That does not make any sense. I ask the witnesses to respond to as many of my questions as they can and to reply to me in writing in regard to those questions they cannot answer today.

Dr. Ronan Glynn

NPHET never said anything about a €9 meal. It said that restaurants, in the traditional sense of what we understand is a restaurant in this country, should open. On masks, we have a choice. We can send out a set of messages and stop looking at the evidence as it evolves, never change our position, never learn and stick with what we have or we can learn, evolve and build on the knowledge that emerges in the context of a virus that nobody knew about it six months ago and a pandemic that nobody in the world has had to deal with, in terms of its scale, in our lifetimes. Yes, things will change but we all - doctors, politicians, the media and every organisation in this country - have a responsibility, if possible, to stop talking about mixed messages. The most important messages have not changed since the start of this pandemic. We need to wash our hands multiple times a day.

We need to stay physically distant from one another to stop giving this virus the opportunity to spread from one person to another. We need to avoid crowds. We need to decrease congregation. We need to practise respiratory etiquette. As soon as there is a symptom, we need to contact our GP and isolate to protect ourselves our families and our loved ones.

The evidence on face coverings has changed. We have evolved with that evidence. Yes, we were not convinced about it at the start, and one of our key concerns at the start was that people would put undue emphasis on face coverings at the expense of other measures. As the Deputy alluded to in the question, some people have done that which is why it is so important that in all the maelstrom that everyone is talking about and everything that is going on around us, that those key basic messages keep getting put out because it is those basic things that, if we all do them collectively and individually, will prevent us from having to take much more restrictive measures that no one, least of all ourselves in NPHET, want to have to recommend.

HIQA released a report last week. NPHET may have had the benefit of it some time earlier. With respect to mask wearing specifically, it said the quality of evidence was low and it concluded: "There is an urgent need for more research, particularly high quality studies that provide direct evidence on the use of face masks by healthy people in the community." The director of the Oxford University Centre for Evidence-Based Medicine addressed the committee two weeks ago. He said there was no evidence whatever that masks did any harm but neither was there any high quality evidence that they were beneficial. Does NPHET share the belief that there is a need for research on the benefit of masks or is it happy that there has been sufficient research on it?

Professor Philip Nolan

Yes of course, additional research is always valuable but sometimes one must act on the basis of the evidence one has, even if it is not all the evidence that one would like to have. Even though the evidence is not of the kind of standard that we would make decisions around different types of chemotherapy, for instance, the evidence is quite strong that when put alongside all the other more important measures ----

What about the evidence being strong?

Professor Philip Nolan

There has never been a randomised control trial for the effectiveness of parachutes but we still use them. A particular type of evidence is needed for a particular type of intervention. The evidence in favour or face masks -----

The Oxford University Centre for Evidence-Based Medicine did not question the benefit of parachutes.

Professor Philip Nolan

There are many things that Professor Heneghan has said that I disagree with. He is right in the sense that there is no evidence that they do any harm. The evidence that supports their utility is good but not of the kind of very high standard that we would require for an intervention that might cause harm. I am certainly more than satisfied that the evidence available to us now supports exactly Dr. Glynn's position that in addition to all the other things that are more important, these are a very useful adjunct in circumstances where we cannot maintain the 2 m-plus physical distancing that we might otherwise like to.

Do the witnesses expect the WHO to change its advice on face masks or does NPHET have any contact with it? It has been very clear that people should wear masks where physical distancing cannot be maintained.

Professor Philip Nolan

The WHO updates its advice all the time, as does the European Centre for Disease Prevention and Control, ECDC. We and NPHET update our positions all the time. As Dr. Glynn said, this is a virus we had not heard of in December. It is not yet a year later. We really have to make decisions on the basis of the evidence that we have. If we get better evidence we can make -----

I thank Professor Nolan. Deputy O'Sullivan has been waiting some time, I wish to bring him in.

I begin by commending the work of NPHET and all its members in recent months, it is much appreciated. First, on meat factories and plants, there is a village in my constituency, Watergrasshill, with a meat factory where there were 120 cases some weeks back. I seek clarity on the HSA inspections. They seem to be mostly pre-announced rather than random inspections. Why is that? Will that continue?

Second, on buses, Deputy Mattie McGrath mentioned the return to school during the week.

NPHET's advice has changed in the past seven or eight days to recommend that face masks should be worn on buses by certain students. Could that decision have been made much earlier? It has caused confusion in bus and coach circles whereby people are scrambling to organise buses. I am looking for clarity on how that decision was made and on whether it could have been made earlier.

The guidelines for social gatherings in private homes are clear, as are the gatherings for gyms. However, there seems to be confusion about gatherings that might take place in community settings. Are those gatherings still subject to the rule on having six people at an indoor gathering? I am referencing the likes of Lamaze classes, antenatal classes and meetings of that nature that occur in a community setting. Deputy Murnane O'Connor made specific reference earlier to dance classes. Could groups such as that be split up? Do dance schools come under the remit of education guidelines or are they considered to be community events? I would like clarity on that.

Dr. Ronan Glynn

We did not change our guidance on face coverings on buses in recent days. What we did was we clarified the position and simply said that teenagers on school buses should do what they currently do if they get on any other public transport, which is to distance and, of course, to wear a face covering.

On the numbers attending gatherings, dance classes should have a maximum of six people. What was the Deputy's first question?

It was on the meat plants, the testing therein and the matter of random versus pre-announced inspections.

Dr. Ronan Glynn

That is a matter for the HSA and I am not in a position to speak for it.

The Deputy has more time.

I will give it to Deputy McAuliffe.

I welcome the attendees. My question is for Dr. Ronan Glynn. I thank him for all the work he has been doing on behalf of the people. Helpfully, on 19 August, he recorded a video on social media in which he outlined where the majority of the 1,200 cases that had emerged over the previous 14 days were from. He identified that 360 came from meat plants, 90 from direct provision centres, 40 were linked to construction, 200 to community transmission, 200 were under investigation and 3% were travel related. How many of those cases were attributed to sporting activities and, in particular, how many were attributed to spectators at sporting activities?

Dr. Ronan Glynn

We do not categorise cases specifically related to sporting activities but a key part of what we categorise is the proportion of cases that arise as a result of close contact with another confirmed case. In the days leading up to 19 August in particular, we had seen that the average number of contacts of cases who had been involved in or attending sporting activities had risen to nine, which was the highest number of close contacts for a given category of case. We have had cases and clusters related to matches, albeit a small number. However, I have been at pains to say that while one organisation came out and characterised this as a recommendation specifically targeted at that organisation, it was not. We simply sought to decrease congregation in as many settings as possible so that congregation could proceed in the settings that are a priority, whether that is schools or our hospital system, for example.

I appreciate that the whole point of this is to keep us safe and to keep the nation safe and I appreciate the work the witnesses are doing. I just want to get to the facts that the recommendations are based on. Cinemas can remain open but attending an outdoor event, whether it is 50 people or 70 people who are socially distanced, is not permitted. Is there any evidence that people had contracted the virus as a result of close contact with an infected person after attending a football match, a soccer match or any other sporting activity?

Is there much of an issue in that respect or is it just a case of being overly cautious?

Dr. Ronan Glynn

We have had cases in clusters linked to sporting activities.

Dr. Ronan Glynn

I am not at liberty to say precisely how many, but we have had several clusters and cases around the country. Those have been linked not only to sporting activities but to other forms of socialisation. We have also had issues regarding people from different households travelling together to and from events and work. The set of recommendations, therefore, was targeted at decreasing congregation in the round, so that congregation could continue in the areas that are most important. Vitally, that was also done so that all sport could continue.

I appreciate that, but again I am just trying to ascertain the data backing up a decision like this. It is a major decision. There is now full restriction on going to a local GAA championship match, regardless of the numbers. We are talking about large open spaces, but regardless of people travelling alone to matches and taking all the precautions, they are forbidden from doing that under the current guidance. While there may be clusters in respect of sporting events, we are conscious, if we take the GAA as an example, that about 90,000 people are training every week and matches are taking place, as they are in soccer and other sports.

There may be clusters but on the issue of spectators, on which the decision was taken, is there evidence to suggest a concern in that area? I say that because what frustrated many people, as Dr. Glynn stated, was that 500 of the 1,200 cases emerged from direct provision centres and meat plants, yet all sports spectators were banned from attending matches. Can Dr. Glynn confirm the guidance from Sport Ireland which stated that parents and-or guardians are entitled to attend under-18 sporting events if their child is playing? Is that the recommendation in respect of NPHET and can Dr. Glynn elaborate on that guidance from Sport Ireland?

Professor Philip Nolan

It is very important to state that the evidential base for this is strong. If we congregate indoors, the risk of transmission is high among adults. If we congregate closely outdoors and do not maintain physical distance of 2 m or more, the risk is moderate to low. The big issue here is not about spectatorship. This is about congregating in numbers greater than 15 outdoors, particularly where people from different households are freely mixing. The very purpose of the recommendation is to allow important activities, such as participation in sports or schooling, to continue. I say that because every contact between two adults that carries the risk of viral transmission carries that risk. The whole purpose of the recommendation is to prevent indoor and outdoor congregation that fosters mixing between households that would spread the virus between households. It is not targeted at any activity but at open mixing between people from different households. The Chairman is correct that the risk is lower outdoors, but it is not negligible outdoors, particularly where people understandably let their guard down.

I thank Professor Nolan.

It is important to get clarification regarding the recommendation of Sporting Ireland concerning underage sporting events.

Professor Philip Nolan

Dr. Glynn has said that anything necessary for the safe conduct-----

Dr. Glynn stated that there were clusters but that he was not at liberty to provide the details. If he does not have the evidence to hand, I accept that as he cannot have everything to hand. Can he provide that information to the committee in writing?

Dr. Ronan Glynn

I can give some information. There was an outbreak in one club, with 22 cases and over 100 contacts. There was another outbreak-----

Did that have anything to do with spectators?

Dr. Ronan Glynn

It was a mixture. There was another outbreak with two positive cases and 72 contacts. Those are the big ones. The point being missed here is that what we are seeing all over the country are cases arising as a result of mixing between households. The intention behind last week's measures, which were relatively simple, notwithstanding the widespread commentary, was that-----

Were there cases in meat plants and other settings as a result?

Dr. Ronan Glynn

-----we decrease congregation in households because what had happened in meat plants and other settings had led to clusters and cases in households. These measures are aimed at decreasing mixing between households so we can stop the virus transmitting and thereby protect the essential parts of the economy and society that we need to keep functioning, including sporting activity.

On the specific point raised by Deputy Doherty, I have confirmed previously that our recommendations are guidance. We wish to be pragmatic. We understand the importance of sport. If a parent or carer needs to attend a training session or match for the purposes of child protection or guardianship, there is no issue whatsoever with that.

I thank the witnesses for their contributions in recent months. I refer to the issue of small rural pubs which may have already been raised. One pub in 15 is open and serving food. In one instance, people are travelling from approximately ten different parishes to the pub. Would we be better off if small pubs in rural areas were allowed to open such that people would not be travelling to pubs in such numbers? It would reduce the level of risk. Has that been considered?

A seroprevalence study involving 5,000 people was to be carried out in Sligo and Dublin. Have the results of the study been determined? Are they available? I understand it was started more than two months ago.

Following on from that issue, in Denmark testing has been incorporated into the blood donation programme such that donors are tested. As blood banks here collect donations all the time, has consideration been given to such testing in order to get a feel for tracking the virus across the country?

Have the consequences of the long-term effects whereby many people cannot get access to healthcare, such as cancer care or orthopaedics, been looked at? How can the provision of care be fast-tracked in areas where there are significant backlogs in accessing the treatment people require?

Professor Philip Nolan

I will comment on the question regarding seroprevalence and Dr. Glynn will address the issues of pubs and the long-term sequelae. An excellent seroprevalence study has been carried out. It shows an overall prevalence of antibodies of approximately 1.7%. The prevalence is higher in Dublin, which was the epicentre of the original pandemic, at approximately 3%, and lower in Sligo, at 0.6%. The study shows two things. It shows that very few people in this country have been infected with the virus and, as such, there is no level of immunity to protect us, which is why we are utterly reliant on the public health measures to protect us through the winter and into next year. The second thing it shows is that our modelling and surveillance system is excellent and that we picked up one in three cases all the way through the pandemic. Allowing for the fact that half of those cases will be asymptomatic, that is what we would have predicted in our most optimistic estimation of how good our surveillance system would be.

With regard to the earlier discussion, we need to remember that we are talking about large numbers but that we also need to think about the small numbers and we need to think about our reproduction number. With regard to all individual cases, whether the person in question is a spectator at a match or goes to a restaurant, if that person infects more than one other person, we are in long-term trouble. The whole objective of what may seem like disproportionate measures to prevent people congregating is literally to prevent that situation occurring in the context of all those separate individuals in their households. We need to keep our national reproduction number below one. Sadly, the only way to do that is to reduce people's level of social mixing such that they only attend the things that are priorities and do not engage in things that are not priorities.

Dr. Ronan Glynn

I refer to the Deputy's question on the long-term effects and, in particular, the impact on our wider health system.

I am sure the witnesses from the HSE spoke earlier about their plan for a resumption of services and their winter planning process. I would say that the single greatest thing that can contribute to addressing the backlogs that have arisen is that we do not go into reverse with this disease and that we keep the levels of infection under control such that the levels of service that have resumed can continue in the vein that they are currently operating and, we hope, can operate to a greater extent over the coming weeks and months. However, that is contingent on the levels of the disease remaining stable.

I take this opportunity to recognise the work of healthcare professionals generally, who, in effect, bounced from managing a pandemic to immediately trying to resume services and get things back up and running. They are now facing into a winter which will have its own challenges, including the need to address backlogs and, potentially, the need to address any rise in cases in hospitals linked to Covid. That is why it is so important that we continue to do what we are doing. Everyone here knows the capacity our healthcare system has. Everyone understands how stretched we are in this country versus many other countries. In response to many of the earlier comments, I would say that when people sometimes wonder why NPHET makes recommendations that seem entirely disproportionate, it is because we are trying to protect our healthcare system and its priorities and ensure that people who are waiting for essential appointments can have those appointments and that they are not further delayed as a result of a diversion of resources to manage Covid.

Will the witnesses come back to me in writing regarding the Danish system? I asked whether the survey being done in Denmark could be applied in Ireland.

Professor Philip Nolan

That is a very good question but, in fact, our zero-prevalence approach is better. Blood transfusion-based zero prevalence would often be criticised because it does not give a good random sample of the population. It includes only people who are giving blood. The system in this country is better than that system.

Is Professor Nolan saying that our system is better than the Danish system?

Professor Philip Nolan

That is correct. Our zero-prevalence study is ongoing and is based on a very carefully structured sample of the population as opposed to, in statistical terms, the biased sample that blood donors represent. They are not randomly selected from society.

Will Professor Nolan provide an answer in writing to Deputy Burke's question and the associated documentation?

Professor Philip Nolan

Sure. The documentation has been published.

I congratulate all the public health officials and support them in their work. From the very outset of the crisis, there were some in society who wanted there to be more restrictions and, at the other end of the spectrum, there were others who believed the response was an overreaction. NPHET has charted a very sensible middle course between those two positions.

In recent phases, we have moved from a situation where activities were possible or not possible because of social distancing requirements to a situation where we seem to be saying that some activities are desirable or not desirable based on social mixing. That has led to some confusion and I do not think we have had that conversation with the Irish people. For example, I was told about a situation in a holiday setting where a restaurant was open with social distancing of 1 m but an outdoor seating area where music was being played, and where distancing of up to 3 m was possible, was closed. It would seem to be far safer to have people eating outdoors with greater distancing but there was not an understanding of the rules by the operators. We need to revisit the discussion around why decisions have been made and clear up the confusion as to whether it is okay if there is distancing of 2 m and not okay if there is not. We need to look again at how we are communicating why some activities are desirable and others are not. The discussion around GAA matches and other outdoor games is one of the areas where clarity is needed. We do not want those activities to go ahead because they involve mixing households, even though distancing of 2 m may be possible.

My next question relates to organised sports events in indoor facilities. Guidance from Sport Ireland talks about multiple pods of six being allowed where sufficient space is available in reference to dance classes, athletics classes and so on. Will the witnesses clarify what is meant by "sufficient space"? In a standard school hall with pods of six, what distance would be needed between those pods?

My final question is about schools. There will be outbreaks in schools. We heard earlier from the HSE that they have a plan for that. Very early on, the first outbreak was in a school in my constituency and the information was circulating more quickly than the public health authorities could respond. I ask that everything be done to name local clusters because they are already known by parents. The rumour mill works very fast and I ask that everything be done to have as much transparency as possible when those outbreaks take place.

Dr. Ronan Glynn

I thank the Deputy. I will make a wider point in response to the first part of his question. In many ways, the communication challenges we are facing now are much more difficult than those we faced months ago because we simply closed everything and so it was clear to everybody what they should and should not do. As we try to get more nuanced and try to be as proportionate as possible, we will get things wrong and some of our communications have not been, and will not be, as crystal clear as they should be but we will continue to work on that. Ultimately, as I replied earlier to Deputy Mattie McGrath, the key messages have not changed. We want to decrease discretionary social contact between people so that the important elements of human contact can continue as we try to navigate our way through the pandemic. From that perspective, it comes back to the basic measures that we speak about so regularly.

I wish to make one small point of clarification. We want matches to go ahead and we want training to go ahead. We understand there are risks associated with that. We understand there will be cases and clusters arising as a result of that but we weigh that up against the potential loss of those activities in terms of mental, social and physical well-being. We made recommendations to reduce other elements of social contact so that those activities could continue.

With regard to organised sports activities, I have not seen Sport Ireland’s guidance but, ultimately, it comes back to people using judgment and understanding that they should be 2 m apart, where possible. If there is a group of six, it should not interact with another group of six. It is about limiting contact between households. If there are six people from six different households and one of them is a case then our public health teams, who have been working incredibly hard over the past number of months, have six different households to contact trace and follow up with. If the other group comes into contact with that, suddenly we have 12 households, we potentially have 12 workplaces and different school settings. All of that has to be contact traced and followed up. The less we congregate and mix between households over the coming weeks, the greater the chances of the current measures having an effect.

We are concerned about the ongoing increase in cases. If this continues, we will run into trouble in terms of hospitalisations and critical care. We have only had 90 cases among people aged 65 years and over in the past two weeks. That is a key reason we have not seen cases in hospitals and critical care units. That simply will not continue if the increase in cases continues. We are being given an opportunity by the dynamics and the profile of the cases at the moment, in that the disease is spreading largely among younger people. We have been given a window of opportunity to take measures, individually and collectively, to stop this before it gets worse. I urge people to please continue to follow the basic public health advice, never mind all of the confusion that surrounds it - cut down your contacts; cut down the number of people to your home; try to meet up with fewer people, if possible; wash your hands; wear a face covering; and avoid crowds. They are the simple measures. They have not, and will not, change over the coming months.

I thank the witnesses for their hard work trying to keep the country safe.

A friend called me yesterday to tell me to turn on "Drivetime" because the Kildare county coroner, Professor Denis Cusack, was on. I heard that, according to him, he had sent his report to Dr. Glynn. I asked the then Minister, Deputy Harris, to examine this-----

Could Deputy Cronin speak into the microphone? Apparently, it is difficult to be heard in the committee room.

Okay. I asked the then Minister for Health, Deputy Harris, to investigate this matter in early June. Will Dr. Glynn examine Professor Cusack's report, please, and undertake a swift process to determine why Kildare suffered so disproportionately? I had believed it was because we had more nursing homes than other counties, but that was not the case. There is some reason for Kildare suffering disproportionately. During the peak, 67 people were transferred from hospitals to nursing homes in north Kildare without testing. I would appreciate if Dr. Glynn investigated the matter.

My second question is on testing at Naas General Hospital. The focus is on the meat factories currently, but it is important that we not take our eye off the ball. The Taoiseach stated that weekly testing of employees in meat factories would commence before moving to fortnightly testing. After a positive case being identified in Naas General Hospital, I am surprised that we are not testing our healthcare workers and other hospital staff more regularly. Such testing had not started in Naas up to the day before yesterday.

Will testing be available for high-risk teachers? I spoke to the Minister for Education and Skills yesterday and asked whether it would be advisable to keep such teachers for remote learning. What is Dr. Glynn's opinion on this matter?

At a health briefing for Kildare's elected representatives last Friday, Dr. Glynn stated that NPHET had certain recommendations concerning employees in meat factories. In terms of contact tracing and the number of people living at the same address, has NPHET engaged the environmental health officer? As of a Kildare County Council meeting last week, the environmental health officer was not looking at homes where many people were living. Will Dr. Glynn start with these questions, please?

Dr. Ronan Glynn

Professor Cusack very helpfully engaged with the Office of the Chief Medical Officer over a number of months in respect of issues in Kildare. We continue to engage with him. After Dublin, Kildare has had the highest number of cases at almost 2,200, representing 8% of cases to date. This is part of the explanation.

I have given an answer on the issue of high-risk teachers. We cannot proclaim or provide a blanket approach. Each individual has a unique set of medical and other circumstances that mean the approach for him or her must be tailored. People need to engage with the occupational health service in the first instance as well as their employers.

Regarding Naas General Hospital, my understanding is that there was a very small cluster of cases there a couple of weeks ago and that everyone who needed to be tested in respect of that cluster was tested.

Why are we not testing healthcare workers regularly?

Dr. Ronan Glynn

We are examining the need for more widespread testing of healthcare workers. We will consider the issue at NPHET in the next week or two. To reference Professor Nolan's point, we need to be careful that the testing we do is warranted and targeted and does not lead to unintended consequences.

I would have thought that testing of healthcare workers was warranted.

Dr. Ronan Glynn

If it needs to be done, we will do it. However, the basic message cannot get lost - if any healthcare worker has any symptom suggestive of Covid, he or she simply should not go to work in the first instance. The worker should contact his or her GP and get tested. That is the most important message to get out there in respect of healthcare workers.

What about the environmental health officer? I still had 30 seconds when the Chairman rang the bell.

Dr. Ronan Glynn

I do not know the specific circumstances to which the Deputy is alluding, but I am not sure that an environmental health officer can go into someone's personal home.

When the information is showing that many cases are arising at one address, should the environmental health officer not get involved to check for overcrowding?

Dr. Ronan Glynn

That depends on the precise circumstances of the individual cluster in question. I cannot give a wider opinion than that.

I thank the witnesses for coming in. I have been listening to the language Dr. Glynn used about how concerned he is and the window of opportunity that is before us. It is very important and timely that he is here to reiterate the message and its simplicity about physical distancing, not mixing households etc. It is the simple message that has applied all along.

Dr. Glynn has been working on the front line of this crisis for the entire period we have experienced it. He has had to communicate lots of very different and complex messages. What messages and communication channels has he found to be most effective in reaching people?

Dr. Ronan Glynn

From the very start we have tried to communicate as openly and effectively as possible. Communication is paramount in a pandemic. People need to know what they need to do and what the situation is. We hold press conferences reasonably frequently, twice a week at the moment. Social media clearly plays a role, but the most effective element of communication over a number of months has been the consistency of the message from our political representatives, media organisations, sporting organisations, community organisations, the public sector and private business. Everyone was on board with the simple messages. I fully understand why those messages have been diluted and many have stopped providing those messages, but we really need to get back to providing those messages. Social media has a very significant role to play and we will try to up the game in the coming weeks in that respect. I fully accept that some people feel we are not providing enough information and we will endeavour to provide more.

Given the current rise in cases, we are at a very delicate point. The measures we took last week are absolutely premised on public buy-in and understanding of the rules around gatherings of six or 15 people and the need to avoid congregation. We need everyone across society to communicate that message if it is to be effective and to prevent us having to recommend further measures.

I thank Dr. Glynn. We are at a most difficult phase, with rising numbers and more complex information. There is a certain fatigue among people. There is a general wish to move on but of course that is not possible in so many different ways. Dr. Glynn's presence here today is very important. I know how busy he is and I thank him for attending. There is an opportunity for a reset concerning where we are and how we move forward. That will depending on how successfully we manage to communicate this message. I am not just talking about those of us in this room, but all of civil society, including the bodies Dr. Glynn has mentioned, such as sporting organisations and businesses. We are at a most nuanced and difficult phase.

The last time Professor Nolan was here we had the opportunity to speak just after the committee hearing about the virus itself and its evolution. Obviously it is a novel virus and we have very little information about it, but even during that first 12-week period Professor Nolan's group was acquiring more and more information about its behaviour and evolution. Can he update the committee on the science of the virus?

Professor Philip Nolan

The virus is extraordinarily stable. Viruses mutate all the time but this one is not doing so to any great extent. The first piece of news is that any change in the behaviour of the disease in the population is due to the behaviour of the population and not the behaviour of the virus. We are also learning about the circumstances in which the virus is transmitted. It transmits very strongly in households, where the attack rate is between 20% and 30%. That is probably lower than one would expect.

It is lower than I would expect. I would have thought it would be total in those circumstances.

Professor Philip Nolan

It is important to know that if it gets into a household everyone in the household will not necessarily get it, but the chances that an individual will pick it up are between one in two to one in four. We are understanding the circumstances in which the virus is transmitted. The risk in a household is high and the risk in schools is lower.

I have only a few seconds left.

To clarify, if household transmission is 20% or 30%, is that of a new detected case or could somebody be asymptomatic and have it, or is it just that they do not have it?

Professor Philip Nolan

It is precisely that. If I pick it up at work and bring it into a typical family household, the chances are that one in two or one in three people in that household will pick it up. If I bring it into an atypical household, let us say a group of college students living together who would not necessarily be as intimate as a family, the chances are somewhat lower, so the attack rate is 10% to 20% in that case. The important message is that we can prevent transmission of the virus. It is not inevitable; it is not magic. It spreads by close, sustained contact, and if we just put that distance between each other and are careful about our hygiene, we can prevent its transmission in households, and we can certainly, by not congregating, prevent its transmission between households. They are the kinds of things we are learning, along with the special circumstances in places, such as meat factories, which seem to particularly promote the transmission of the virus.

On that issue of meat factories, Dr. Glynn mentioned the need for a proportionate response and Professor Nolan also mentioned the need for proportionality. As counties Kildare, Laois and Offaly were locked down, we heard from Meat Industry Ireland and the HSA, and they confirmed that 39 meat plants had been inspected, of which 30 inspections were pre-announced. The day after it was announced that we, as a State, were not in a position to move to phase 4, Dr. Glynn pointed out there had been 47 cases in meat plants and four clusters, and that was the most recent of a large number of clusters. We have had no clusters in any hospitality business yet, in one weekend, there were 6,000 inspections of licensed premises, of which less than 0.5% showed any lack of compliance. Is Dr. Glynn happy that that aspect of the State's response was proportionate to the risk?

Dr. Ronan Glynn

From my perspective, we need to decrease congregations across settings, we need to decrease risk across settings, we need-----

I have heard all of that. I hope that everybody recognises the need to wash their hands and to avoid congregated settings and places that are busy. I am asking whether 39 visits to meat plants, when there has been cluster after cluster after cluster in this State and in many other states across the world, is proportionate, given there were 6,000 visits to licensed premises in one weekend and there have been no clusters in any of those. There have, of course, been ten outbreaks in licensed premises in the UK, all of which are open whereas ours are closed. I am asking whether that is proportionate.

Dr. Ronan Glynn

My answer is that we need to do everything we can across all sectors to decrease further cases and clusters, whether that is in restaurants or bars or in meat processing facilities. Enforcement and visitation is one element of that but it is just one element. Ultimately, it comes back to human behaviour.

Dr. Glynn is happy that it is proportionate. I will move on to the next question. The affected areas order was made in respect of every area of the State on 7 April. Has that been reviewed in respect of any area of the State since then? It was made on the advice of the Chief Medical Officer. As acting Chief Medical Officer, has Dr. Glynn been asked whether there is known or believed to be sustained human transmission in every single area of the State? Has there been a review of any area of the State since that order was made?

Dr. Ronan Glynn

We review the data in regard to every county in the country every single day and we will continue to do that.

There were five counties in respect of which there was a four-week period with no reported case. Is Dr. Glynn happy that, in those counties and in the areas of those counties, there was sustained human transmission at the time there was no reported case for four weeks?

Dr. Ronan Glynn

We need a period of time to be sure there is not a case.

What period of time is needed?

Dr. Ronan Glynn

Neither I nor the Chairman can sit here today and say where there will be cases tomorrow.

I appreciate that. I am not asking Dr. Glynn to predict the future. He is a scientist and what he says is based on evidence rather than conjuring up anything. I am asking him what is the period of time. He said he needs a period of time. What is the period of time?

Dr. Ronan Glynn

Given that we have no vaccine and no treatment and we have a lethal virus circulating in the country, I do not see that time changing any time soon. We have had cases in 25 counties over the past-----

Dr. Glynn said he believes there is sustained human transmission in a county where there has been no reported cases for four weeks.

Dr. Ronan Glynn

I am not sure what the specific question is. If it is whether measures could have been released entirely in some of those counties, my answer would be "No".

I will try to make it clear. In circumstances where there is no reported case of Covid-19 in a county for a period of four weeks, in Dr. Glynn's view is it fair to say that there is sustained human transmission in that county during that period of time?

Dr. Ronan Glynn

What we can say about that is that no confirmed case has been identified in that county in those four weeks. That is as much as we can say.

That is all I am asking. Can Dr. Glynn say there is sustained human transmission, or that there is known to be or believed to be sustained human translation in that period of time?

Dr. Ronan Glynn

What we can say is there has not been a confirmed case in that county over that time.

Likewise, can we say there is sustained human transmission if there is no reported case?

Dr. Ronan Glynn

We can. We can certainly say there is potential for sustained human transmission.

Potential is not-----

Dr. Ronan Glynn

Again, we have seen this play out in recent weeks.

We heard Dr. Glynn say today that in Germany 40% of cases are associated with travel. We were told about outbreaks in bars in Spain and the United Kingdom, when we decided we would not open ours. If Dr. Glynn is aware of these figures from Germany, Spain and the United Kingdom, presumably the health authorities in those countries are also aware of them. Beyond the fact that we have a really bad health system in this country, can Dr. Glynn explain why our approach has been to limit travel whereas those countries have not limited travel, or at least travel within the European Union? They have, of course, brought in very stringent testing and quarantining for people coming from outside European Union, which we have singularly failed or neglected to do. Their approach has been very different from ours. Will Dr. Glynn explain this?

Dr. Ronan Glynn

To come back to the Chairman's first point, I do not want it taken out of context and I was very clear that I said I had read a newspaper article this morning that suggested 40% of recent cases in Germany were travel related. I said that it was not from a definitive or scientific publication.

I agree. While Dr. Glynn has been answering questions I had an opportunity. I very much appreciate all of the questions he is answering. His advice is key not just to the State's health response but also how the economy functions at present. The Robert Koch Institute, which is one of the primary institutes looking at this in Germany, very much backs up the figures Dr. Glynn cited. I am not disputing the figures. I am saying if the figures are correct and Dr. Glynn knows about them and is making decisions here based on them, then surely the health authorities in those countries know about them. I am wondering why they are arriving at very different decisions.

Is it not the case that our health system is quite bad but if we continue on the road we are on economically, we will not be able to fund the health system we used to have, much less the health system we so desperately need? This may not be a consideration for Dr. Glynn. I am not saying it is not a consideration for him but he is a health official and he is doing a very difficult job, and I acknowledge this, but his primary responsibility is solely for health. As Mr. Reid acknowledged earlier, we also have to be able to fund our health system.

Dr. Ronan Glynn

Absolutely, and I thank the Chairman for acknowledging it. What I would say is that of course health is my priority but I also fully recognise that public health and our public health system are absolutely contingent on a functioning economy. If the economy is unduly affected by this, it will affect our health system.

That does come into our considerations. That is precisely why, for example, we moved so quickly on Kildare, Laois and Offaly. It is why I am so concerned about cases at the moment. We do not have magic bullets for this disease and we are entirely reliant on solidarity, co-operation and individual and collective behaviours to keep it under control. Otherwise we will not have a choice but to go backwards with stronger measures.

I am the last person who wants to have to recommend measures that will have a further impact on the economy and people's lives, which is why I am asking all parts of society today please to double down again on their behaviours and messages to their families, members of their organisations and anyone they come into contact with. Let us all be upfront about our role in this and ask our friends and families to do their bit. It is only by all of us together being vocal and honest and saying that people have to wash their hands and do the right thing that we will keep this under control. If we do not do that, it will, unfortunately, have impacts for the economy whether we like it or not.

I have two brief questions. The expert advisory group on nursing homes recently reported to the Department. Are any of its members being appointed to NPHET? Anecdotally I have heard, very regrettably, about a lot more suicides than I have for a considerable period of time. This is during the summer before we head into a long, dark winter. Are there any representatives of psychiatry or other mental health representatives being appointed to NPHET which is, essentially, the decision-making body for our State? Largely, elected representatives are following the health advice.

Dr. Ronan Glynn

NPHET undertook a review of its membership and functions over the past number of weeks. As the Chairman knows, the Government intends to publish a future framework over the next short while. We intended to review and update its membership, but given that the framework is due to be published in the next fortnight it is prudent to wait and review that framework and NPHET's role within it and ensure that our membership is appropriate to our role following the publication of that framework.

Am I correct in saying that many countries, including Ireland, have witnessed an increase in detected cases but that has not, thankfully, been accompanied by an increase in hospitalisations, ICU admissions and deaths? How much have we increased our ICU capacity by since the initial lockdown in March? It seems to be an international trend. From what I understand, Dr. Glynn said the only reason for that is because elderly people have not contracted the virus up to now and once they do we will see an increase. Am I correct in summarising his position?

Dr. Ronan Glynn

I will hand over to Professor Nolan. We have no reason or evidence base to believe that anything other than what I have described will happen if we allow this disease to take hold and spread among those who are older and medically vulnerable.

I thank Dr. Glynn for answering all of the questions here today. I appreciate that he has had to take time out of what I am sure is an extraordinarily busy schedule to do so. Was Professor Nolan going to answer the question about ICU capacity increases?

Professor Philip Nolan

I have two brief comments. Our strategy is different from other countries because we are an island nation.

We are not; we are part of an island nation.

Professor Philip Nolan

We are part of an island nation with a high population density. Our original epidemic was seeded by travel. It would be worth our while to look at the population density map of Europe and see how different Ireland is from much larger European countries and the potential of the disease to spread very quickly from one outbreak in one part of the country very rapidly to all of the parts of the country. That is why counties that may be green for weeks on end can suddenly turn red because of an outbreak in another part of the country.

I can confirm, from our analysis and the analysis provided by Dr. Glynn and others, two reasons why we are seeing fewer hospitalisations.

One is that we are detecting more cases that we would have missed in the past. Asymptomatic cases that would not have come to our attention in the past are now being tracked, traced and isolated. They are very unlikely to be admitted to hospital. Going back to the early stage of the pandemic, however, people aged between 20 and 39 had between a 2% and 5% chance of being hospitalised, and every second person aged between 70 and 80 was hospitalised. We also know-----

Sorry? Between what ages?

Professor Philip Nolan

One in two people aged between 70 and 80, throughout the pandemic to date, outside of long-term residential care, was admitted to hospital. Because we are seeing milder disease, the ratios will not be that high in future, but we have seen hospitalisations.

Why are we seeing milder disease?

Professor Philip Nolan

We are seeing milder disease because to prevent transmission of the disease, which was very rapid in the early part of the pandemic, we are testing asymptomatic contacts and isolating them. Those people-----

We are seeing milder infections.

Professor Philip Nolan

Of course. The objective here is to track down all cases, no matter how mild, in order that they do not transmit the virus to other people. Therefore, if one has-----

Is Professor Nolan saying that every single case involving someone aged over 60 in Ireland is being hospitalised?

Professor Philip Nolan

We have had 21 hospitalisations from the 1,300 cases we have had in the past 14 days, so it is not true to say we have had no admissions to hospital.

I never suggested it was, but is Professor Nolan saying every single case involving someone aged over 60 is being hospitalised?

Professor Philip Nolan

No. Leaving to one side the people being cared for in long-term residential care, 50% of people between the ages of 70 and 80 in the community have-----

Many residential care facilities have no medical officers, for example. There is care but it is very low-level medical care. If someone in such a facility had the flu, for example, he or she would be hospitalised.

Professor Philip Nolan

Yes.

I wish to make one final point, and then Dr. Glynn might wish to add something. What the history of the pandemic shows us is that if there is a high level of disease in the community, it spreads to older people. That spread will be slower now because those older people are being much more cautious, and the virus will be slower to enter long-term residential care because infection prevention and control understands the presymptomatic or asymptomatic transmission of the virus and because of-----

I wish to bring this to a close. I could stay here and ask questions all day but I fear that would not be a productive use of the witnesses' time. It might be of mine, but their time is far more precious. My final question is this: what has been the increase in our ICU capacity since March?

Dr. Ronan Glynn

That had increased to more than 400 beds at one point, but I will provide the precise and current number to the Chairman in writing this afternoon.

I thank Dr. Glynn.

Again, I thank both witnesses for coming here, answering all the questions and staying so long. I wish them the very best of luck in their endeavours to keep this under control.

Sitting suspended at 3.03 p.m. and resumed at 3.35 p.m.