COVID-19 Management in Ireland: A Call for Data Collection and Risk Stratified Quarantine/Testing of All High-Risk Inward Travel

Common Sense ...

I just finished listening to the Taoiseach Leo Varadkar outline that travel and flight restrictions would not be imposed in Ireland because they “don’t work.” Come again. What's the alternative, a big heartwarming COVID-19 Cead Mile Failte? I've got a scenario in my head, a flight full of people landing in Dublin, inbound from a high-risk region. Two have low-grade fevers and a sore throat, and several others are infected with SARS-CoV-2 but still haven't developed any symptoms. They come through visa control, walk past the token COVID-19 information stand, and are off on their merry way. As ridiculous as this scenario sounds, it's a pretty fair description of Ireland's current management of inward travel from high-risk zones and must be considered the major reason Ireland has gone from 0 cases of COVID-19 to 28 cases in just several days.

Despite Ireland being in the throes of the worst public health crisis of our generation we seem to be woefully complacent about our airport containment strategy. The scenario above, which we can assume is playing out across Europe, would result in the very real potential of burdening our already stressed healthcare infrastructure and stretching the already stretched staff-patient ratios to breaking point. In the scenario above we would also have several new cases occupying the limited resources of our public health teams to conduct contact tracing. Worst of all, in the above scenario, there are hundreds of chances to spread the virus throughout Ireland.

We have 26 confirmed cases in all of Ireland, 25 directly imported from Northern Italy, and the other case assumed to be community-acquired transmission. But let’s reiterate just to be clear. The virus didn't swim here; all cases of COVID-19 in Ireland have been directly or indirectly imported via inward flights from high-risk zones. Which begs the question, why exactly have we not imposed travel bans or at the very least started to use risk-stratified mandatory quarantine/testing on all inward travel from high-risk zones? Why haven't we been gathering data (purpose of the trip, trip itinerary, contact number, etc.?) from these high-risk travelers? Because it doesn’t work?

Has our dialogue really degenerated to this level of political doublespeak, or have I slipped into some bizarre alternate universe where counterintuitive appeals to authority are overriding commonsense? A place where the scientific rationale guiding our current COVID-19 strategy is presumably so esoteric that even the most basic mechanistic explanation can’t be provided to the public. If travel bans "don't work," let’s understand why and let’s look at the data, models, and studies used to guide this strategy? Surely, during the biggest healthcare crisis of our generation, Ireland's response strategy is evidence-based and validated? I am not opposed to the argument that there are economic considerations, but let's all have the gonadal fortitude to put it all on the table so our national dialogue is appropriately informed. 

I can only assume that the HSE's stance on travel is based on the advice of the WHO, which has advised countries that travel restrictions don't work based on mathematical models like the one linked here. Have we conducted our own Ireland specific mathematical models which are guiding our policy, or are we deriving these conclusions from studies based on China models? Because WHO itself by its own admission has stated we are in "uncharted territory". How big of a priority is Ireland for the WHO, and to what extent should we follow their advice without question? The WHO is not infallible. Within the last week, we have seen them backpedal on their own guidelines regarding the lack of potential for asymptomatic spread, and is now conceding spread can occur 24-48 hours before symptom onset. (still sounds a bit arbitrary and contrary to case reports and scientific studies)

There are two types of COVID-19 Countries: Those on Lockdown and those that have lost control

When it comes to COVID-19 the real killer is complacency and the greatest risk factor is inaction ....

Are we to assume that countries like Japan, Australia, Vietnam, the US, China, Taiwan, Singapore, which are currently imposing quarantines and travel restrictions, are wasting their time? Extrapolating from the “travel ban/restriction doesn't work” premise, we must also assume that city lockdowns and provincial lockdowns must also be minimally effective. So why has Italy just put Lombardy on lockdown effectively, meaning 16 million people are now in quarantine. Could Italy's rapid descent have been mitigated with more proactive containment measures? Surely the lesson from Italy is that when it comes to COVID-19 the real killer is complacency. What about data from China, Vietnam, and China-Taiwan, world leaders in tackling epidemics. All this data seems to actively support a case for travel bans/travel restrictions and risk-stratified management?

Despite Vietnam sharing a border with China and reporting its first case on January 23rd, a full 37 days before Ireland's first case on March 1st, it now has fewer cases of COVID-19 than Ireland. Think about that for a minute? Supposedly a developing nation, with a weaker healthcare system, right on China’s southern border, and a full 10,000 kilometers from Ireland is outperforming Ireland in its response strategy despite us having a month of a head start on them to prepare.

What about all of China's major outbreak zones outside of the epicenter Wuhan? Cities of 10 million people like my second home Hangzhou have reported no new homegrown cases of COVID-19 in days. These cities all have population densities and other unfavorable characteristics compared to Ireland and have still been able to control the spread.

Are we already too late? The SARS-COV-2 Data Lag

When you look up into the night sky at distant stars, you see what those stars looked like millions of years ago. In a similar way, when you look at the SARS-CoV-2 attack rate data, it’s like looking back in time. The exact number of people currently infected with SARS-CoV-2 in Ireland is impossible to quantify. Still, I think it wouldn’t too rash to assume we certainly have more than 26 cases in Ireland and can expect growth of the outbreak in Ireland to follow scale adjusted growth patterns similar to other European states that have been hesitant to pull the trigger and move from containment to mitigation. Looking at HSEs worst-case scenarios they are forecasting 1.9 million cases. Yet travel restrictions "don't work".

Looking at how COVID-19 epidemics have progressed in other European countries like Ireland that are or were hesitant to impose travel bans, city lockdowns, bans on mass gatherings, there are obvious parallels we can draw. After the initial community-acquired infection is confirmed, the attack rate undergoes explosive exponential growth. Growth remains unchecked until significant mitigation measures are imposed, usually in the form of mandatory quarantines, city lockdowns, etc.

Bridging to mitigation: Reducing the Epidemic curve

I think it’s fair to speculate that the opportunity for Ireland to get ahead of COVID-19 through the use of a proactive containment strategy may have come and gone. Trying to outright stop COVID-19 in Ireland by imposing travel bans, flight restrictions, etc. would be a bit like closing the stable door after the horse has bolted. However, these controls would still offer a chance for us to reduce the burden on our healthcare sector and buy us some much needed time to improve our capacities and allow the public and private sector time to adjust to what will inevitably result in significant disruptions to normal life.

How the Chinese do Risk Stratified Management to Control SARS-COV-2

In consideration of the economic factors, let's find a happy medium. The Covid-19 management system in Irish airports is frankly embarrassing. It looks like something a transition year student would do for their school project. In the absence of outright travel bans, which would understandably have a devastating economic impact, we could at least optimize our airport strategy in the following practical ways:

Ireland’s Airport COVID-19 Management Hierarchy of Needs

1)     Data collection (20-day past travel history, Ireland trip itinerary, the purpose of the trip, contact number, etc.) Temperature testing could also be conducted to at least identify symptomatic individuals for immediate quarantine. Masks and hand sanitizer could be given or sold here. 

2)     Risk stratified management: Mandatory quarantine combined with testing of all inward travel from high-risk zones.

3)     Complete travel ban on all inward travel from high-risk zones

On the Use of Masks: Common sense

Absence of evidence of effectiveness should not be equated to evidence of ineffectiveness, especially when facing a novel situation with limited alternative options.

Travel bans "don't work" guess what else doesn't work ..yup you guessed it masks "don't work". Again we are left scratching our heads on another piece of counterintuitive advice. WHO has issued guidance that masks do not need to be used by the general public and are only effective for use on symptomatic infected people to stop the spread of the disease. Previously the WHO stated that viral shedding in asymptomatic individuals was not a major issue. Now they have backtracked and stated that 24-48 hours prior to symptom onset there is the potential for infection. So logically we must assume now that the use of masks by the general public would probably help in reducing or delaying the spread of the virus.

Even the mighty WHO is learning on its feet. What about looking to the world's experts on dealing with coronavirus epidemics. Yup as I've said before outside of China, there aren't many SARS experts and guess what, China's advice is pretty clear, masks work. They have spent hundreds of millions of dollars to procure medical-grade masks, a project which I have been actively engaged on for the last several weeks here in Ireland on behalf of Alibaba. There are also several pathophysiologic rationales for mask usage. We know the virus uses the ACE2 receptor to bind and enter its host. These ACE2 receptors are expressed primarily in the lungs, nasopharynx (nose and throat) and even the eyes. Reducing the access of the virus to these binding sites would obviously reduce the risk of infection.

Mask Procurement in Ireland

For local primary care physicians, private hospitals, businesses or government bodies looking to source masks, please pop me a private message. We have access to stocks of KN95/FFP2, compliant with Chinese and EU regulations (GB2626 standard and EN149 FFP2) and complete with testing reports and relevant certification (English label, CE mark, etc). Also, access to stocks of 2ply surgical masks

KN95/FFP2 Cup type

KN95/FFP2 Folding Type