Extending My Critique of Irelands COVID-19 Contact Tracing Strategy and a Rationale for Immediate Restrictions on Population Movements

In a recent interview with RTE Prime Time, I outlined my assertion that one of the more challenging aspects in Ireland's response to COVID-19 was a lack of transparency on the scientific rationale underpinning our COVID-19 response. In this Prime Time interview, I referred to an open letter I wrote to Chief Medical Officer Tony Holohan and Head of the HSE Paul Reid in which I asked for some answers to questions on what I perceived as major flaws in Ireland’s implementation of contact tracing.

Scientific and Empirical Evidence on Shortcomings of Contact Tracing in Ireland

My criticism was based upon a substantial body of evidence. In this letter, I referenced mathematical models outlined in a study published in the Lancet, a case study in the NEJM reporting spread of the virus in asymptomatic individuals, metanalysis on the R0 value, and studies on virus transmission dynamics also published in the NEJM. Since I published that letter, we have also unfortunately seen damning empirical evidence on the shortcomings of a contact tracing dependent containment strategies like the one Ireland and other countries in Europe are implementing. These shortcomings are playing out in genuinely horrific ways all across Europe and best exemplified in the devastating impact Covid-19 is having in Italy. 

Changing Tack

Since I published my first article Ireland has not changed its stance on contact tracing. I would urge the government to reconsider. I'd like to preface further discussion by going on record as stating that I know contact tracing is a vital part of our COVID-19 response but would also point out there is strong evidence pointing to the necessity of augmenting our current strategy.

Green Jersey Time

I am extremely grateful for the tireless work being done by the HSE, DOH, and public health workers around the country, we are in your debt. However, I still think Ireland's contact tracing teams are fighting this battle with one hand tied behind their back. Let's be clear, our version of contact tracing can only be effective if it is supported by a comprehensive campaign of population-wide testing and augmented by a significant curtailment of population movements.

Expecting the population to self-diagnose

Ireland’s current version of contact tracing is heavily reliant on the self-reporting of infected individuals. Its reliance on self-reporting is another foundational flaw that completely undermines the whole approach. In contact tracing that relies on self-reporting, we are dependent on sick individuals becoming their own clinicians and to diagnose a disease with overlapping symptoms with a broad range of far more common and benign infections.

 For self-reporting to work, we must assume that individuals have a solid grasp of the variable clinical presentations of COVID-19. The public is well-schooled on the major COVID-19 red flags such as a history of exposure to infected individuals or travel to a high-risk area in combination with the clinical constellation of fever, dry cough, myalgia, headache, and fatigue. However, it is now well established that symptomatic individuals can lack all or some of the red flag symptoms and present instead with atypical findings such as gastrointestinal disruption, nausea, vomiting, and diarrhea.

The Subjectivity of Symptomatology and Variability of Host Response

Symptomatology is not an intrinsic property of a virus and is solely dependent on the host response. In simple English, this means two people infected with the same virus can feel and react very differently. There is a high degree of subjectivity in how people "feel" during mild COVID-19 infections, which constitute about 80% of all cases.

Without widespread testing and solid data on seroprevalence, it is highly likely that large numbers of infected individuals cannot be identified through contact tracing, due solely to their failure to self-report. We must also consider the problems community transmission poses to accurate contact tracing. Importantly, Ireland’s extremely strict testing criteria require a clear exposure to either a travel or contact risk and the presence of a clearly defined constellation of typical clinical presentations making it extremely difficult for individuals that fall outside testing criteria to undergo testing. Beyond all this, contact tracing is dependent on a person (presumably sick) having the ability to accurately recall details of their movements and all contacts with other people.

How to Fix Contact Tracing in Ireland: Comprehensive Population Testing and Restricting Population Movements

The HSE and Department of Health are on the right track with contact tracing. They are hopefully ready to pull the trigger on relaxing the current testing criteria and increasing the number of people tested and expanding contact tracing capacity. More widespread testing of the population will significantly increase the efficacy of contact tracing and if combined with geosync data from some kind of IT solution will allow us to follow proven models and methods like those used in China to such great effect. The next two important steps to improve contact tracing are to ensure that we don’t allow additional infected individuals to enter the country and to reduce the spread of the virus in the population.

#Oneanddone

Ireland still has a real chance to act decisively and, most importantly, save people's lives. The HSE has predicted over 1 million infected and tens of thousands dead in Ireland. Simply not acceptable and fully preventable. I think if we sorted ourselves out as a nation, it's not inconceivable that we could have 0 new cases of COVID-19 in under one month. Data out of China is showing no new cases in several days in most of the major outbreak cities (cities with greater population and higher population densities). Of the new cases being reported, they are all attributable to imported cases that are currently under strict quarantine.

I Promise I Won’t go to the Pub: A Social Distancing Honor System is Destined to Fail

I don't agree that implementing "early" or preemptive restrictions on population movements will result in problems with compliance, particularly if the police and military enforce these restrictions. It would also be good to see where the government is getting its information about these compliance issues. Surely lack of compliance on a small scale is preferable to unrestricted movement on a large scale? It is already clear that containment plans based on some social distancing honor system simply won't work. Some level of government supervision and oversight is necessary and this should be rapidly calibrated to mitigate against the spread of the epidemic.

Pull the Plaster: #pulltheplaster

China’s reaction to COVID-19 resulted in its economy taking a close to 600 billion dollar hit. The shockwaves of its actions reverberating throughout the world, translating to precipitous drops in share values of the likes not seen since the 2008 banking crisis. The effect on global supply chains has been grim. However, things are already getting back to normal in China. Almost 100% of workers have returned to their place of employment with most in the final days of their mandatory 14-day self-isolation. 76% of people are already back in work. Logistics and freight are already operating at about 75% capacity.

On the consumer side of things, there are already signs of recovery with China Woman's day e-commerce festival recording the largest GMV in recorded history. Ireland has to be like China. Pull the Plaster fast, take the initial hit, and reduce the spread of the virus within the country, secure our borders using risk-stratified mandatory quarantine and testing. During this lockdown, we can figure it out, but don't figure it out while people are dying. China is predicting to have no new cases at the end of March. That's just three months in the most populated country in the world. Let's follow a proven model and get this done in one.