An Open Letter to Dr.Tony Holohan, Chief Medical Officer at Irish Department of Health and Paul Reid, Director General of Irish Health Executive Service (HSE): Exploring the Adequacy of Irelands Sars-CoV-2 Response and Outlining the Dangers of Our “Contact Tracing dependent” containment strategy
Dear Dr. Holohan and Mr. Reid,
I am writing this letter on behalf of the Irish people to question and hopefully get some reassuring answers on the appropriateness of our current COVID-19 response strategy and whether it aligns with international best practices. I think it is fair to define our current policy as a “contact tracing dependent ” containment strategy.
The basic principle of our current containment strategy is to wait until people develop symptomatic infection (COVID-19) with the SARS-CoV-2 virus and then confirm these cases using RT-PCR testing. Positive tests then guide a strategy of retrospective tracing of the movements and contacts of the infected person with those in the general population and also define targets for self-isolation and/or hospital admission.
First of all, I would like to draw your attention to a very recent scientific study published in The Lancet (the world’s most prestigious medical journal), specifically addressing the problems of a “contact tracing dependent” strategy in containing SARS-CoV-2 and reducing the incidence of COVID-19. Here is the link here:
I have selected an excerpt from the Lancet study linked above to highlight what I feel is the inadequacy and dangers of Ireland’s current approach to the containment of SARS-CoV-2.
To control the majority of outbreaks, for R0 of 2·5, more than 70% of contacts had to be traced, and for an Ro of 3·5, more than 90% of contacts had to be traced. The delay between symptom onset and isolation had the largest role in determining whether an outbreak was controllable when R0 was 1·5. For R0 values of 2·5 or 3·5, if there were 40 initial cases, contact tracing and isolation were only potentially feasible when less than 1% of transmission occurred before symptom onset.
Let’s look at what we know about SARS-CoV-2 in the context of this study and its relation to Ireland’s current containment strategy.
The virus has an average incubation period of 7 days with case studies from China, indicating a range of 1-14 days. Within 24 hours after infection, viral shedding occurs, meaning asymptomatic individuals can unknowingly spread the disease. Additionally, we know that significant rates of transmission (far greater than 1%) can occur before symptom onset and helps account for the community transmission now occurring in China, South Korea, Iran, the US, the UK, and other affected areas.
As we can see highlighted in the excerpt from the Lancet, this extended incubation period combined with asymptomatic shedding significantly undermines any contact tracing strategy. Although Ireland currently has only 9 cases, I think it would be naïve to think that we will not have more than 40 cases very soon reaching the threshold outlined in the study.
The best studies on the R0 value of SARS-CoV-2 are linked here
WHO has calculated the maximum R0 at about 2.4, however, the average across most studies conducted in China and around the world found the average RO to be 3.28 and median to be 2.79, which exceed WHO estimates from 1.4 to 2.5. This high R0 value is another major factor undermining the feasibility of Ireland’s contact tracing strategy. I do not think it is possible to guarantee that 70% contact tracing can be achieved in Ireland, and failures in this area could have disastrous consequences. If our current “contact tracing only” strategy continues, we will inevitably see community transmission of the virus very soon.
Calling for clarity on virulence, infectivity, mortality
I feel The Department of Health and the HSE have a duty to the people to offer an authoritative voice clearly stating the facts and data on the dangers of the SARS-CoV 2. A major issue facing Ireland is that dialog on the issue in the media seems to be heavily influenced by an appeal to authority fallacy. The media is bombarding the public with conflicting information. On one side we have GPs, college professors, etc. appearing on national news, on the radio and in local newspapers downplaying the severity of the situation and drawing a false equivalence between SARS-CoV-2 and far less severe infections like seasonal influenza (like seasonal influenza was something benign) or even the common cold.
On the other hand, The WHO is stating the virus is orders of magnitude more dangerous than seasonal flu. The WHO’s calculations put the mortality rate at 3.4%, which means SARS-CoV-2, the cause of COVID-19, kills about 30 times more people than influenza. Currently, the HSE website includes no updated data on the mortality rate, the R0 value, etc. Additionally, no guidelines on media responsibilities have been disseminated to local GPs.
The Minister for Health, HSE, and DOH continue to talk about us avoiding panic in the face of SARS-CoV-2. Undoubtedly, the most effective panic mitigation strategy would have been to reduce the risk of infection in Ireland to zero. Early adoption of a proactive strategy involving risk-stratified mandatory quarantine of all inward travel from high-risk zones could have made this a non-issue for Ireland. Instead, we are facing the genuine possibility of community spread.
Travel bans, quarantine, bans on mass gatherings, etc: Some Suggestions
Ireland is and or at least was, in one of the best positions to contain or minimize the impact of this pandemic. As an island nation, we have very clearly defined entry points for inward travelers which should have been appropriately managed. We also have a favorable population density, which also should help us avoid the worst ravages of the pandemic if adequate control measures are implemented.
As a minimum, we should align with international best practices and adopt the following measures:
- In lieu of a complete ban on travel, we should at least implement mandatory quarantine and testing procedures (14 days minimum) on all inward travel from high-risk regions.
- A ban on all non-essential mass gatherings
- More rapid update of public guidance on HSE websites. At present, it seems like we are about a week or more behind the curve
- Offer definitive guidance to media and local primary care staff on the severity of the infection and the potential for significant loss of life, economic losses and impact on our normal life.
- Outline media responsibilities and offer guidance to healthcare professionals and academic institutions
- Use political ties with China to ask for help in designing diagnostic, testing, treatment, and containment strategies.
I think it’s fair to say the Chinese are world leaders when it comes to battling SARS-CoV-2. The country has imposed stringent containment protocols, which I have summarized here for your convenience. I think we deserve a scientific rationale (not a political one) on why travel restrictions and stringent quarantine protocols are not being imposed on all inward travel from high-risk regions.
So far, all cases on the island of Ireland have been imported from northern Italy. Surely if we had already imposed a travel ban or imposed stringent quarantine protocols (14 days isolation on all inward travel from affected regions), we would still have no cases in Ireland? Are we missing something?
Additionally, I would call for more rapid updates to the HSE guidelines on the HSE website. Several days after Italy had hundreds of cases of SARS-CoV-2 infection, there was no updated guidance Italy travel/contact as a risk factor. The website still only listed “travel to China” as a risk factor.
In closing, I would like to say I have purposely avoided politicizing this letter and have chosen only to focus on the scientific data available. If you or the HSE do respond, I would appreciate a scientific answer to my questions. In this letter, I have not included any data about the capacities of our healthcare system to deal with largescale community spread. I have also not offered any data on the availability of critical care units supported by ventilators and ECOM which will become a significant issue if the virus gets a foothold amongst the general population.
Dr. Paul O’Brien is editor in chief of Chemlinked, a private business intelligence firm providing clear and concise regulatory advice and market intelligence for businesses operating in Asia, especially China. Irish by birth, he is a graduate of University College Cork. This article was originally published on his private blog, and is re-produced here with permission.