What did Government consider in planning the reopening, and what could go wrong?

Next week, the first steps will be taken on a broader reopening of society that marks a step-change in the Irish experience of the pandemic.

Scenarios drawn up for the Government this week sketch out a range of outcomes, from a smooth transition aided by growing vaccination, to a damaging surge leading to thousands of hospitalisations.

The political stakes could not be higher: the coalition hopes it will mark the point at which, after a long march through winter and early spring, day-to-day life becomes tangibly better for voters.

Conversely, the costs for failure could be ruinous for the Government. In contrast to Christmas, there is little difference between the advice from Nphet and the chosen policy path. But while success will likely drive a political dividend, failure would nonetheless be damaging – perhaps fatal – for the Government.

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Which is more likely, and what could go wrong?

Thanks to the experiences of Christmas and last summer, we know a reasonable amount about reopening from a baseline of cases around the same as now, and also significantly lower cases. However, that’s of limited use, as there are at least three new factors to contend with.

Variant

Firstly, there is the B117 variant. Much is unknown about precisely how much more transmissible it is, but what we do know is not good. Figures given to Ministers show Nphet estimates B117 is between 40 and 90 per cent more infectious. A series of scenarios drawn up for the Government illustrate this using the R number, the basic estimate of the rate of growth in the pandemic judged by how many others an infected person in turn infects.

B117 means that levels of social activity from earlier in the pandemic would produce bigger waves of infection. For example, a May 2020 level of activity, thought to give an R number of around one, could drive it to between 1.2 and 1.6. If we were socialising like we were in September, towards the end of the first tranche of reopening, the R number would grow from 1.6 to 2.5. The estimated R number in December, when hospitality was largely open, was 2.0, but with B117, which was growing around Christmas, it could be as high as 2.3 to 3.2.

Given the prevalence of the variant, which is dominant in Ireland, reopening brings with it the risk of greater infection, trammelled by the other two other factors.

Reopening

Firstly, the type of reopening. Nphet and the Government hope that by focusing on the outdoors, growth in the pandemic could be constrained.

If there is a “step change” with R only rising relatively quickly to about 1.5 from May 10th, there could still be significant levels of infection between then and the end of September – around 101,000 cases, with a peak of 1,100-1,200 per day. However, the hope is that the phased approach, focused on the outdoors, will mitigate this.

The models given to Government also examine a scenario where R is 1.25 from May 10th, and 1.5 from June 7th.

If increased social contact is deferred until June 7th, the projected increase in case counts is effectively eliminated, the letter notes.

Vaccination

That is down to the third factor: vaccination. At least since St Patrick’s Day, there has been a growing acceptance that B117 is simply too infectious, and the post-Christmas wave of infection was too great, to achieve the kinds of levels of transmission seen last summer by non-pharmaceutical interventions – lockdowns, to you and me. This explains why many of the more eye-catching changes announced this week won’t kick in until June.

It’s not really articulated publicly by Government or Nphet, but the policy has been to try and keep cases close to their current baseline, where the threat to the hospital system is not systemic, while reopening the most important parts of society slowly.

The other parts of lockdown that are particularly important for keeping cases down are retained. But the ultimate way out is waiting for the protective shield of vaccination. Indeed, this week’s letter states it fairly baldly. It warns that the analyses are based “on vaccine uptake and speed of deployment”.

“It should also be noted that there is an assumption that non-pharmaceutical interventions (reduced contacts, physical distancing, face coverings, hygiene and ventilation) will remain in place in some form unless and until herd immunity is achieved through vaccination.”

The next couple of months will be the first real test of whether vaccines, combined with measured and specific relaxations, can deliver a slightly more normal life.

Risks

So, what kind of protective effect might vaccination have? Models shown to Government suggest that if R grows more slowly during May and into June, there will be an associated impact but it will ultimately be offset by vaccination. The phased, slower increase to an R of 1.5 from June 7th “shows a small increase before vaccination starts to suppress transmission and a limited increase in hospitalisations”.

What could go wrong? Well, the risk remains that Covid will snap out of control, meaning all bets could be off. For example, R could grow rapidly to 1.9 by May 10th, driven by a level of social contact last seen last summer. It should be noted the avenues for that level of social contact, with significant levels of indoor mixing across a variety of settings such as pubs, restaurants and houses, aren’t really available under the restrictions outlined for May and June. But the effects could be devastating, even with vaccines.

It could fuel a “large surge of cases, peaking at over 7,000 cases per day” in July, with a mid-range estimate of 384,000 cases in total. Even with vaccines “this leads to a significant demand for hospital care”, with 10,000 admissions, 250 people requiring critical care and 850 in general care.

Notwithstanding this, the letter does hold out hope that vaccination may be able to provide sufficient cover for these kinds of activities later in the summer. Modelling suggests that delaying a rise to an R number of 1.9 for 4 weeks “greatly attenuates this surge, and greatly reduces risk”, while a delay of 8 weeks “to early July, eliminates the surge”.

So the later that occurs, the greater the protection, suggesting that activities which would drive a damaging wave now, will cause a ripple if a widespread and effective vaccination campaign is completed over the summer.

As is always the case with Covid, there are huge caveats attached, and major uncertainty means much depends on the next few weeks. To some extent, we are flying blind, a fact picked out in the letter to Minister for Health Stephen Donnelly.

Greater reopening involving indoor social contact “remains very high risk”, and the degree to which it will be possible depends on how the pandemic evolves in the next few weeks.

More data, both locally and internationally, is needed on the B117 variant, Nphet told the Government, while also “we need to understand the actual impact of the phased re-opening in May and June, and the parallel vaccination programme”, before assumptions can be made about greater reopening in July and August.

And, as is always the case, it rests in our hands.