How can a greater mixing of people amid high Covid cases be considered 'cautious'?

This week, which government had intended to mark the end of all non-pharmaceutical Covid-19 protection measures, is instead marked by confusion.

A government which had been hoping for a grand reopening was compelled by the facts to instead opt for what they characterise as “cautious” steps forward, and the hastily-assembled safety guidelines leave much to be desired.

The government was very keen to state that there is no intention to reintroduce the restrictions previously lifted, but it is not clear that they have really learned the lessons of how to achieve that or that their measures are sufficiently cautious in the ways that matter.

In the face of cases rising to levels not seen since January, and high numbers of Covid patients in ICU (soon to be joined by the predictable fraction of this week’s newly-infected cases who will need such care) how can any move that allows greater mixing of people without compensatory mitigations be considered in any way “cautious”?

Martyn Turner

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It has finally been publicly acknowledged that vaccines alone won't end this pandemic, but the tendency to reach for a simple solution seems to endure

Rather, it will inevitably lead to even higher case numbers, and further crisis in our health system. As the ICUs fill up, scheduled surgeries requiring post-op ICU care will be cancelled, and we may need to resort to the so-called surge capacity.

But as Dr Colman O’Loughlin pointed out this week, this is not fresh cavalry marching over the hills, but the redeployment of staff from other busy areas, which end up being “desurged”. More Covid care means less of everything else.

There has been much derision of the guidelines around this week’s reopening steps, with some so ineffectual as to be almost comical – what are the chances that a socially-distanced queue for a nightclub bar will actually be maintained? And even if it was maintained, what effect would that have in the face of an airborne virus?

While efforts of various ministers have gone into fixing these anomalies in the interests of their department’s brief, the most important problem with the guidelines is the unforgivable omission of an overall strategy that is based on the scientific evidence accumulated over the 20 months of this pandemic.

It has finally been publicly acknowledged that vaccines alone won’t end this pandemic, but the tendency to reach for a simple solution seems to endure, with antigen testing now being mooted as the path out of here. Antigen testing will be very useful, but only as part of a broader strategy. We need to combine all the tools at our disposal, and that means a three-pronged approach of prevention, vaccination and control (dubbed PVC by Gabriel Scally).

At the heart of prevention lies a proper understanding of transmission. There are unobtrusive and effective mechanisms to block transmission by blocking, diluting or removing the virus in the air.

Theoretical, experimental, and real-world data show that masks work, show that ventilation works, and show that HEPA filtration works. Why were we even contemplating abandoning mask mandates in the face of an airborne virus, when we should have been requiring a better grade of mask and expanding it to include, for example, spectators at sporting events?

In Austria, masks must be FFP2/N95 standard or above – here we are simply asked to use a face covering (which sometimes manifests as an improvised and ineffectual t-shirt pulled up over the nose). Why are we not requiring masks for primary school children as they are doing in other European countries, and as endorsed by the American CDC?

Failing to put mitigations in place in hospitality venues is going to mean a lot of superspreader events

Why are we still counting how many people can go into a particular venue based on the type of activity, and the presence of tables? We need clear ventilation standards for all indoor spaces. We need to turn away from allowing events based on what is taking place and towards allowing activities based on the ventilation capacity.

It is not our “personal responsibility” as customers, or employees, or pupils to ensure that this takes place. Instead this should be managed as a health and safety issue, much like food and water safety systems. The ventilation capacity of different places should be assessed and that information should be displayed as “scores on doors”, reassuring customers, staff and students, that the space is safe for them.

There is an alternative reality we could be occupying right now. One where air hygiene is managed in the background, much like food and water hygiene

This will be particularly important for clinically vulnerable individuals, who may feel de facto excluded from any space where masks and ventilation are not up to standard.

Finally, our long-term strategy for dealing with Covid must include proper control of infection in the form of test, trace, isolate and support. This falls under the realm of regional public health departments, a service which is drastically under-resourced in Ireland.

We need to reinstate proper contact tracing, we need to make testing as easy and accessible as possible, and we need to support people who need to isolate so that they don’t lose income. A properly resourced regional public health department will also be instrumental in bringing vaccination to some of the hard-to-reach individuals.

We urgently need to recognise that there is a vast range of possibilities between lockdowns and “letting it rip”. Failing to put mitigations in place in hospitality venues is going to mean a lot of superspreader events. We’ll be back to the conversations of this time last year, looking at exponential growth on a graph, arguing after the fact over which types of activity were worse than the other for causing cases to rise.

There is an alternative reality we could be occupying right now. One where air hygiene is managed in the background, much like food and water hygiene. These systems are invisible to the general public, and make our work, education and leisure activities safer and are an achievable public health approach to manage the pandemic, and avoid disease and disruption.