From time to time, until the crisis has passed, the HEPL blog series authors will be given the opportunity to provide short updates on their country/region’s continuing response to this worldwide catastrophe and their further reflections on those responses. Each update will be labelled accordingly with the original response at the bottom of each post.

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HEPL blog series: Country Responses to the Covid19 Pandemic

Ireland’s response to the coronavirus pandemic – the August update (2020)

Sara Burke, Steve Thomas, Rikke Siersbaek, Centre for Health Policy and Management, School of Medicine, Trinity College Dublin

Ireland’s measures to restrict the transmission of COVID-19 introduced since March successfully contained the virus to the middle of July evident in the declines in numbers of new cases, admission rates to hospitals and ICUs and the declining numbers of deaths. A five-phased reopening plan commenced on 18 May. Phases one to three were introduced from May to mid-July.

From mid-July, the numbers of new cases began to increase with the R-number rising above 1. By early August, the R-number was 1.8 with particular concern in relation to high numbers in a few counties outside Dublin, largely related to clusters in food processing plants and Direct Provision centres (where asylum seekers are accommodated). These counties were put into lockdown for two weeks from 8 August. Up to then the majority of cases were in the greater Dublin area. Once again government and health leaders are urging the public to practice basic COVID-19 prevention measures including physical distancing, hand and respiratory hygiene, limiting contact with people, the wearing of face coverings in crowded/enclosed spaces and only essential travel outside Ireland.

Ireland’s reopening has been slower than other European countries. On 27 June, a new Irish government was formed with a new Taoiseach (prime minister) and health minister. This coincided with a new acting Chief Medical Officer and Secretary General in the health department. Despite changes in leadership, the COVID-19 response has been one of continuity and caution.

While government measures are driven by public health advice, there is some divergence between public health science and government responses since June. For example, the initial five phases were reduced to four, phase two was speeded up to allow people to travel within their own county when the public health advice was to stay within 20 kilometres. The National Public Health Emergency Team (NPHET) recommended a 7-day compulsory quarantine for everyone entering Ireland which has never been adopted as government policy.

Phase four, intended to commence on 20 July and then on 19 August, was postponed twice on advice of NPHET. This phase includes re-opening pubs and bars. On 6 August, the opening hours of restaurants and pubs serving food was pulled back to 11pm; however, NPHET recommended it be 10.30pm.

There is also divergence between measures in Northern Ireland and the Republic of Ireland despite a Memorandum of Agreement signed on 6 April to co-operate on COVID-19. Northern Ireland is following UK advice largely devised by Westminster which has resulted in faster opening up and removal of travel restrictions than in Ireland.

Ireland has been slow to introduce mandatory face coverings with regulations only put in place on 10 July for mandatory face coverings on public transport. From 10 August, face coverings will also be mandatory in retail outlets.

A COVID-tracker App which was initially promised for April was launched by the Health Service Executive (HSE) on 7 July. Uptake of the App has been high, with over 1.5 million downloads (of total population of 4.9 million). In early August a similar App – StopCOVID NI – was launched in Northern Ireland. The two have interoperability, uniquely allowing for cross-border contact tracing. The HSE App source code was donated to the Linux Foundation Public Health Initiative and Covid Shield contributing to global efforts to suppress the pandemic.

On 22 July, the Irish government published  a ‘green’ list of 15 countries with a lower rate of COVID-19. While non-essential travel is still advised against, people coming to Ireland from those countries can travel to Ireland without having to self-isolate for 14 days. This list was amended on 4 August when five countries were removed from the list. The travel advice is complicated by the UK Common Travel Area, the EU freedom of movement as well as incoming flights from the USA

Of particular concern to the public is the safe return to school in September. On 27 July, government launched a Roadmap for reopening schools.

The contract which made all private hospitals available to the public health system ended in June. On 22 July, the HSE published a plan to resume non-COVID health and social care. Infection prevention is resulting in reduced capacity while waiting times are up (between 40%-130% for non-COVID 19 care) due to suspended services during the pandemic. Services are planned to run at 50-70% of their usual capacity with further demands expected over winter. The lifting of restrictions and months ahead will reveal whether the health system has the capability to rapidly test, trace, isolate and contain the virus.

It is too soon to tell if the government response will manage once again to reverse the numbers of new cases and community transmissions needed to allow further opening up measures go ahead on 31 August.

Ireland’s response to the coronavirus pandemic – Update (May 2020)

Sara Burke, Steve Thomas

On 1^st May 2020, the Taoiseach Leo Varadkar made his fourth public address to the nation outlining a clear five-stage plan for opening up society again in the context of COVID-19. This announcement extended most restrictions in place until 18^th May apart from two changes from 5^th May (increase in daily exercise range from 2km to 5km and those cocooning are now able to leave their homes for exercise only).

The opening-up plan runs until mid-August but with schools not reopening until September and a long-term ongoing need for physical distancing. The plan will only progress from one stage to the next based on adequate progress on five criteria: the latest data regarding the progression of the disease; the capacity of the health service; the capacity of the testing and tracing system; measures to protect vulnerable groups; and an assessment of the impact of excess morbidity and mortality.

Speaking at the daily briefing of the National Public Health Emergency Team (NPHET) on 7^th May, Professor Philip Nolan, Chair of the NPHET Irish Epidemiological Modelling Advisory Group, said; ‘The number of ICU admissions, new cases and deaths is now falling and has been for over a week. This is driven by a reduction of transmission of the virus in the community and reinforces the importance of our behaviours going forward’. On 7^th May the reproduction number was between 0.5 and 0.6.

At the HSE weekly briefing on 3^rd May, HSE CEO Paul Reid outlined how in the absence of a surge, the HSE are putting a plan in place to deal with non-COVID cases. This will mean a resumption of services suspended as well as dealing with a backlog of people not presenting due to the virus and excessive waiting lists that existed pre-covid-19. This will involve new ways of providing care and utilising under-used capacity in both public hospitals and the contracted private sector hospital capacity.

Problems with testing capacity at the end of March led to long waits for testing and results with those displaying symptoms. To remedy this the HSE contracted with German testing firms to clear the backlog. This led to a strong upsurge in new cases which peaked at 936 cases on 23^rd April 2020. In the week of 26^th April 2020, a formal agreement between the HSE and the Department of Health was agreed to scale up testing to 100,000 tests a week by mid-May. While officially it is stated that tests are being turned around in a 24-36 hour period, there are persistent reports of delayed testing results for people, especially those in the community.

In addition, the crisis of infections in care homes has continued. Up to 8^th May, 62% of all coronavirus deaths were care home residents. The infection rate across health care staff has also been quite high with 6,498 infected (29% of the total) as of 8^th May. Since the middle of April, testing has been prioritised in healthcare facilities including healthcare staff.

While the numbers of new cases of COVID-19, hospitalisations and deaths caused by the virus are decreasing, restrictions on day-to-day life remain. The population continues with high levels of compliance with safe behaviours and adhering to restrictions but there is a sense of frustration in relation to the slow exit strategy. The Achilles heels of the Government’s response have been the limited testing and tracing capacity and the response in residential care homes. One key concern going forward is the impact on non-COVID care and how the pandemic may exacerbate existing system weaknesses, such as the very long waiting times for elective care.

Ireland’s Response to the Coronavirus Pandemic – Original post (April 2020)

Steve Thomas¹, Catherine Darker², Ann Nolan³, Sarah Barry¹, Kevin Kelleher⁴, Sara Burke¹

1. Centre for Health Policy and Management, Trinity College Dublin
2. Discipline of Public Health and Primary Care, Trinity College Dublin
3. Centre for Global Health, Trinity College Dublin
4. National Office for Health Protection, Health Service Executive

The first case of COVID-19 in Ireland was notified on 29^th February 2020, although Ireland was preparing for the pandemic since the outbreak in Wuhan, China. Ireland focussed its National Public Health Emergency Team on COVID-19, with its first meeting on January 27^th, and has issued regular statements from 30^th January, including one on 1st February that Ireland’s policy was one of containment (NPHET 2020). A Coronavirus Expert Advisory Group (CEAG) has met since 5^th February to advise the NPHET.

On March 7^th NPHET first issued guidelines in relation to preventing disease spread. On March 9^th along with the cancelling of the St Patrick’s day festival the Government announced a package of reforms including €2.4 billion towards income support, an initial €200 million for business liquidity, and €435 million for expansion of health service capacity in treatment, tracing and testing.

On March 12^th Ireland moved into the delay phase following scientific advice from the CEAG which indicated that early social distancing would be most effective. Key elements of this, announced by the Taoiseach in an address to the nation, included the closure of schools, colleges and childcare facilities on 13^th March, cancelling of indoor mass gatherings of 100 people or more and outdoor mass gatherings of more than 500 people and a strong encouragement for people to work remotely. Shops were to remain open. On 15^th March pubs were then advised to close.

On March 17^th, St Patrick’s Day, the Taoiseach gave a powerful address to the nation broadcast live which helped communicate key messages and explain the Government’s approach while also calling the country to high standards of behaviour with social distancing and compassion. Earlier in the day the HSE launched a “Be on call for Ireland” campaign aimed at health care staff not currently working in the public sector which has attracted an unprecedented 60,000 volunteers as of 23^rd March. In addition, it was announced that patients getting a remote consultation in relation to COVID-19 (both telephone and video conferencing) would incur no charge but that GPs would be reimbursed by the HSE. This removed the financial barrier to private patients for accessing this service. GPs appear to have been able to meet this new demand and implemented an online referral process quickly.

On March 18^th a package of financial measures with the banks was announced to help household and business borrowers. On March 24^th all non-essential retail outlets were told to close. Also the Government approved a framework agreement with the private hospitals to operate effectively as public hospitals for the duration of the Emergency, thus adding 2,000 beds across 19 hospitals including nine labs, 47 ICU beds and 194 ventilators along with all private hospital staff. The Minster of Health declared: “There can be no public vs private here.” The agreement was formalised on 30^th March.

Also on March 24^th the Government introduced a new substantial income support scheme through Government payment of a temporary wage subsidy of 70% of take home pay and enhanced emergency unemployment benefit.

Ireland moved into a mitigation phase on March 27^th, which is to last until Easter Sunday, April 12th. People were told to stay at home except for emergency workers. People were also allowed to leave their homes for essential shopping, essential care and for daily exercise within 2 km of their homes. A significant new measure, “Cocooning”, was also introduced for everybody over 70 and those more vulnerable to the coronavirus.

On 2^nd April, Tánaiste Simon Coveney announced ‘The Community Call’, a new initiative situated in 31 community centres across the country that will mobilise volunteerism to support elderly and vulnerable citizens.

In many ways the Irish state has reacted well to the current crisis so far. There has been clear and effective leadership alongside strong communication based on science. Social distancing and measures aimed at moving into lockdown were done reasonably quickly and with a lot of compliance. Notable weaknesses in the Irish health system were tackled head-on and early, such as the low number of ICU beds, expansion of staffing and removal of the two-tier nature of hospital access and the high access costs for parts of the system. Other effective strategies included a strong public health focus, good evidence well communicated through the HSE website as the main source of advice, widespread public campaigns endorsed by key stakeholders and daily press briefings from the Chief Medical officer.

The addresses to the nation given by Taoiseach Leo Varadkar at key points have been both stirring and unifying and have undoubtedly helped the national mood. More prosaically, the income support measures and help for borrowers has been enacted quite quickly. There have been some inevitable missteps along the way in relation to the slow expansion of the limited testing capacity vs demand and associated long-waits for tests, the failure to block travel from heavily infected regions such as Italy earlier, and the quite late cancellation of the St Patrick’s festival. There are also challenges in relation to the differing responses north and south of the border. Furthermore, a coordinated bottom-up approach, which has been found to be important elsewhere (WHO 2020), through community supports and mobilising of local authorities has been late.

Nevertheless, thus far there are signs that the decisions taken have been relatively effective. The curve is flattening and the population and the health system is coping at present, notwithstanding personal tragedies. Of course, the peak has not yet been reached and may not until mid-April but there are signs that growth in new infections is stalling. Clearly, preparations for a hard Brexit may have enabled different parts of society to move quickly to help essential services and supplies under restrictions and lockdown. In some ways the crisis has also enabled the Irish health system to be more responsive to patient needs and move towards universal healthcare through the promise that private patients won’t get faster access to health care and through the public-private partnership which has private hospitals operating as public sector providers.

National Public Health Emergency Team (2020) Statement from the NPHET on Saturday 1^st February. https://www.gov.ie/en/press-release/d21bfd-statement-from-the-national-public-health-emergency-team-saturday-1s/ Accessed 1^st April 2020

Department for Foreign Affairs (2018), Preparing for the Withdrawal of the United Kingdom from the European Union on 29^th March 2019. Contingency action plan. https://www.dfa.ie/media/dfa/eu/brexit/brexitcontingency/No-Deal-Brexit-Contingency-Action-Plan-December-18.pdf Accessed 30th March 2020

WHO (2020) Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19). https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf Accessed 3^rd April 2020.

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