From containment to mitigation

The experience of previous pandemics will be crucial in informing the fight against Covid-19

What have we learned from the recent experience in responding to SARS, Ebola, H1N1? As we face the challenge of a novel virus, we must ensure that we apply the knowledge gleaned from past pandemics. We have been watching from our island nation as Covid-19, a novel coronavirus, spread from Wuhan in China across the globe. As of the time of writing, it has a strong grip not just in Northern Italy, but also in France, Spain, Germany, and Switzerland. We must now do all we can to protect our people, especially those most vulnerable to severe disease. Dr Nahid Bhadelia published an excellent article in Nature last month with key lessons learned focusing on how we identify the sick, how we isolate and care for them, and how we keep our healthcare workers well (N Bhadelia et al, Infect Control Hosp Epidemiol 34, 825–831; 2013).

Scientists and medics across the globe have sequenced the virus and clinical assays for detection are already in clinical use, despite the short time since we became aware of this novel virus. There is, however, much we do not yet know about Covid-19 and the impact it will have in Ireland. Risk is very hard to understand and it is even harder to rationalise improbable low-risk events when they relate to ourselves or our loved ones. The two new cases of community transmission confirmed on 8 March bring the total cases to 21 in Ireland. It is looking inevitable that we will soon move from containment to mitigation. We as doctors in the Irish health system, are used to going to bat for our patients every day and I have no doubt that once again we will do the same now, as we face caring for patients with this new, unknown disease for which none of us have any immunity.

Our public health doctors have been working heroically throughout the containment period and buying us time to get as prepared as possible for the weeks and months ahead. It is key as a nation and as a health service that we learn from effective containment measures elsewhere. The messaging from the Department of Health and the HSE is clear: We need to slow the spread of the disease throughout our communities. We know that the attack rate is very high. We know that 10-to-20 per cent of patients will require hospital admission and one-third of these patients will require ICU care. We also know that in Ireland, the lack of capacity in the public hospitals, our general wards and our ICUs will pose additional challenges for the healthcare team as we endeavour to care for all our patients as we face this challenge.

There is understandable fear among the community at large, the majority of whom are at low risk for severe disease. Eighty per cent of people, if infected, will likely remain at home until they recover. All of our concern is with our vulnerable patients, the elderly, those on immunosuppression, those with chronic conditions and those charged with providing care in these very challenging times. It is a worry for doctors that our ICU teams will end up ventilating patients in unsafe environments because of the lack of capacity. It took 10 years of campaigning to get the HSE Prospectus report, published in 2009, which addressed ICU capacity and has yet to be implemented. It is very welcome news that Paul Reid has now approved 22 new ICU beds. This is a step in the right direction but it falls short of current unmet need, let alone the additional needs we will face in the coming weeks due to very ill patients with Covid-19.

Should we face additional deaths among ICU staff because of working in unsafe conditions, serious questions will have to be asked of our politicians who have neglected to address this critical capacity deficit for over two decades. For now, we must park these questions and focus on slowing the spread of disease, making optimal use of all the capacity we have in Ireland (public and private), and keeping our staff well and their working conditions safe.

Unity is essential; we need to tackle this as a society. As doctors, we must galvanise the individual members of the public to band together for the collective good. We must isolate and contain as much as possible to slow the spread. Moving from in-hospital testing to home testing by our National Ambulance Service is a very welcome development. We know that if we can get the nation to change our habits — meticulous hand-washing, coughing into our elbows, avoiding touching our nose, eyes, mouth — we can slow the spread of the virus; which will help our hospitals manage the influx of sick patients over a longer period of time.

Some members of the public are stockpiling masks, personal protective equipment (PPE) and hand gels. If these behaviours continue, they will lead to a shortage of key products for frontline healthcare workers.

Up to 60 per cent of clinicians got sick during the H1N1 outbreak in New York. Tony Holohan and Paul Reid will need significant resources at their disposable to enable emergency staffing plans to mitigate worker shortages as staff get sick. Emergency measures announced by the interim Cabinet on Monday 9 March are very welcome. Small businesses and independent contractors need the promised financial assistance if people are to be able to self-isolate when sick without severe financial impact.

It is possible that we will face situations in the coming weeks in our hospitals not usually seen in peacetime. We must all pull together to get the nation through this with the minimum of avoidable deaths among patients and staff. We often say we are a society, not an economy, and in the coming weeks and months we must live that out, minding each other, making the best use of our resources. Never has clinical leadership been more needed. We all need to row-in behind our public health specialists and our national team to ensure that we deliver the best possible outcome for our nation.

And when this is over and done, we must ensure that there is enough capacity in the future so that we have some redundancy for meaningful surge capacity in our health system.