From intensive care to Covid tests: how have we prepared for the second wave and have we learned from the spring surge?

By | September 26, 2020

In case there was any doubt about our current predicament, Dr Ronan Glynn, the acting chief medical officer, declared it officially this week: Ireland has entered a second wave of Covid-19.

We’re moving into the second chapter,” he said. “It’s a particularly difficult time for the country because everyone is sick and tired of this at this stage and the idea of having to phase into restrictions, measures, decreasing our social contacts, is frankly a horrible one for people.”

We may find it hard to cope psychologically with months of increased restrictions and the calamitous prospect of a renewed upsurge of deaths. But we may be better equipped to deal with the latest surge than we were when Covid-19 first struck here in late February and March.

What have we learned about tackling the virus and crushing the curve since the eventful spring, when the then Taoiseach Leo Varadkar ordered a lockdown?

The government of the time and the health authorities succeeded in some respects in limiting the damage. Unlike authorities in the UK and the US, they acted promptly in imposing restrictions and curbing the rapid spread of the virus.

But in other ways, the Irish authorities were caught badly off guard: the biggest disaster of the crisis so far has been the failure to protect residents in nursing homes, which have been linked to over half the Irish deaths.

There are other groups that have been disproportionately put at risk of infection: healthcare professionals, meat plant workers and those who live in direct provision.

Our success in dealing with the virus will depend on how the authorities have adapted to these difficulties and changed their practices.

Improved treatments

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Dr Ronan Glynn, Acting Chief Medical Officer, Department of Health.

Dr Ronan Glynn, Acting Chief Medical Officer, Department of Health.

Colin Keegan

Dr Ronan Glynn, Acting Chief Medical Officer, Department of Health.

The growing medical knowledge of how to treat patients will play a role in whether this renewed upsurge is as damaging as the previous one.

“We have learned a lot about the virus in the past six months,” says Dr Laura Durcan, a Beaumont Hospital rheumatologist and member of the national council of the Irish Hospital Consultants Association. “It is no longer an unknown entity.”

By June, research had indicated that the steroid Dexamethasone can be a lifesaver for patients who are critically ill with Covid-19.

Dr John Bates, an intensive care consultant in Galway and dean of the Joint Faculty of Intensive Care Medicine, says: “We know that Dexamethasone reduces mortality in patients who need mechanical ventilation by about a quarter.”

Remdesivir, an antiviral drug that was originally developed to treat Ebola, may not be a lifesaver, but clinical trials show it can cut the duration of symptoms from 15 days to 11.

Durcan says we now also know better what drugs do not work. Despite the endorsement by US president Donald Trump, the malaria drug hydroxychloroquine has been found to be ineffective in treating Covid-19.

Boosting intensive care

The success of doctors in saving lives during the second wave could depend on how well-prepared intensive care units (ICUs) are.

One of the frequently cited reasons for the rapid lockdown in March was the shortage of places for patients in ICUs, where the most seriously ill Covid patients are commonly treated. There were fears that the hospitals would be overwhelmed.

Before the pandemic, the state had just 257 intensive care unit beds, and since the pandemic, that capacity has increased modestly to 280.

“We managed to get to 400 beds during the first surge,” says intensive care consultant John Bates. “But that required us to shut down most scheduled surgical care in a lot of hospitals. We would be concerned if that happened again.”

Having the trained intensive care staff on hand to treat patients is as important as the equipment itself.

In the spring emergency, ICUs were prepared for the surge by diverting staff from operating theatres, and also using theatre equipment and spaces. Bates says this approach was taken because the staff working there had a similar mix of skills.

He is concerned about what will happen in the winter flu season, when there could also be a rise in Covid admissions to hospital.

The HSE’s winter plan has promised 17 extra intensive care beds as well as other additional capacity in hospitals. “You have to recruit nurses and train them. They would need to be recruiting them now if they want to create extra capacity over winter,” Bates says.

On the plus side, ICUs are physically better equipped to deal with a surge than they were in spring. Bates says there is now no shortage of ventilators.

There are now also hopes that the normal winter flu surge will not be as severe as in previous years. “There has been a lighter flu season in the southern hemisphere, and that usually gives us an indication of what might happen here,” Bates says.

Because people are travelling less, maintaining social distancing and taking other precautions, flu does not seem to have spread as widely in southern hemisphere this year.

A report in The Economist this month showed that from May to mid-August of 2015-19 an average of 86,000 people in Australia tested positive for the flu each year, and about 130 died of it. But this winter its government has registered only 627 influenza infections and just a single death.

Hospital preparations

Healthcare staff and other frontline workers are now much better equipped with personal protective equipment (PPE) than they were at the start of the pandemic.

Hospitals are going to great lengths to screen patients and staff for Covid-19 and reduce risks of infection, but in many cases their old-fashioned designs and poor ventilation still make this difficult, according to Durcan. Some emergency departments have the space to maintain social distancing, but Durcan says that in Beaumont Hospital, staff are limited by poor 1980s infrastructure.

The spread of Covid-19 as an airborne pathogen has highlighted how patients should be accommodated in single rooms with their own bathrooms, she says.

“In my hospital, 25pc of the rooms are single and most of the rest of them are six-bed units where everyone shares a bathroom,” she adds. “From an infection control point of view, you are putting six sick people into one room and getting them to share a bathroom.”

Protecting nursing home residents

Reports in recent weeks have highlighted the spread of Covid-19 among young people, and there have been some suggestions that this is in some ways less damaging.

But Professor Philip Nolan, chairman of the National Public Health Emergency Team’s (Nphet) Irish epidemiological modelling advisory group, warned that there has also recently been an increase in cases among older people. The incidence in over-65s is now about four times what it was five weeks ago.

Dr Colm Henry, the HSE’s chief clinical officer, said this week that it was not possible to keep nursing homes completely immune from a virus openly spreading through the community.

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Dr Colm Henry, Chief Clinical Officer, HSE

Dr Colm Henry, Chief Clinical Officer, HSE

Colin Keegan

Dr Colm Henry, Chief Clinical Officer, HSE

While the failure to protect nursing home residents in the spring proved to be disastrous and is likely to have resulted in hundreds of deaths, there are hopes that they will be better protected during this second wave.

During the summer, a report by an expert panel, led by University College Dublin professor of public health Cecily Kelleher made 86 recommendations to reform how older people are cared for in nursing homes.

Prof Kelleher told Review that the supply of PPE in nursing homes and the testing of residents and staff had improved.

“In general, we learned from the first wave of this that where there is wide community transmission, you have to be vigilant around vulnerable groups such as residents of nursing homes.

“In our report, we were very clear that there needs to be rapid testing and turnaround of results, and staff needed to be able to take swabs. That is in place, I believe.”

The HSE has also created Covid-19 response teams to deal with outbreaks in nursing homes.

John Sheehan, a Cork GP and councillor who is medical officer of the Farranlea community nursing home, says that more precautions are now taken with staff and visitors.

“The screening of patients coming out of hospitals into nursing homes has vastly improved. In our nursing home, they put in an isolation procedure for two weeks. So when a patient comes in, the risk of them spreading it to another resident is significantly reduced.

“There has been improved infection control and the HSE is moving towards a maximum of four in multi-occupancy rooms,” he says. “That will take time, but it should reduce the risk. If you look at the transmission in nursing homes, multi-occupancy rooms was a factor.

“Staff education, infection control measures and PPE have all improved and that should reduce the risk. It is also important that the nursing homes can now do the testing themselves.”

Staff in nursing homes have worked tirelessly through the crisis, often for meagre rewards, and it will be hard to maintain morale through the winter.

Contact tracing and going local

An effective test-and-tracing operation around the country is seen as essential in reducing the spread of the virus, but this becomes more difficult when the virus surges.

A study by Imperial College London found that if 80pc of cases and contacts are identified and there is immediate testing following symptom onset and quarantine of contacts within 24 hours, then the reproductive rate of the virus can be reduced by up to 26pc.

Ireland’s test-and-tracing system has worked better than that in Britain, where it has fallen apart, according to Anthony Staines, professor of health systems at Dublin City University.

Prof Staines said we had a large-scale test-and-trace system in operation in May and June, but this was scaled down in June and July. The country has the capacity for 15,000 tests a day.

“Our system is reasonably accessible and reasonably quick, but it is still not fast enough,” he says.

Professor Mary Horgan, an infectious diseases consultant, says we need a more refined way of tackling outbreaks at a local level.

“What we need now is real-time information about an outbreak in a local area. There should be immediate testing and tracing, so that you get on top of the infection in a small locality with local contact tracers and local public health doctors.

“We need to understand how it is transmitted, so that we have a more bespoke way of introducing restrictions.”

This local approach is the one used in Germany, where contact tracing is the responsibility of regional public health authorities.

Germany was also able to rely on a pharmaceutical industry that quickly produced viable tests and a hospital system that had so much spare capacity that it was able to treat patients from neighbouring EU countries as well as German patients.

In the current phase of the pandemic, the Irish authorities seem keener on local restrictions than national lockdowns, which is seen as the sledgehammer solution. They now seem willing to differentiate between counties and regions.

“The county-by-county approach seems reasonable, but the message has been confusing,” says Staines. “The way it was put across, there were five levels that a county could be at, but Dublin was not in any of them.”

Maintaining public morale

While the medical outlook may have improved and precautions have been put in place, the response to the crisis has probably deteriorated in one important respect.

The messages delivered to the public are a lot less clear than in spring when there was a simple message for the public: stay at home and avoid social contact.

Since Micheál Martin took over as Taoiseach, the advice has been ambiguous. On the one hand, the Government wanted to open up the country to revive the economy and maintain our sanity. On the other, it has had to impose restrictions and stop the spread of the virus.

Another reason for the mixed messaging is that we now have three parties in government, and a Tánaiste who has been accused of acting as though he was the chief.

The public is constantly being advised to avoid “house parties”, but the message seems to conjure up an image of students raving in a bedsit, when it is just as likely to be a family gathering.

“The problem is not necessarily 47 teenagers crammed into a two-bed semi-D somewhere having a party,” says Staines. “It could be 12 people having a very civilised dinner party in Foxrock.”

The challenge now is to keep the public onside and motivated in the coming months, according to Durcan.

“Everyone got really gunned up for the battle in March. But we need to maintain the troops for the war that isn’t going away.”

Back in March, the then Taoiseach Leo Varadkar borrowed a line from Winston Churchill when he said: “Never will so many ask so much of so few.”

As we get ready for the long haul, another line of Churchill’s gives a sense of the difficult task ahead: “This is not the end. It is not even the beginning of the end, but it is, perhaps, the end of the beginning.”

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