About 10 days ago, the HSE invited me to a meeting on some aspect of coronavirus. After I made some comment or other, I was told, “Cliona, this is not research.”
I immediately responded, "But we know so little about this virus and the infection it causes, anything at all that we do regarding Covid-19 is research." The air filled with the sound of a very large penny dropping.
Inevitably, another tidal wave of coronavirus infections will gather momentum as soon as we are all set “free” in five weeks’ time. How can we deal with this next onslaught better than we did last time round?
In the short term, we need drastically upgraded testing, tracing, analytical and communication strategies, if we are to have any hope of keeping the virus under control next time round. Research, analysis and data should inform every one of our decisions.
Our current tracing strategy is failing, although we don't seem to really know why. Who is analysing the data that have been collected since April?
During the first few months of the pandemic we were able to claim reasonable success by testing people who self-reported symptoms. However, we now know that many people do not have symptoms, even if they are infected.
We also know that a significant proportion of people will not report symptoms or go for testing, mainly because of fear of losing their jobs, of losing income or of the test. This is more challenging to any public health strategy.
We now need tests that we can use to screen for infection – to see where the virus is and who it is being passed on to – before anyone shows signs of infection.
For this to be effective, we need to be able to test hundreds of thousands of people – school children, teachers, students, factory workers, hospital patients, cleaners, people in care homes, people entering the country – whether they have symptoms or not.
We need to test all these people regularly – often several times a week. So we need a test that is not invasive or uncomfortable like the current nasopharyngeal swab test, which people are reluctant to undergo a second time. And this test needs to be technically simple and cheap, in contrast to the PCR (polymerase chain reaction) test, which is currently the method used to detect viral nucleic acid in swabs.
Anybody who tests positive with the quick and cheap assay can have their infectious status confirmed using the more rigorous PCR assay. In most cases, people who test positive will be able to recover in their own homes, where they can self-isolate in comfort. We are getting much better at identifying the small number of people who will need hospital care.
So how will this quick and cheap assay work? How about a self-administered nasal swab? Or saliva? Last April, the science community first heard that the virus could be detected in saliva. There are now dozens of saliva-based tests in the pipeline. Why don’t we commission several research labs to undertake optimisation and validation of the 10 most likely tests, so we know for ourselves which best suit our diverse needs?
We then need analysis to inform strategies to ensure we are screening the relevant populations. All patients entering doctors’ surgeries, health centres, dentists, hospitals etc should be tested; healthcare workers should be tested before and after work; babies and creche workers, primary and secondary school teachers and students, university students and academics should be tested regularly; people in care homes – residents, carers and visitors – anybody dealing with the public, factory workers, businesses, shop assistants, everybody entering the country.
We also know our current tracing strategy is failing, although we don’t seem to really know why. Who is analysing the data that have been collected since April? Dozens of computer science, public health, logistics MSc and PhD students should be recruited to this task and informing new better tracing strategies.
How might we contact trace differently? First we need data from the above analysis. Secondly, we might consider a more local approach that links local data to local policy to local intervention to local hospitalisation.
Now that we know there are so many more dimensions to this crisis, our consultative processes need to be diversified
And our self- isolation strategy is failing – significant numbers of people refuse to self-isolate or do not follow the rule of self-isolation. Are they afraid of lost jobs? Lost income? Of loneliness? Of claustrophobia? Of boredom? Or do they just not see the point?
People have a sense that there is no point in self-isolation if tracing is not pursued rigorously. We need to harness the expertise of behaviourists, social scientists, psychologists, economists and science communicators to analyse the data, inform policy and strategy development.
Even if we develop better and more successful testing, tracing and isolating strategies, we are going to need buy-in from every citizen and visitor to Ireland if we are to keep the virus under control. A much more sophisticated and penetrating communications programme will have to accompany any new upgraded testing, tracing and isolating strategies. We will also need a much better informed public if we are to have any hope of rolling out vaccination, should a safe one be identified.
The Government, HSE, people on the National Public Health Emergency Team (Nphet) and on subgroups of Nphet have worked with enormous commitment, energy, expertise and determination to deal with what was primarily perceived as a public health issue.
Now that we know there are so many more dimensions to this crisis, our consultative processes need to be diversified. If we are to have any hope of keeping our economy, schools, universities, museums and theatres open over the next years, we need new ways of testing tracing, analysing and communicating. And we need way more flexibility so that advice can be acted upon swiftly, outcomes are analysed and robust data are generated that can be used to inform policy and change outcomes.
Cliona O’Farrelly is professor of comparative immunology at TCD