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Preventing a covid-19 pandemic

BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m810 (Published 28 February 2020) Cite this as: BMJ 2020;368:m810

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Rapid Response:

Bergamo or Busan: What will be the outcome of Ireland’s response to the COVID-19 pandemic?

Dear Editor,

In reference to your recent editorial [1], the last 72 hours has seen significant escalation of COVID-19 infection rates across Ireland with community transmission emerging across the country. It has emerged that several newly diagnosed cases of COVID-19 have had community exposure involving several frontline healthcare staff. This disease outbreak has been upgraded to “pandemic” (the highest level of health emergency) by the WHO as of 11/3/2020. [2] We are likely to see a significant increase in cases in the coming weeks in Ireland according to simulations of a COVID-19 transmission models. [3] Because of our significant relative undercapacity in terms of isolation units and intensive care beds compared to some other countries currently struggling with the outbreak, if we follow the transmission model seen in other countries the critical care elements of our healthcare system are likely to reach capacity very quickly.

What has happened in China shows that an effective and aggressive public health response including quarantine, social distancing, and isolation of infected populations can contain the epidemic, or at least reduce the numbers of patients requiring critical care at any one time. [4] This brings important lessons for the many countries where COVID-19 is beginning to spread such as Ireland.

However, it is much more uncertain whether we can and will implement such stringent public health measures in a timely fashion. The response of Singapore, Hong Kong and South Korea, all of which had severe acute respiratory syndrome (SARS) epidemics in 2002–03, provide hope and many lessons to other countries. In these countries, COVID-19 has been managed well to date by early government action and an aggressive public health response. [3]

With our relative undercapacity in terms of critical care beds (50 per million inhabitants) compared to Italy (125 per million inhabitants) and South Korea (204 per million inhabitants), for example, it is imperative we trigger a radical public health response, without delay. If we wish to avoid an epidemic peak that overwhelms the health service we must flatten the curve of transmission. [3]

We are exactly 14 days behind Italy in terms of positive cases rising above 5 patients per million and adjusting our trajectory now with serious and radical efforts is our best hope to save as many lives as possible. The general public have a vital role to play in the coming weeks in regard to following public health guidance and using general practice and other health services appropriately.

In simple terms, the key to containing an outbreak is to identify and quarantine infected individuals as quickly as possible preventing them from passing on the infection. For this to work, the first and most important building block is having an agreed protocol for the identification, diagnosis and treatment of infected individuals and more importantly to be able to effectively implement that protocol.

We are calling for the following key steps to implemented immediately in Ireland:
1. An aggressive, transparent and ongoing information campaign to the general public to convey the importance of social distancing and social isolation and thus help to slow the progression of this disease outbreak;
2. Redeployment of healthcare staff to public health roles such as triage, contact tracing and testing;
3. High volume testing, with rapid result communication to better target outbreak clusters;
4. Effective quarantine of infected individuals either at home or in hospital;

These are obvious measures, but proper implementation is ultimately what will decide if we will end up more like Bergamo (Italy) or Busan (South Korea).

References.
1. Watkins J. Preventing a covid-19 pandemic. BMJ 2020; 368: m810.
2. WHO. Coronavirus disease 2019 (COVID-19) Situation Report – 51. 2020 (accessed March 11th 2020).
3. Anderson RM, Heesterbeek H, Klinkenberg D, Hollingsworth TD. How will country-based mitigation measures influence the course of the COVID-19 epidemic? The Lancet 2020.
4. WHO. Coronavirus disease 2019 (COVID-19) situation report—44 (March 4, 2020). 2020 (accessed March 5, 2020).

Competing interests: No competing interests

11 March 2020
Liam G Glynn
Academic GP
Dr Mike O Callaghan and Dr Khalifa Musaraf
University of Limerick
Graduate Entry Medical School, University of Limerick