Sarah Cremin · 1 Sarah Cremin From: Cillian F De Gascun Sent: Wednesday 24 June 2020 22:11 To:...

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Sarah Cremin

From: Cillian F De Gascun <[email protected]>Sent: Wednesday 24 June 2020 22:11To: Covid19Subject: Follow-up matters arising from SCC-19R meeting on 11.06.20: your ref SCC19R-I-0205Attachments: 4. COVID-19 EAG Minutes 26.02.2020.pdf; 3. COVID-19 EAG Minutes 19.02.2020.pdf; 1. EAG

05.02.20-letter to CMO 10.02.20.pdf; 1. COVID-19 EAG Minutes 05.02.2020 .pdf; 2. COVID-19 EAG Minutes 12-02-2020.pdf; 7. COVID-19 EAG Minutes 09.03.2020.pdf; 9. COVID-19 EAG Minutes 12.03.2020.pdf; 5. COVID-19 EAG Minutes 04.03.2020.pdf; 8. COVID-19 EAG Minutes 11.03.2020.pdf; 10. COVID-19 EAG Minutes 16.03.2020.pdf; 11. COVID-19 EAG Minutes 18.03.2020.pdf; 6. COVID-19 EAG Minutes 06.03.20.pdf; 12. COVID-19 EAG Minutes 25.03.20.pdf; 13. COVID-19 EAG Minutes 27.03.20.pdf

Categories: Green Category

Correspondence item number SCC19R‐R‐0339, 340 and 341 Dear Ms Turnbull

Regarding your recent correspondence and Reference: SCC19R-I-0205

I attach in this (and following) email(s) the EAG minutes and advices to NPHET up to May 13th. I would also point out that the minutes to the end of April and the advices to May 13th are already available on the DoH website. I'm sending a sequence of emails due to the number of documents involved: apologies for any inconvenience. Kind regards Cillian ‐‐

Cillian De Gascun MD, FRCPI, FRCPath (Virology), FFPathRCPI Consultant Virologist & Laboratory Director MCRN 022549

UCD National Virus Reference Laboratory Belfield Campus Dublin 4

Tel: +353 1 716 1223

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2019-nCoV Expert Advisory Group Meeting

Title of Meeting: 2019-nCoV Expert Advisory Group Meeting (Meeting 1)

Location of Meeting: Health Protection Surveillance Centre, Dublin

Members/In attendance:

Dr Cillian de Gascun (CdG) Director NVRL, Consultant Virologist (Chair) Dr Ronan Glynn (RG) Deputy CMO, DOH Dr Vida Hamilton (VH) National Clinical Advisor and Group Lead, Acute Hospitals Dr Joanne O’Gorman (JOG) Consultant Microbiologist, HPSC and Rotunda Hospital Dr Colman O’ Loughlin (COL) Consultant Intensive Care Medicine, Mater Hospital Dr Gerard O’Connor (GOC) Consultant Emergency Medicine, Mater Hospital Prof Aurelie Fabre (AF) Consultant Pathologist, St Vincent’s Hospital Dr Derval Igoe (DI) Consultant Public Health Medicine, NVRL/HPSC Dr John Cuddihy (JCy) Director, Health Protection Surveillance Centre Dr Aoife Cotter (AC) Consultant Infectious Diseases, National Isolation Unit Prof Colm Bergin (CB) Consultant Infectious Diseases, St James’s Hospital Prof Martin Cormican (MC) Consultant Microbiologist, National Clinical Lead HCAI/AMR Ms Josephine Galway (JG) Director of Nursing for HCAI/AMR, AMRIC Team, HPSC Dr Jeanette McCallion (JM) Health Products Regulatory Authority Dr Jeff Connell (JCo) Head of Testing, UCD NVRL Dr Margaret O’ Sullivan (MOS) Chair, National Zoonoses Committee, Consultant Public Health Medicine Mr Robert Glennon Immunisation Policy Unit Department of Health (Admin Secretary)

Teleconference: Dr David Hanlon (DH) HSE National Clinical Advisor and Group Lead for Primary Care

Apologies: Prof Karina Butler (KB) Chair, National Immunisation Advisory Committee, Consultant Paediatric ID

Date/Time of Meeting: Wed 05/02/2020

Time: 2pm to 4.30pm

Prepared by: Dr Paul Mullane, SpR Public Health Medicine, National Immunisation Office (Medical Secretary)

Date Circulated:10/02/2020

Date/Time of Next Meeting:

Wed 12/02/2020 2pm to 4pm

Item No.

1

Welcome, introductions, terms of reference, membership

CdG welcomed all members to first meeting of 2019-nCoV Expert Advisory Group (EAG).

The Role of EAG is to provide expert guidance to address technical queries from other bodies (e.g.

National Public Health Emergency Team (NPHET), HSE) on topics pertaining to 2019-nCoV,

including in relation to the evolution of 2019-nCoV epidemiology, emergency preparedness, and

guidance on infection prevention & control. The terms of reference (TOR) were reviewed and

accepted.

EAG meetings will be held on Wednesdays to allow for requests for advice from NPHET (meetings

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taking place on Tuesdays). Weekly meetings planned for foreseeable future dependent on

evolution of the situation.

2

Summary of current situation:

International: JCy provided an overview of the current international situation including numbers

of cases and deaths, and provided details of the ECDC’s current risk assessment.

National: Information on number of tests requested and results is being monitored. To date, a

maximum of 5 tests have been carried out per day. 2019-nCoV has not been detected in any

sample submitted.

3

Current understanding of the virus, transmission characteristics, and epidemiology

CdG tabled a knowledge overview framework document. This document covers the main topic areas where the EAG is likely to be asked to respond on and/or to provide guidance. EAG members were asked to add any additional items to this. Currently 99% of cases are arising in China, mainly in Hubei province. The mean incubation period is 5 days [range 2-14 days]. There is a lot of uncertainty presently re: 2019-nCoV transmissibility. Key question is whether there is transmission from asymptomatic cases. Subject to accurate and complete reporting, when 2 incubation periods have elapsed following instigation of containment measures in China then we would hope that the epidemic curve would begin to stabilise or shift downward, if they are successful.

There is currently no specific antiviral therapy available. Some patients have been treated on a compassionate basis with certain antiviral agents. This will be kept under review to see if any of these agents are shown to have a therapeutic effect. If yes, then consideration will be given to advising on sourcing these agents. There is no vaccine available. The group will gather evidence on virus survival on surfaces as it emerges.

• Actions:

• Group will review the containment strategy and the evidence as to whether it’s working internationally on an ongoing basis

• Group will consider the robustness of both present containment measures and future mitigation measures in Ireland

4

Review of current Irish guidance

(a) Risk assessment algorithms (Primary care, NAS, acute hospitals)

Overall the group is satisfied with how the algorithms were developed and disseminated; they

have been useful in the various clinical settings. Some amendments were advised as set out

below.

Actions:

• With the amendments below, the algorithms will all be marked as reviewed and

approved by the 2019-nCoV Expert Advisory Group Meeting, dated and with version

control. Minor amendments can be made by HPSC in consultation with the Chair. Major

changes will be reviewed by the group when required at its weekly meeting for sign off.

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• Changes in IPC to droplet and contact precautions, except when undertaking AGP, as

discussed and documented later in this section, will be reflected in all the algorithms as

appropriate

• Hyperlinks in all algorithms to mainland China to be amended to mainland china

(excluding Hong Kong and Macau).

Primary Care amendments:

• Clarification of scope in title: i.e. for General practice and healthcare settings other than

receiving hospitals

NAS amendments:

• No additional changes

Acute Hospitals:

• Amend to “not detected” rather than negative

• Amend testing process, no need for confirmatory testing now. Also can use combined

oropharyngeal and nasopharyngeal swab as an alternative to NPA in those patients

presenting with URTI

• Amend management bullet to say manage, supported by ID/microbiologist input, in line with

IPC guidance

Also noted:

Work is ongoing with acute hospitals on explaining need for admission pending diagnosis as part

of the strategic containment response, and not basing admission decisions on clinical condition.

All the various means of presentation to hospital(e.g. in labour, via OPD, directly to ward) are also

being identified by hospital sites to ensure that appropriate arrangements are in place

The importance of having a locally appointed lead for IP&C, training, and preparedness; was

highlighted

There was discussion about the current list of receiving hospitals (all model 3 and 4 hospitals) and

whether this needs review. This is to be taken up within the HCID group, as not within the EAG

remit.

It was also highlighted that 2 separate guidelines exist for acute care and for intensive care.

Additional Guidance proposed:

• How samples should be taken and packaged (as category B) and delivered to lab

• Guidance on the discharge process for 2019-nCoV infected patients who have a resolved

infection

• Guidance on the management and monitoring of symptomatic patients who have a

positive risk assessment exposure in whom 2019-nCoV has not been detected in the first

sample.

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Action: Proposed new guidance to be developed by HPSC /National Public Heath Outbreak

Response Team

(b) Laboratory testing guidelines

Revised guidance is in preparation and will be circulated to the group and on the website soon

Group support having an explicit statement on the website that all testing at present should be

done at NVRL. This is in the context of the likelihood that commercial kits will become available in

the near future.

Action: Include explicit statement on HPSC website stating that all testing should be conducted at

NVRL

(c) Infection Prevention and Control Guidelines

The initial IPC recommendations were for aerosol/airborne precautions in acute hospital settings

and contact and droplet precautions in primary care. In line with WHO guidance, this has been

updated to droplet and contact precaution in both the acute sector and primary care. This

guidance is in draft, and will be published shortly

EAG members were in favour of this change, with the caveat that if a hospital site is currently

using higher protection as part of their normative practice, this can continue. The Group noted

the importance of hand hygiene, and agreed that HCW should use PPE that they are familiar with

using.

It was also clarified that FFP2 or FFP3 masks can be used interchangeably. WHO guidance is to

use FFP2 masks for aerosol generating procedures (AGP); the ECDC recommendation to use FFP3

masks for AGP hasn’t provided a rationale for this recommendation

Action: New IPC guidance to be circulated and uploaded on the HPSC website

(d) Contact tracing guidelines –(interim working document for Public Health, not for

website)

The definition of close and casual contacts was reviewed. The group agreed to include a time

and distance parameter in the definition (not in ECDC guidance, but viewed as practical and

operational in Ireland). There is a need to flag that 2 metres is greater than the 1 metre used

for droplet precautions, but this is for PH purposes. Close contact for HCW is to be defined

explicitly (>15 minutes within 2 metres distance)

Threshold for initiating contact tracing. EAG does not agree with using clinical severity as a

criterion. Advised that the criterion to use is the risk assessment of the exposure. If

considered very likely based on risk exposure history, then there should be flexibility in the

guidance on initiating contact tracing pre confirmation. Otherwise initiation of contact tracing

should commence on confirmation.

Restrictions for close contacts: the current guidance needs to be strengthened. Close

contacts should not go to work. The importance of having arrangements in place to

compensate persons faced with this restriction was highlighted. This would apply in many

situations, including those who are self-employed. In addition, the lack of enabling legislation

to enforce these restrictions for a contact was highlighted as a gap.

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Duration of contact tracing: group agreed with 14 day period following last exposure

Actions:

• RG will raise the issues from EAG regarding adequate compensation for those affected by

restrictions and legal difficulties that may arise in enforcing restrictions identified at

NPHET.

• These changes will be made to the contact tracing guidance, which will remain an interim

document

(e) Community non-healthcare settings: Education sector

Noted

(f) Care in the home and community (PUI and cases)

This draft document had been circulated for comment. Members will submit comments via email

in the coming days. In general the view of the group was that in light of the quick turnaround for

test results, in this containment phase it would be better to focus on keeping suspected cases in

hospital pending diagnosis. However, the Group was not unanimous on this point, so the item will

remain on the agenda pending review of an additional guidance document currently in

preparation at HPSC. It was also noted that some patients could choose to self-discharge against

advice. This scenario has to be addressed in the final guidance.

Action:

• Guidance under development to come back to EAG for review: need to resolve questions

in relation to admission pending test results, and how to manage patients who self-

discharge in advance of test results

5

Issues for advice/discussion referred by NPHET

The NPHET had requested the EAG to:

“Review current guidance and international practice pertaining to the issue of self-isolation for

asymptomatic individuals who have returned from mainland China within the past 14 days and

provide a recommendation for the approach to this in Ireland”

Matter discussed. Noted that current Irish and ECDC guidance differs from that in place in the UK

(recommend self-isolation x 14 days).

Decision: The Group concluded that the available evidence does not support imposing what it

considers to be a disproportionate burden on the individual at this time.

Action: RG requested that FAQs should include information that would provide clarity on the

rationale for different approaches being taken in Ireland and the UK.

6

Issues referred from HSE Nil at present VH asked what type of issues would be invited. CdG indicated that this would include technical and scientific questions re the virus, testing, IP&C, transmissibility etc. The group intends to defer to national organisations for specialty-specific guidance (should it be deemed necessary) outside

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of these areas, and does not intend to review such guidance unless a clear conflict with public health advice is identified.

7

Plan for group meetings, way of working

Weekly meetings planned at present.

Agenda for next meetings to flag issues referred from NPHET and HSE.

8

AOB RG – There is proposed press statement this evening from DoH (05/02/20) – hardcopies were provided to group members; EAG group members were satisfied for their names to appear. Note – this may invite media queries – and advice is to liaise with Department ([email protected]) or HSE Press offices if members are happy to speak to the media. Noted also that EAG is being convened in the context of NPHET and other committees already established and working on 2019-nCoV. Agreed that a patient representative and representatives from respiratory medicine and occupational health medicine would be invited onto the Group. Also agreed that the Group membership would be kept under review as the situation evolves. Action

• Patient representative, occupational health medicine and respiratory medicine representatives to be invited to join the group

9 Date of Next Meeting 12th February 2020 2pm to 4pm

Abbreviations: 2019-nCoV 2019 novel Coronavirus AGP Aerosol-Generating Procedure AMR Anti-Microbial Resistance AMRIC Antimicrobial Resistance and Infection Control CMO Chief Medical Officer DOH Department of Health EAG Expert Advisory Group ECDC European Centre for Disease Prevention and Control FAQ Frequently Asked Questions FFP Filtering Face Piece HCAI Healthcare-Associated Infection HCID High Consequences Infectious Diseases Planning and Coordination Group HCW Health Care Worker HPSC Health Protection Surveillance Centre HSE Health Service Executive ID Infectious Disease IPC Infection Prevention and Control NAS National Ambulance Service NIU National Isolation Unit NPA Naso-Pharyngeal Aspirate NPHET National Public Health Emergency Team NVRL National Virus Reference Laboratory OPD Out-Patients Department PH Public Health PPE Personal Protective Equipment PUI Person/Patient Under Investigation WHO World Health Organisation

mailto:[email protected]

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COVID-19 Expert Advisory Group Meeting

Title of Meeting: COVID-19 Expert Advisory Group Meeting (Meeting 2)



Dr Cillian de Gascun (CdG) Director NVRL, Consultant Virologist (Chair) Dr Ronan Glynn (RG) Deputy CMO, DOH Dr Vida Hamilton (VH) National Clinical Advisor and Group Lead, Acute Hospitals Dr Joanne O’Gorman (JOG) Consultant Microbiologist, HPSC and Rotunda Hospital Dr Colman O’ Loughlin (COL) Consultant Intensive Care Medicine, Mater Hospital Dr Gerard O’Connor (GOC) Consultant Emergency Medicine, Mater Hospital Dr Derval Igoe (DI) Consultant Public Health Medicine, NVRL/HPSC Dr John Cuddihy (JCy) Director, Health Protection Surveillance Centre Dr Aoife Cotter (AC) Consultant Infectious Diseases, National Isolation Unit Prof Martin Cormican (MC) Consultant Microbiologist, National Clinical Lead HCAI/AMR Ms Josephine Galway (JG) Director of Nursing for HCAI/AMR, AMRIC Team, HPSC Dr Jeanette McCallion (JM) Health Products Regulatory Authority Dr Jeff Connell (JCo) Head of Testing, UCD NVRL Dr Margaret O’ Sullivan (MOS) Chair, National Zoonoses Committee, Consultant Public Health Medicine Dr David Hanlon (DH) HSE National Clinical Advisor and Group Lead for Primary Care Prof Karina Butler (KB) Chair, National Immunisation Advisory Committee, Consultant Paediatric ID Dr Lynda Sisson (LS) Consultant in Occupational Medicine, Dean of Faculty of Occupational Medicine, RCPI Mr Robert Glennon Immunisation Policy Unit Department of Health (Admin Secretary)

Teleconference: Prof Colm Bergin (CB) Consultant Infectious Diseases, St James’s Hospital

Apologies: Prof Aurelie Fabre (AF) Consultant Pathologist, St Vincent’s Hospital

Observer: Dr Aoife Colgan, Surveillance Scientist, HPSC


Time: 2pm to 4pm

Prepared by: Dr Paul Mullane, SpR Public Health Medicine, National Immunisation Office (Medical Secretary)

Date Circulated:


Wed 19/02/2020; 2pm to 4pm

Item No.

1

Welcome new members

Dr Lynda Sisson, Consultant in Occupational Medicine was welcomed as a new member.

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2

Minutes and matters arising

Minor amendments were suggested to the minutes of the last meeting (05/02/2020). These will be

incorporated and amended minutes circulated.

Chair reminded members to provide nominations/suggestions for a Patient representative and a

representative from Respiratory Medicine.

FAQs on HPSC website have been updated to explain rationale for difference in Ireland vs. UK re:

self-isolation policy for those returning from China.

3


International: JCy provided an overview of the current international situation (as per WHO sit rep)

including numbers of cases and deaths, and provided details of the ECDC’s current risk assessment.

Of note, daily number of cases as per Chinese authorities appears to be reducing.

National: 65 individuals tested thus far. 2019-nCoV has not been detected in any sample submitted.

4


Nomenclature discussed – WHO has designated condition/disease – COVID-19 – “Coronavirus Disease 2019”. SARS-CoV-2 designated as name of the virus as per International Committee on Taxonomy of Viruses. HSE communications suggest a transition period using both old (2019-nCoV) and new (COVID-19) names then phase in the new name completely.

(a) ECDC paper: Scenarios for a further increase in the spread of COVID-19

Context – at the last meeting the Group recommended that it would review the international evidence on containment strategy on an ongoing basis. The above draft ECDC paper was discussed. ECDC characterise 4 potential scenarios for Europe in order to facilitate preparedness:

1. Ongoing containment 2. Sustained but sporadic community spread 3. Widespread sustained transmission with increasing pressure on healthcare system 4. Widespread sustained transmission with healthcare systems that are unable to cope

Each scenario is described in terms of :

a) Characterisation b) Factors increasing probability of moving to the next scenario c) Options for Public Health action

Options for PH action were considered for each scenario (1-4) as applied to the Irish setting. Current policy in the high containment phase was discussed. In Ireland, this is as per WHO advice that patients being tested are admitted until result confirmed as not detected. The critical importance of containment measures was discussed and emphasised. There was also discussion as to whether containment is better achieved in the acute hospital sector vs. other settings. Should Ireland move to mitigation phase, it was suggested that, if available, a community based testing option may be more appropriate than having people present to an acute facility for same. Feedback from clinical colleagues on the group is that the system is under some pressure; a few presentations per day to an acute hospital can place the system under strain, others report several

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patients presenting to ED per day, some without prior notification. VH explained that each receiving hospital as part of their plans is asked to identify location in the hospital separate to ED where patients who come in as per protocol via NAS can be assessed. If pressures are apparent then VH will ask the hospital groups/estates to identify potential locations for suitable isolation. It was noted that this request will bring with it a need for additional funding. If the current algorithms for cases presenting in general practice and outside receiving hospitals are used, this will ensure prior notification of a suspected case with the person being brought to the designated area/isolation room at a hospital facility. Frontline services would be reassured if the message to pre-alert acute services was conveyed clearly both to the public and to community HCWs. HSE Communications acknowledge the need to make sure that this message is widely known, and are working on improving awareness of this Suitable family accommodation was also discussed. Rooms with en-suite can allow hospitals to manage 3 to 4 children accompanied by a well adult at present. Children’s Health Ireland is looking to identify this infrastructure at present (some capacity is available in Tallaght currently). As part of active case finding, should Ireland test those with severe acute respiratory illness with no epidemiological links to exposures, as proposed for consideration in the scenario document? If implemented, this would have widespread implications in terms of IPC. The group felt that some epidemiological context would be needed prior to introduction. Group to review again at its meeting next week. With regard to pandemic plans, HPSC has drafted a plan with is being shared with DOH. Actions:

• Group members to read this draft paper in detail and make recommendations

• Group will continue to review the containment strategy and the evidence as to whether it’s working internationally on an ongoing basis

• Group will consider the robustness of both present containment measures and future mitigation measures in Ireland

• VH to liaise with acute hospital committees re: availability and suitability of current accommodation arrangements for containment, options for enhancing same, and also with estates on proposals for alternative infrastructure for those pending results

5

New Irish guidance/queries

(a) Management of individuals who require COVID-19 testing, but who do not medically require admittance to hospital at the time of identification Members were directed to the document ‘National interim guidelines on home isolation of a patient undergoing diagnostic testing’ presented at the last meeting. WHO advice is to hospitalise these patients pending test results, but as per discussion above, the availability of alternative locations might relieve pressure from acute hospitals. Discharge home pending results is complicated and could potentially compromise efforts to contain the infection; members are asked to review the document and provide feedback. Testing capacity was also discussed to see if increasing frequency would help reduce the time waiting for a result. Based on current numbers requiring testing, it’s unlikely that more frequent e.g. twice daily, testing would shorten the hospital wait-time significantly as samples from individuals presenting late in the evening would still be tested next morning, and the NVRL could not justify an out-of-hours 24/7 service at present. Capacity can increase in line with demand and if necessary SARS-CoV-2 testing can be prioritised over other routine testing if necessary; if commercial kits become available this could also facilitate a

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decentralised testing capacity. For the time being however, it was agreed that testing should be performed at the NVRL.

(b) Patients who discharge against medical advice pending test results

Document reviewed and discussed by Group. Further clarity is required in the document on scenarios where people leave the acute hospital setting in this context, i.e. triaged but self-discharges before assessment; assessed as suspect case but declines testing; tested but self-discharges pending results. Practical considerations regarding transport method home discussed – if patient cannot use their own vehicle the NAS should be requested to convey patient to their home, with appropriate IPC measures applied. Suitability of accommodation for self-isolation – checklist contained in guidance document. The process for PH risk assessment needs to be agreed. Advice leaflets for patient and household contacts, PPE and contact number in case of deterioration must be provided to the patient before they leave the hospital. It was acknowledged that more detail should be included in the document on the liaison between the clinician and public health with regard to provision of test results etc. Senior ED physicians review test results when they become available in the event of discharges against medical advice and follow up with patients as standard practice for other scenarios – in this instance, if SARS-CoV-2 detected, there needs to be liaison with PH to update the risk assessment. PH will follow up the patients until the end of the 14 day monitoring period. The question of legislation was raised in relation to the potential situation whereby suspected and confirmed cases may need to be detained, and also the issue also of asymptomatic contacts. The Department is currently considering legislative options and will update the Group next week.

(c) Discharge process for COVID-19 infected patients who have a resolved infection: Review of

available international guidance Document reviewed and discussed by Group. Content needs to align with document ‘Guidelines on home isolation of a patient undergoing diagnostic testing’. Information on the topic of discharge process for patients with a resolved infection is currently limited. Available data have been collated from different bodies (PHE, ECDC, CDC, WHO) on their interim arrangements. This is an interim working document – EAG members on any (international) clinical groups/networks are requested to liaise with colleagues to determine whether any additional data/evidence/interim arrangements available. WHO clinical platforms were also suggested as potential fora members could join.

Actions:

• Suggested amendments to be incorporated into documents (a) (b) and (c) above.

• Further comments/amendments invited from EAG members by end of this week (14/02/2020)

• AC will link with clinical colleagues in the UK so see if they are in a position to share their discharge criteria/protocols

(d) Case definition comparison and queries

A document with case definitions from Ireland, PHE, ECDC, WHO, CDC and PH Canada was presented for comparison and discussion. Note: the Irish case definition was adapted from both the ECDC and PHE case definitions.

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Comments were invited on the comprehensiveness and accuracy of the Irish case definition.

It was emphasised that the de facto application of the case definition in real world scenarios must reflect the case definition as written.

The differences between the case definitions in Ireland and Northern Ireland were discussed in terms of potential practical implications – a MOU with the NI Public Health Agency is in the process of being drafted to facilitate cross-border cooperation. It is not possible to have one case definition for the island of Ireland.

It was agreed that the additional clinical criterion of ‘fever of unknown cause with no other symptoms’ with the appropriate travel/contact exposure should be added to the Irish case definition.

Action: Irish case definition to be updated to include ‘fever of unknown cause with no other

symptoms’ as an additional clinical criterion for a suspect case.

LS presented an additional document to the Group entitled ‘Healthcare worker contact definitions’.

These definitions apply where HCWs have exposure to laboratory confirmed COVID-19 cases or

‘highly likely suspected infectious cases’. This document is consistent with the current PH contact

tracing guidance and definitions of close and casual contacts. The information contained therein

needs to be reflected in the current contact tracing algorithm.

HCWs returning from COVID-19 affected areas – guidance and algorithm in development.

Minor amendments suggested – ‘cumulative exposure’ to be further qualified as ‘cumulative

exposure to a case during a shift’.

‘Laboratory HCWs using inappropriate techniques’ – redefine as ‘Laboratory HCWs not adhering to

good practice’.

KB noted inconsistencies between the algorithm and the contact tracing guidance, and asked that

these be addressed.

Action: Amendments above to be incorporated. LS will also develop algorithm for this.

6


EAG provided its recommendation to NPHET following the last meeting, that imposing self-isolation

for asymptomatic individuals who have returned from mainland China within the past 14 days would

be a disproportionate burden on the individual at this time and that the available evidence does not

support it.

The recommendation has been accepted by NPHET.

No new issues have been referred for discussion.

7

Issues referred from HSE

Queries have been raised regarding management of suspect paediatric cases and parents (who may

or may not be symptomatic also) from an IPC standpoint in paediatric hospitals and maternity

settings – more specific guidance for these settings should be drafted.

Action: Convene subgroup for paediatric/maternity settings to develop guidance and FAQs re: IPC.

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KB and JOG to discuss further, and revert to Group.

Queries have also been raised regarding the management of the critically ill patient. There is a draft

guidance document from the Acute Operations division. It will provide guidance in relation to

questions received about PPE items to be used; advice for pregnant staff etc. For the final document,

IPC needs to be aligned with national IPC guidance.

Intensive Care Society of Ireland also has a guidance document available on its website.

There is also a paper covering intubation of the deteriorating patient infected with COVID-19

advising that the patient is transported to a designated area of ICU (“Toronto document”).

VH highlighted that the Group was made aware of these guidance documents at previous meeting.

CdG acknowledged this, and reiterated that EAG is happy for professional organisations to develop

specialty specific guidance. However, as queries from the frontline are often directed to EAG

members, it would be useful if the finalised guidance documents could be circulated to the EAG for

information.

Action: COL to circulate these documents for information to members.

8 AOB Nil

9 Date of Next Meeting 19th February 2020; 2pm to 4pm

Abbreviations: 2019-nCoV 2019 novel Coronavirus AMR Anti-Microbial Resistance AMRIC Antimicrobial Resistance and Infection Control CDC Centers for Disease Control and Prevention CMO Chief Medical Officer COVID-19 Coronavirus Disease 2019 DOH Department of Health EAG Expert Advisory Group ECDC European Centre for Disease Prevention and Control ED Emergency Department FAQ Frequently Asked Questions HCAI Healthcare-Associated Infection HCW Health Care Worker HPSC Health Protection Surveillance Centre HSE Health Service Executive ICU Intensive Care Unit ID Infectious Disease ILI Influenza-Like Illness IPC Infection Prevention and Control MOU Memorandum Of Understanding NAS National Ambulance Service NI Northern Ireland NPHET National Public Health Emergency Team NVRL National Virus Reference Laboratory PH Public Health PHE Public Health England PPE Personal Protective Equipment RCPI Royal College of Physicians of Ireland WHO World Health Organisation

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Dr Cillian de Gascun (CdG) Director NVRL, Consultant Virologist (Chair) Dr Ronan Glynn (RG) Deputy CMO, DOH Dr Vida Hamilton (VH) National Clinical Advisor and Group Lead, Acute Hospitals Dr Joanne O’Gorman (JOG) Consultant Microbiologist, HPSC and Rotunda Hospital Dr Gerard O’Connor (GOC) Consultant Emergency Medicine, Mater Hospital Dr Derval Igoe (DI) Consultant Public Health Medicine, NVRL/HPSC Dr John Cuddihy (JCy) Director, Health Protection Surveillance Centre Dr Aoife Cotter (AC) Consultant Infectious Diseases, National Isolation Unit Prof Martin Cormican (MC) Consultant Microbiologist, National Clinical Lead HCAI/AMR Ms Josephine Galway (JG) Director of Nursing for HCAI/AMR, AMRIC Team, HPSC Dr Jeanette McCallion (JM) Health Products Regulatory Authority Dr Jeff Connell (JCo) Head of Testing, UCD NVRL Dr David Hanlon (DH) HSE National Clinical Advisor and Group Lead for Primary Care Prof Karina Butler (KB) Chair, National Immunisation Advisory Committee, Consultant Paediatric ID Mr Robert Glennon Immunisation Policy Unit Department of Health (Admin Secretary) Prof Colm Bergin (CB) Consultant Infectious Diseases, St James’s Hospital

Teleconference:

Dr Margaret O’ Sullivan (MOS) Chair, National Zoonoses Committee, Consultant Public Health Medicine Dr Lynda Sisson (LS) Consultant in Occupational Medicine, Dean of Faculty of Occupational Medicine, RCPI

Apologies: Dr Colman O’ Loughlin (COL) Consultant Intensive Care Medicine, Mater Hospital Dr Sean Gaine Consultant Respiratory Medicine



Time: 2pm to 4pm

Prepared by: Dr Laura Heavey, SpR Public Health Medicine, HPSC (Medical Secretary)

Date Circulated: 24/02/2020


Wed 26/02/2020; 2pm to 4pm

Item No.

Welcome new members

Laura Heavey has joined the group as medical secretary.

Dr Seán Gaine, respiratory physician, has joined the group, but sends apologies for today’s meeting.

CDG will issue an invitation to the Irish Society of Clinical Microbiologists (ISCM) following a request

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for representation.

No patient representative has yet been appointed: nominations sought. MC offered to contact

someone, with GOC to follow up if MC unsuccessful.

A representative from paediatric emergency medicine is being sought through Child Health Ireland.


Minor amendments were suggested to the minutes of the last meeting (12/02/2020). These will be

incorporated and amended minutes circulated.

1. VH shared concerns coming from staff in acute hospitals regards keeping suspected patients with

COVID 19 isolated in hospital when they are clinically well.

It was noted that acute hospitals have identified some existing facilities that could function as

isolation beds but which may require additional resources to make them operational. RG suggested

that a paper identifying the location of these facilities and the additional resources required to make

them operational should, in the first instance, be prepared and discussed at the HSE’s NCMT and, if

necessary, then brought to NPHET for discussion.

2. The concept of moving from having all hospitals designated as receiving hospitals managing a

small number of confirmed cases, to a “hub and spoke” model across hospital groups, with the NIU

as the ultimate hub with a smaller number of spokes during the current containment phase, was

discussed.

AC felt that this model would be most appropriate in the interests of patient safety and care, and the

EAG agreed that this approach should be examined. VH noted that acute hospitals would prepare a

paper on the proposed model. It was agreed that this would then be brought to the EAG for

discussion.

RG noted that a meeting will be held shortly with relevant Government Departments to discuss

suitable locations for isolation of a large number of contacts should that situation arise.

It was noted that a working group will this week begin to assess options for home testing and home

care for patients with COVID 19 who don’t require hospital admission for clinical management. A

care pathway for paediatric cases of COVID 19 also needs to be developed.

3. VH raised the issue of testing for SARS-CoV-2 when patients do not meet the current case

definition. It was agreed that testing could be necessary in some instances if clinical suspicion was

high, even if all conditions of the case definition (e.g. geographic exposure) were not met. It was

agreed that the treating clinician, following discussion with the relevant public health specialist and

local ID or microbiology consultant, could ask the NVRL to perform testing in the appropriate clinical

setting.

4. LH provided brief update on ECDC discussions on adapting influenza surveillance systems for

SARS-CoV-2 surveillance. Finland has already commenced testing of SARI cases of unknown cause for

SARS-CoV-2 and the Netherlands is testing samples from GP sentinel sites for ILI. These options

could be considered here in future if the risk of undetected community transmission rises i.e. cases

of COVID 19 are detected in Ireland or there is an increase in cases in other European countries.

5. RG provided a brief update on legislation. It will likely be signed by the minister tomorrow. This

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will make COVID 19 a notifiable disease and allow for quarantine of those who are a probable source

of infection.

6. AC has not received feedback from UK colleagues re discharge policy yet.

7. A query was raised re the definition of ‘fever’. The EAG agreed that a temperature of 38 degrees

or higher should be considered a fever, if the measurement was taken by a health care worker.

Algorithms will need to be updated to reflect this change.

8. Governance of the guidance development process was clarified. When a change to the guidance is

made, the new guidance will be shared with the EAG for sign off before it is circulated more widely.

Actions:

• VH to prepare proposal for extra resources required to find additional isolation spaces for

acute hospitals and bring to NCMT for discussion.

• VH/acute hospitals to prepare a document outlining a proposal to move to a ‘hub and spoke

model’ for the management of confirmed cases of Covid-19 during the containment phase. It

is anticipated that EAG will review the hub and spoke model proposal when available.

• RG to provide an update on alternative isolation facilities for large groups of contacts which

are potentially available outside of hospitals at the next meeting.

• Follow up on home testing and care at next meeting: to remain on the agenda pending

escalation of the current containment policy.JCy to prepare a notification for the system on

the necessity for the treating clinician to consult public health and local ID or microbiology

consultant before sending a test for SARS-CoV-2, if testing a patient who does not meet the

case definition.

• Follow up with AC re discharge criteria at next meeting.

• Update algorithms to reflect new definition of fever (HPSC).

3


International: Recent updates supplied in the meeting pack.

National: JCy provided a brief update on the Irish citizens on board the Westerdam and Diamond

Princess cruise ships.

4


(a) Epidemiology of the outbreak in China

The latest paper on asymptomatic and pre-symptomatic transmission based on a cluster of 4

cases in China was discussed. There was also a publication in the NEJM describing testing of

asymptomatic travellers returning from Wuhan on a repatriation flight to Germany. Two

travellers (of 114 screened) tested positive but did not report symptoms. Others with

symptoms tested negative. EAG will keep this issue under review.

(b) Pandemic plans

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The newly-established Modelling group is to meet for the first time next week regarding future projections of the impact of COVID 19. JCy emphasised that there is another group discussing the operational impacts of these projections and preparation for same. JM noted that there are currently no recommendations to stockpile any medicines, such as antivirals and antibiotics. The European Medicines Agency is trying to ensure that countries co-operate with each other in terms of stockpiling. JG noted that a small group from HCID is looking at alternative PPE recommendations if masks are short in supply.

5


(a) Widening of the case definition for affected areas DI discussed the latest update from the ECDC advisory forum. ECDC will provide an official outcome of the meeting within 48 hours. China to remain in the case definition as an affected area, although it was noted that certain provinces have very low incidence rates. Singapore and Hong Kong authorities have announced that they have evidence of community transmission. It is possible that they may be added to the list of affected areas. There is also still concern about ongoing transmission from an animal source in China.

(b) Exclusion and self-isolation of returning healthcare workers

Testing of asymptomatic close contacts was discussed. JG asked who would do the testing if this testing was to take place at home. The EAG did not feel this was necessary at this point. The document regarding the self-isolation of all travellers (including health care workers) from Hubei (who are not close contacts of a COVID 19 case) was reviewed and discussed by the Group. Since the last meeting, the Department of Social Welfare have said that there is an emergency needs allowance that could cater for those excluded from work. DI said there is still no legislation to make people comply with self-isolation however. The option of excluding health care workers travelling from Hubei from work for 14 days after exposure, but not asking them to self-isolate, was also discussed. The argument for treating health care workers differently is to protect the vulnerable groups they work with, such as the elderly and immunocompromised. Only excluding those coming from Hubei is related to the high transmission in that province. AC said that rather than targeting specific countries and regions, we should be using a standard definition for incidence rates that are considered to reflect a high risk of community transmission. The Chair referred this issue to the Public health and Occupational Medicine working group for further discussion. Action:

• Public health and Occupational Medicine to discuss options for health care workers returning from Hubei and provide their recommendation to the group next week

(c) Algorithm for management of health care workers with occupational exposure The algorithm for management of health care workers with an occupational exposure to SARS-CoV-2 in Ireland was discussed. There is no out of hours cover for occupational Medicine. If a health care worker contact were to become unwell out of hours, they should call their GP or NAS and follow the usual care pathway for a suspect case. LS discussed the definition of aerosol generating procedures. The CDC definition is different to the Irish definition and includes nebulisation therapy. MC and JG asked LS to send guidance and they will review.

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A query re fitting of masks for health care workers with beards was discussed. JG advised that fit testing with FFP3 masks can achieve a fit with some beards and should be practiced. PHE are discussing a recommendation to shave beards in certain situations.

Action:

• LS to share CDC guidance on aerosol generating procedures with IPC team for

review.

6


Nil

7


Queries have been raised regarding repatriation of cases with COVID 19. The HCID group is currently

reviewing the guidelines on repatriation of Ebola cases and will review the issues for COVID 19. MC

noted repatriation of remains also needs to be considered.

Action: Defer to HCID group for now: EAG happy to review as necessary.

Query re: need to fast-track the procurement of a critical care POD for the NIU. AC said this POD

would not be necessary for COVID 19, but normal procurement processes should continue as part of

preparations in case of future VHF cases.

Action: Chair to reply to Tom McGuinness.

8

AOB Queries from Sport Institute Ireland, re the Olympic team. The EAG decided this was not the most appropriate forum to address the various issues raised. The queries should go to the interdepartmental Health Threats Coordination group and also need to be considered by the Department of Transport, Tourism and Sport. Ultimately, any advice provided will be based on guidance emanating from the HPSC with regard to mass gatherings. Action: Chair to write a response outlining the above. JOG shared a request for a discussion forum (via a weekly teleconference) for Microbiology consultants to receive the latest COVID 19 updates. KB confirmed that IDSI has already implemented same. Action: JCy and JOG to follow up on arranging this. MC raised ongoing concerns about the differences in recommendations regarding the type of masks necessary for PPE. MC asked if ECDC could be contacted to explain their recommendation. Action: JCy to forward this query to ECDC via KK.

9 Date of Next Meeting 26th February 2020; 2pm to 4pm

Abbreviations: 2019-nCoV 2019 novel Coronavirus AMR Anti-Microbial Resistance AMRIC Antimicrobial Resistance and Infection Control CDC Centers for Disease Control and Prevention CMO Chief Medical Officer

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COVID-19 Coronavirus Disease 2019 DOH Department of Health EAG Expert Advisory Group ECDC European Centre for Disease Prevention and Control ED Emergency Department FAQ Frequently Asked Questions HCAI Healthcare-Associated Infection HCW Health Care Worker HPSC Health Protection Surveillance Centre HSE Health Service Executive HCID High Consequence Infectious Disease ICU Intensive Care Unit ID Infectious Disease ILI Influenza-Like Illness IPC Infection Prevention and Control MOU Memorandum Of Understanding NAS National Ambulance Service NI Northern Ireland NPHET National Public Health Emergency Team NVRL National Virus Reference Laboratory PH Public Health PHE Public Health England PPE Personal Protective Equipment RCPI Royal College of Physicians of Ireland VHF Viral haemorrhagic fever WHO World Health Organisation

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Location of Meeting: Mercy International Centre - 64A Lower Baggot Street Dublin 2

TOR of group

•To function as an expert sub-group of the National Public Health Emergency Team (NPHET) that will monitor and review this evidence and provide expert advice to the NPHET, the Health Service Executive and others as appropriate. •To review current advice and guidance on 2019-nCoV preparedness and response, identify gaps, and update and provide clear, evidence-based expert advice on preparedness and response.


Dr Cillian de Gascun (CdG) Director NVRL, Consultant Virologist (Chair) Dr Ronan Glynn (RG) Deputy CMO, DOH Dr Vida Hamilton (VH) National Clinical Advisor and Group Lead, Acute Hospitals Dr Joanne O’Gorman (JOG) Consultant Microbiologist, HPSC and Rotunda Hospital Dr Gerard O’Connor (GOC) Consultant Emergency Medicine, Mater Hospital Dr Derval Igoe (DI) Consultant Public Health Medicine, NVRL/HPSC Dr John Cuddihy (JCy) Director, Health Protection Surveillance Centre Dr Aoife Cotter (AC) Consultant Infectious Diseases, National Isolation Unit Prof Martin Cormican (MC) Consultant Microbiologist, National Clinical Lead HCAI/AMR Ms Josephine Galway (JG) Director of Nursing for HCAI/AMR, AMRIC Team, HPSC Dr David Hanlon (DH) HSE National Clinical Advisor and Group Lead for Primary Care Prof Karina Butler (KB) Chair, National Immunisation Advisory Committee, Consultant Paediatric ID Mr Robert Glennon Immunisation Policy Unit Department of Health (Admin Secretary) Dr Sean Gaine (SG) Consultant in Respiratory Medicine Ms Melissa Redmond Chairperson of Patients for Patient Safety Ireland Dr Ciara Martin (CM) Consultant Paediatric Emergency Physician Dr Margaret O’ Sullivan (MOS) Chair, National Zoonoses Committee, Consultant Public Health Medicine Dr Lynda Sisson (LS) Consultant in Occupational Medicine, Dean of Faculty of Occupational Medicine, RCPI Dr Mary O’Riordan (MOR) Consultant in Public Health Medicine, HPSC Dr Fiona Cianci (FC) Consultant in Public Health Medicine, HPSC

Teleconference: Professor Aurelie Fabre Consultant Histopathologist

Apologies:

Prof Colm Bergin (CB) Consultant Infectious Diseases, St James’s Hospital Jeanette Dr Jeanette McCallion (JM) Health Products Regulatory Authority Dr Vida Hamilton (VH) National Clinical Advisor and Group Lead, Acute Hospitals Dr Jeff Connell (JCo) Head of Testing, UCD NVRL



Time: 2pm to 4pm

Prepared by: Dr Laura Heavey, SpR Public Health Medicine, HPSC (Medical Secretary)


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Wed 4/3/2020; 2pm to 4pm

Item No.

1.

Welcome new members

The Chair welcomed Dr Sean Gaine (Respiratory Medicine), Dr Ciara Martin (Paediatric Emergency

Medicine) and Ms Melissa Redmond (Patients for Patient Safety Ireland) to the group.

2.


Minutes were accepted by those present (19/02/2020). An amendment from Jeanette McCallion

was received via email. This will be incorporated and amended minutes circulated.

• RG informed the group that a report on alternative isolation facilities for suspected cases is

being prepared by the Departments of Housing, Education and Defence this week. More

information on available options will be provided at the next meeting.

• AC provided an update on hospital discharge criteria currently being used in the UK for

confirmed cases of COVID 19:

o The clinician must be satisfied that the clinical symptoms have resolved.

o There must also be 2 consecutive respiratory samples, taken at least 24 hours apart,

where the virus is not detected. Samples from the upper respiratory tract are

acceptable if it is not possible to obtain lower respiratory tract samples. If other sites

were positive for the virus initially (such as blood, urine and stool), the case must be

discussed with public health, to assess the ongoing risk of transmission post-

discharge.

3.


International: JCy presented details from the WHO situation report. Of most concern are the new

areas with community transmission; Iran, South Korea and 4 regions in northern Italy (Emilia-

Romagna, Lombardy, Piedmont, Veneto).

National: 143 specimens from 117 patients have been tested : viral RNA was not detected in any of

the samples. There was a sharp increase in testing over the weekend, related to the Italian outbreak

and many people returning from mid-term break.

4.


(a) Summary of recent literature

A summary of recent publications was shared with the group for information.

(b) Pandemic plans MOR gave an overview of the draft document on pandemic preparedness. Containment and mitigation measures were outlined. The EAG was asked to consider if all the appropriate

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measures are currently in place for containment and to consider the need for non-pharmaceutical interventions, such as social distancing measures at each phase of the response. GOC asked if there was evidence of effectiveness of these measures. DI said it is very difficult to determine which measures are most effective, as a number of them are usually applied at once as part of a package. The management of the current outbreak in Italy may generate some evidence in the next few weeks. There was a discussion of the ethical issues that can arise during a pandemic (such as the use of quarantine and isolation, shortages of ICU beds and PPE, etc). DI noted that a bioethicist in the DOH had prepared a paper on ethical issues that can arise during an influenza pandemic. RG advised that this document is being reviewed in DOH in the context of COVID 19. Action:

• RG to ask Siobhan O’Sullivan, bioethicist, to give a presentation at the next EAG meeting.

• MOR requested feedback from the EAG on the first draft of the pandemic preparedness document via email.

5.


(a) Mass gatherings and churches DI gave an overview of the current guidance on mass gatherings, which was used to inform the decision by NPHET to cancel the Ireland-Italy rugby match. NPHET has set up a subgroup to consider the issue of mass gatherings in more detail. Their aim is to set clear criteria to guide what events can go ahead in the coming weeks. Feedback was provided on the guidance for churches and other religious settings. GOC asked that ‘phone the ED’ be removed to ensure the guidance was in line with the algorithms on the HPSC website. DH asked that ‘phone your GP immediately’ be replaced with ‘phone your GP without delay’. Those without a GP are advised to contact 999. Action: DI to provide feedback to authors of guidance for churches

(b) Options paper on testing and home care for suspected cases and management of cases in

the community The first paper on home isolation while a suspected case waits for the results of SARS-Co-V 2 testing was approved by NPHET. A caregiver who has already been exposed to the patient can drive the patient to ED, rather than waiting for an ambulance. The hospital must be informed in advance that they are coming. The algorithms for care need to be changed to reflect this. The EAG was in agreement with NPHET’s decision. MOR outlined the options for testing at home and care of mild cases of COVID 19 at home, acknowledging that there is no perfect system. The UK is currently the only country doing home testing, using health protection teams. All persons who test positive for SARS-CoV-2 are still admitted to hospital in the UK. Netherlands and Denmark are preparing guidance for home testing and home care, but these have not been shared with the wider European community. The EAG advised that there are a number of key steps involved in home testing and care: 1. Collecting the sample 2. The clinical assessment of the patient’s need for further medical assessment/treatment 3. Reporting the results to the patient

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4. Aftercare, including the detection and management of deterioration Ideally, there would be continuity of care for the patient during this process. There was agreement that nurses could do the testing and assessment, but they should have access to a doctor who can review the patient if there are concerns about their condition. A number of locations for testing were discussed, including the patient’s home, GP practice or an alternative site on the hospital grounds outside of the ED. Beaumont Hospital have developed a ‘pod’ outside of the ED where the tests are performed. It was suggested that pilot testing outside the hospital setting could be performed using GP practices involved in ILI surveillance. AC noted that there must be clear criteria outlining who can be tested at home if this becomes an option (i.e. patients with mild symptoms) and who needs to attend the hospital (patients with more severe symptoms or in risk groups for developing severe disease). The group asked that alternative modes of transport to hospitals or other testing sites be explored. There is great pressure on the ambulance service at present. JOG noted the UK have been using mini buses. DH emphasised that any model of home care or testing that is created for the containment phase should be able to transition to providing care in the mitigation phases. MC noted that the risk communication must be managed carefully. Otherwise, patients who develop COVID 19 will be too anxious to have their care provided at home and patients with other illnesses may be too anxious to attend the healthcare setting, due to fears of becoming infected with SARS-CoV-2.

Action:

• JCy will feed back the views of the EAG to NCMT

(c) IPC issues

1. MC clarified that nebuliser therapy creates aerosolised particles of medicine, but there is

no reason to expect nebuliser therapy will generate virus containing aerosols.

Action: LS to change occupational medicine guidance on health care setting exposures to SARS-CoV-2 to reflect the above point.

2. There is a sub group of HCID reviewing the alternatives for PPE in case of a supply

shortage.

3. Guidance on the management of pregnant women with COVID 19 in the intrapartum and postpartum periods was reviewed and approved by the EAG. The key issue is the possibility of separating the mother from the newborn and how long this separation would continue. This will be decided on a case by case basis for now. In the case of separation, expressing breast milk would be encouraged, as there is no current evidence to suggest that SARS-Co-V 2 can be transmitted via breastmilk.

(d) Containment measures for returned travellers and health care workers coming from

affected areas

The EAG agreed that self-isolation at home is currently not recommended for all returned

travellers from areas with community transmission. The risk of transmission of the virus

from asymptomatic carriers is not well understood. However, it was felt that health care

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workers were a special group, due to their contact with vulnerable, elderly and immune-

compromised patients. After a long discussion, it was decided that healthcare workers

returning from areas with high levels of community transmission (i.e. Hubei province in

China, Iran, Daegu and Cheongdo provinces in South Korea and the 11 Italian towns under

quarantine) should be excluded from work for 14 days after their last exposure. They would

require passive follow up with public health. Health care workers returning from other

affected areas not mentioned above could attend work if they were asymptomatic. The

group agreed that those health care workers who are allowed to work need active

monitoring for symptoms and should stop work immediately if they develop any symptoms.

MC expressed concerns that large numbers of health care workers excluded from working

could have significant impacts on patient care and infection control practices. This must be

kept under review. The EAG made the above recommendation given that we are currently in

the intense containment phase and acknowledged that this could change as the situation

evolves.

Action: LS and LH to update the document on the management of health care workers

returning from travel in affected areas and share with the wider system

(e) Active case finding

This was discussed in the context of containment. Some changes were made to the

algorithms, regarding the timing of the removal of IPC precautions when SARS-CoV-2 is not

detected. JOG noted that if SARS-CoV-2 is not detected, IPC precautions should remain in

place if another infectious respiratory illness is suspected. AC commented that if clinical

suspicion for COVID 19 was high, IPC precautions might need to remain in place until after

repeat testing. The group agreed that testing for SARS-CoV-2 should be considered for

patients with SARI of unknown origin, even if there was no clear history of exposure to

COVID-19.

Action: DI to amend algorithms and re-circulate to the group for approval.

DI discussed other countries’ practices regarding the testing of asymptomatic contacts of a

case of COVID 19. There is still uncertainty regarding transmission of the virus from

asymptomatic cases to others. However, as part of intense containment, contact tracing

would need to be considered for those who were exposed to asymptomatic cases. JG

advised that clarity would be needed regarding the optimal timing of testing and the interval

between subsequent tests, if the first test is negative. A pathway of care would need to be

outlined for asymptomatic cases, with clear guidance on the duration and location of

isolation.

Action: DI and LH to prepare a review of the current evidence on the risk of transmission

when asymptomatic, testing of asymptomatic close contacts and a review of current practice

in other countries regarding the management of asymptomatic cases with SARS-CoV-2. This

will be discussed at the next meeting with a view to making a recommendation on testing

and management of asymptomatic contacts.

6 Issues for advice/discussion referred by NPHET

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Nil

7


Not all hospitals have provided feedback on the ‘hub and spoke’ model. For now, all hospitals with

emergency departments will remain receiving hospitals for suspected cases of COVID 19.

Action: EAG happy to review as necessary.

8

AOB There was another query raised about the types of face mask that can be used for those with beards. Action: JOG advised there are ongoing efforts to source PPARS masks. In the meantime, those who cannot achieve a good fit with the available face masks may need to avoid AGPs, such as intubation of patients with COVID 19. Rotas for areas providing critical care should take this into consideration.

9 Date of Next Meeting 4th March 2020; 2pm to 4pm

Abbreviations: AGPs Aerosol Generating Procedures AMR Anti-Microbial Resistance AMRIC Antimicrobial Resistance and Infection Control CDC Centers for Disease Control and Prevention CMO Chief Medical Officer COVID-19 Coronavirus Disease 2019 DOH Department of Health EAG Expert Advisory Group ECDC European Centre for Disease Prevention and Control ED Emergency Department FAQ Frequently Asked Questions HCAI Healthcare-Associated Infection HCW Health Care Worker HPSC Health Protection Surveillance Centre HSE Health Service Executive HCID High Consequence Infectious Disease ICU Intensive Care Unit ID Infectious Disease ILI Influenza-Like Illness IPC Infection Prevention and Control MOU Memorandum Of Understanding NAS National Ambulance Service NI Northern Ireland NPHET National Public Health Emergency Team NVRL National Virus Reference Laboratory PH Public Health PHE Public Health England PPE Personal Protective Equipment RCPI Royal College of Physicians of Ireland WHO World Health Organisation

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Dr Cillian de Gascun (CdG) Director NVRL, Consultant Virologist (Chair) Dr Derval Igoe (DI) Consultant Public Health Medicine, NVRL/HPSC Dr John Cuddihy (JCy) Director, Health Protection Surveillance Centre Dr Jeanette McCallion (JM) Health Products Regulatory Authority Prof Karina Butler (KB) Chair, National Immunisation Advisory Committee, Consultant Paediatric ID Mr Robert Glennon Immunisation Policy Unit Department of Health (Admin Secretary) Prof Colm Bergin (CB) Consultant Infectious Diseases, St James’s Hospital Dr Colman O’Loughlin (COL) Consultant in Intensive Care Medicine

Teleconference:

Dr Gerard O’Connor (GOC) Consultant Emergency Medicine, Mater Hospital Dr Vida Hamilton (VH) National Clinical Advisor and Group Lead, Acute Hospitals Prof Martin Cormican (MC) Consultant Microbiologist, National Clinical Lead HCAI/AMR Dr David Hanlon (DH) HSE National Clinical Advisor and Group Lead for Primary Care Damien Nee (DN) Patients for Patient Safety Ireland Dr Ciara Martin (CM) Consultant in Paediatric Emergency Medicine

Apologies:

Dr Ronan Glynn (RG) Deputy CMO, DOH Dr Joanne O’Gorman (JOG) Consultant Microbiologist, HPSC and Rotunda Hospital Dr Aoife Cotter (AC) Consultant Infectious Diseases, National Isolation Unit Ms Josephine Galway (JG) Director of Nursing for HCAI/AMR, AMRIC Team, HPSC Prof Aurelie Fabre Consultant Pathologist Dr Margaret O’ Sullivan (MOS) Chair, National Zoonoses Committee, Consultant Public Health Medicine


Date/Time of Meeting: Thursday 12/03/2020

Time: 430pm to 6pm

Prepared by: Dr Laura Heavey, SpR Public Health Medicine, HPSC

Date Circulated:


Wed 18/03/2020; 2pm to 4pm

Item No.

1

Due to the time sensitive nature of the questions from NPHET, these were addressed as soon as the

meeting was convened

Can the EAG provide guidance to NPHET as to whether the taking of samples in people suspected

of COVID-19 constitutes an aerosol-generating procedure?

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Taking samples for SARS-CoV-2 testing is not an AGP, with the exception of nasopharyngeal aspirates

so the group advised that taking nasopharyngeal aspirates should be avoided.

As part of the measures recommended by NPHET last evening, individuals with 'flu like symptoms

have been asked to stay at home. Can the EAG urgently examine and advise NPHET as to which

symptoms are constituted by this term?"

Fever or chills and/or signs and symptoms of respiratory tract infection (which would include cough

and difficulty breathing). Symptoms should be of recent onset (i.e. in the past 10 days). Fever or

chills can be subjective and reported by the patient, if a thermometer is not available. Otherwise

fever is a temperature >38. The group agreed that the general list of flu symptoms on the HSE

website is not consistent with COVID 19 disease.

Who should be tested for Covid19 in the context of the recommendations made last night?

It was agreed that hospitalized patients and health care workers should be prioritized for testing,

regardless of travel history, if they have symptoms consistent with COVID 19 (outlined in the

algorithms).

DH conveyed the concerns of GPs. For community testing, they suggested elderly patients or those

with co-morbidities should be tested, as a positive test result could alter their management and lead

to increased clinical monitoring for signs of deterioration.

Other priority groups would include anyone in a residential setting (i.e. nursing home, etc), anyone

elderly (age was not defined over 60 or 65?) or anyone with a history of cardiac or pulmonary

disease, diabetes or immune compromise, if they have symptoms consistent with COVID 19,

regardless of their travel history.

The EAG agreed that all of the above patients would likely have their clinical management altered by

a test result and therefore would be prioritized. However, it was acknowledged that if contact

tracing is going to continue as part of intense containment, than anyone with ILI and a history of

international travel should be tested. DI requested clarity on this from NPHET. If contact tracing is a

key measure as part of the current phase, then everyone with ILI, regardless of travel history, should

be tested.

The EAG expressed concern about the feasibility of increasing sampling and testing. CDG advised

that testing capacity is probably around 5,000-6,000 tests per week, but outlined the plans to

increase the number of labs doing the testing. However, tests from hospitalised patients will be

prioritised, with results available in 18-24 hours, and community testing results will take longer – 48-

72 hours. More commercial kits will also need to be sourced.

Hospital testing algorithms

Feedback from the group was noted and ammendments will be made to the algorithms urgently for

sharing with the system tomorrow. VH advised that all patients being admitted to ICU should be

tested for COVID 19.

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2

AOB

DN shared a new research paper in pre-print with the group. The modelling is different to all

available evidence so far, in that the authors are suggesting that presymptomatic transmission may

account for 48-77% of cases, much higher than any previous estimates. He raised concerns about

those coming to Ireland from Italy on the last scheduled flights out of Italy and suggested that these

flights be cancelled. CDG advised that these flights will contain Irish citizens returning home and they

should be allowed to return. VH suggested that all passengers should be advised in the airport that

they will need to self-isolate for 14 days. CDG agreed to share the concerns from the EAG with

NPHET.

9 Date of Next Meeting 18th March; 2pm to 4pm

Abbreviations: 2019-nCoV 2019 novel Coronavirus AMR Anti-Microbial Resistance AMRIC Antimicrobial Resistance and Infection Control CDC Centers for Disease Control and Prevention CMO Chief Medical Officer COVID-19 Coronavirus Disease 2019 DOH Department of Health EAG Expert Advisory Group ECDC European Centre for Disease Prevention and Control ED Emergency Department FAQ Frequently Asked Questions HCAI Healthcare-Associated Infection HCW Health Care Worker HPSC Health Protection Surveillance Centre HSE Health Service Executive ICU Intensive Care Unit ID Infectious Disease ILI Influenza-Like Illness IPC Infection Prevention and Control MOU Memorandum Of Understanding NAS National Ambulance Service NI Northern Ireland NPHET National Public Health Emergency Team NVRL National Virus Reference Laboratory PH Public Health PHE Public Health England PPE Personal Protective Equipment RCPI Royal College of Physicians of Ireland WHO World Health Organisation

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Title of Meeting: COVID-19 Expert Advisory Group Meeting

Location of Meeting: Department of Health, Miesian Plaza, Dublin 2


Dr Cillian de Gascun (CdG) Director NVRL, Consultant Virologist (Chair)

Videoconference:

Dr Derval Igoe (DI) Consultant Public Health Medicine, NVRL/HPSC Dr Alan Smith (AS) Deputy CMO, DOH Damien Nee (DN) Patients for Patient Safety, Ireland Dr Gerard O’Connor (GOC) Consultant Emergency Medicine, Mater Hospital Prof Karina Butler (KB) Chair, National Immunisation Advisory Committee, Consultant Paediatric ID Mr Robert Glennon Immunisation Policy Unit Department of Health (Admin Secretary) Dr Ciara Martin (CM) Consultant in Paediatric Emergency Medicine Prof Martin Cormican (MC) Consultant Microbiologist, National Clinical Lead HCAI/AMR Dr Lynda Sisson (LS) Consultant in Occupational Medicine, Dean of Faculty of Occupational Medicine, RCPI Prof Aurelie Fabre (AF) Consultant Pathologist Dr John Cuddihy (JCy) Director, Health Protection Surveillance Centre Dr Aoife Cotter (AC) Consultant Infectious Diseases, National Isolation Unit Dr Vida Hamilton (VH) National Clinical Advisor and Group Lead, Acute Hospitals Dr Margaret O’ Sullivan (MOS) Chair, National Zoonoses Committee, Consultant Public Health Medicine Dr Colman O’Loughlin (COL) Consultant in Intensive Care Medicine Helen Murphy (HM) Infection Prevention and Control Nurse Manager, Lead Nurse AMR HCAI Response Team Dr Lorraine Doherty (LD) National Clinical Lead for Health Protection Prof Colm Bergin (CB) Consultant Infectious Diseases, St James’s Hospital Ms Josephine Galway (JG) Director of Nursing for HCAI/AMR, AMRIC Team, HPSC Dr Lelia Thornton (LT) Consultant in Public Health Medicine, HPSC

Apologies:

Dr Jeanette McCallion (JM) Health Products Regulatory Authority Prof Sean Gaines (SG) Consultant in Respiratory Medicine Dr Joanne O’Gorman (JOG) Consultant Microbiologist, HPSC and Rotunda Hospital Dr David Hanlon (DH) HSE National Clinical Advisor and Group Lead for Primary Care Dr Michael O’Connell (MOC) Consultant Obstetrician and Master of Coombe Hospital Dr Jeff Connell (JCo) NVRL

Secretariat: Dr Laura Heavey SpR Public Health Medicine, HPSC Mr Robert Glennon Immunisation Policy Unit Department of Health (Admin Secretary)

Observer:

Date/Time of Meeting: Mon 20/04/2020

Time: 2pm to 4pm

Prepared by: Dr Laura Heavey, SpR Public Health Medicine, HPSC


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Wednesday 22nd April at 2pm

Item No.

1


The minutes from the last meeting were accepted. CDG provided an update on a

parliamentary question regarding the COVID 19 pandemic response – the EAG membership,

terms of reference, minutes of these meetings, and the advice provided to NPHET will be

shared in order to answer the query.

2

Nursing homes and residential care facilities

The new pathway for testing and care for those in residential care facilities was discussed. The EAG felt that it is not clear how this new care and testing pathway will be implemented e.g. how many times will staff and patients be tested? There will be a need for a planned regular schedule of testing-this has not yet been developed. This new approach raises a number of questions for occupational health management, including the timing of onset of contact tracing, which will come back to EAG for discussion. Regarding contacts of asymptomatic staff outside the residential facility – they should have careful questioning for subtle symptoms (including anosmia and GI issues) and if truly asymptomatic, non-healthcare contacts should be contact traced from 24 hours pre-diagnosis. It was suggested that a similar pathway may be need to be developed for acute hospitals in order to restart non-COVID 19-related care in a safe manner. It was noted that some hospitals have already begun screening all admissions.

Action:

• The new pathway was accepted by EAG without any amendments, but it was agreed that there needs to be significant work done to make this operational. This work is believed to be ongoing.

• EAG advises that NPHET considers prioritising mask use by HCWs for near patient care in all nursing homes, if this recommendation cannot yet be implemented across the healthcare system.

3

High risk groups for COVID 19 disease CDG discussed the document on immunosuppressants from CAG. There would be a change in that fewer people on immunosuppressants would be asked to cocoon, compared to current advice. It was mentioned that there is very little hard data to suggest that this group are actually at higher risk of COVID 19 disease. A recent letter in the Lancet from a liver transplant centre in Lombardy was noted. There were 3 deaths in post-transplant patients who had low levels of immune suppression, but had other co-morbidities such as diabetes, hypertension and obesity. The patients with recent transplants with a high level of immunosuppression did not have any severe disease.

Decision:

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• EAG welcomed the document with no major amendments, but advises that the document is reviewed by an immunologist prior to it being finalised.

4

Acute Hospital Preparedness

A plan to re-start the provision of semi-urgent and routine non-COVID 19 care was deemed necessary by the group. This needs to be developed urgently to look at major surgery for cancer and vascular disease in particular. It has been discussed at the Acute Operations sub group of NPHET. Screening of patients, PPE and testing in-house prior to elective AGPs all need to be considered. Ideally there would be a plan at a national level so that the whole system is following the same co-ordinated approach.

Action:

• A subgroup of EAG will look at these issues and bring some recommendations to the group for review.

5

COVID 19 research CB had to leave the meeting with apologies. The EAG approved the document.

Action:

• EAG approved the paper on the approach to clinical trials.

6

Issues referred by NPHET

Nil

8

AOB A question was raised about the definition of healthcare-associated COVID-19 infection. A document with a suggestion for a definition was shared with the group before the meeting. The usual incubation period is 5 days, so this has been suggested for COVID 19, rather than the usual 48 hours. Decision: the definition of Hospital acquired COVID-19 was agreed It was also suggested that to determine health care acquired versus community acquired cases, screening for COVID-19 may need to happen for all patients at admission. Many are now presenting to hospital with unusual symptoms and this is contributing to hospital outbreaks. For those coming in electively, they may need to attend earlier for screening, similar to how screening was done for MRSA. This needs to be clarified in the document. Action:

• These points to be reviewed in the context of development of a pathway for acute hospitals for provision of semi-urgent non COVID care

• A question was raised regarding use of masks in the community. The HIQA evidence synthesis has just been completed.

Action:

• Use of face masks in the community to be on the agenda for the meeting on 22nd April

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9 Date of Next Meeting Wednesday 22nd April at 2pm

Abbreviations: COVID 19 2019 novel Coronavirus AMR Anti-Microbial Resistance AMRIC Antimicrobial Resistance and Infection Control CDC Centers for Disease Control and Prevention CMO Chief Medical Officer COVID-19 Coronavirus Disease 2019 DOH Department of Health EAG Expert Advisory Group ECDC European Centre for Disease Prevention and Control ED Emergency Department FAQ Frequently Asked Questions HCAI Healthcare-Associated Infection HCW Health Care Worker HPSC Health Protection Surveillance Centre HSE Health Service Executive ICU Intensive Care Unit ID Infectious Disease ILI Influenza-Like Illness IPC Infection Prevention and Control MOU Memorandum Of Understanding NAS National Ambulance Service NI Northern Ireland NPHET National Public Health Emergency Team NVRL National Virus Reference Laboratory PH Public Health PHE Public Health England PPE Personal Protective Equipment RCPI Royal College of Physicians of Ireland WHO World Health Organisation

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Location of Meeting: Department of Health, Dublin

TOR of group



Dr Cillian de Gascun (CdG) Director NVRL, Consultant Virologist (Chair) Dr Ronan Glynn (RG) Deputy CMO, DOH Dr Vida Hamilton (VH) National Clinical Advisor and Group Lead, Acute Hospitals Dr Joanne O’Gorman (JOG) Consultant Microbiologist, HPSC and Rotunda Hospital Dr Gerard O’Connor (GOC) Consultant Emergency Medicine, Mater Hospital Dr Derval Igoe (DI) Consultant Public Health Medicine, NVRL/HPSC Dr John Cuddihy (JCy) Director, Health Protection Surveillance Centre Dr Aoife Cotter (AC) Consultant Infectious Diseases, National Isolation Unit Prof Martin Cormican (MC) Consultant Microbiologist, National Clinical Lead HCAI/AMR Dr David Hanlon (DH) HSE National Clinical Advisor and Group Lead for Primary Care Prof Karina Butler (KB) Chair, National Immunisation Advisory Committee, Consultant Paediatric ID Mr Robert Glennon Immunisation Policy Unit Department of Health (Admin Secretary) Dr Sean Gaine (SG) Consultant in Respiratory Medicine Dr Ciara Martin (CM) Consultant Paediatric Emergency Physician Dr Lynda Sisson (LS) Consultant in Occupational Medicine, Dean of Faculty of Occupational Medicine, RCPI Professor Aurelie Fabre (AF) Consultant Histopathologist Prof Colm Bergin (CB) Consultant Infectious Diseases, St James’s Hospital Dr Jeanette McCallion (JM) Health Products Regulatory Authority Ms Helen Murphy (HM) Infection Prevention and Control Nurse Manager, HPSC

Teleconference: Dr Margaret O’ Sullivan (MOS) Chair, National Zoonoses Committee, Consultant Public Health Medicine

Apologies:

Dr Jeff Connell (JCo) Head of Testing, UCD NVRL Dr Laura Heavey SpR Public Health Medicine, HPSC (Medical Secretary) Dr Colman O’Loughlin (COL) Consultant Intensive Care Medicine, Mater Hospital Ms Josephine Galway (JG) Director of Nursing for HCAI/AMR, AMRIC Team, HPSC



Time: 2pm to 5pm

Prepared by:

Dr Aoife Colgan, Surveillance Scientist, HPSC


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Wed 11/3/2020; 2pm to 4pm

Item No.

Welcome new members/guests

CdG welcomed

• Helen Murphy (HM), Infection Prevention and Control Nurse Manager from AMRIC team,

HPSC) to the group

• Siobhan O’Sullivan (SoS) , Chief Bioethics Officer in the Department of Health to the group to

present on Ethics during a Pandemic

RG proposed extending invitation to a pharmacist representative to the group

1.


Minutes of last meeting (26/02/2020) accepted as accurate by those present.

Amendment by email that Colman O’Loughlin had been in attendance at meeting and should be

added to In Attendance list.

GOC highlighted point from page 3 of minutes that “phone the ED” should be removed from

guidance on HPSC website but that some documents remaining on HPSC website link to a gov.ie

page that still provides this advice. GOC to forward relevant gov.ie page links to RG for amendment.

a. RG awaiting feedback on alternative isolation facilities-due today. DI highlighted importance

of considering size if alternative facility identified as it should be large enough to

accommodate large numbers for isolation of passengers from cruise ship, if necessary.

2.


International: JCy provided an update based on the WHO SIT REPORT from 03/03/30. WHO risk

assessment for all areas (China, regional and global) now categorised as Very High. Of concern is

large number of cases outside of china, the largest increases seen in the Republic of Korea, Italy, Iran

and the UK. The ECDC case definition has changed to include expanded list of countries, and they

now link to the WHO daily sit rep. Feedback from Ireland and other countries about operational

difficulties in implementing new ECDC case definition; ECDC and WHO in consultation about revising

case definition. CDG provided update from NPHET that decision has been made not to align with

new ECDC case definition; to use our own list of affected areas but with expansion from 11

quarantined towns to the 4 affected regions (Lombardy, Veneto, Emilia-Romagna and Piedmont) in

Italy. The new criteria will not to be applied retrospectively and will be reviewed on a weekly basis.

National: 2 confirmed cases in Ireland since last meeting. Both cases had recent travel to northern

Italy. We are now midway between scenario 0 and 1 as detailed in ECDC document on spread of

COVID-19 – this is a slight ramp up since last week. Most up to date figure for number of tests done

nationally is 470. It is being agreed through NPHET that testing will soon be rolled out to other

laboratories nationally.

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3.


(a) Who-china joint mission: CDG pointed to some key aspects of report namely:

• The secondary attack rate in households was 3-10%

• Contact tracing and testing of close contacts identified relatively small percentages

of close contacts affected – this varied by region

• Virus detected in Upper Respiratory Tract samples up to 2 days before persist for 11

days after symptom onset. Also provided figures for viral RNA detection from other

specimen types. The question of whether persistent viral RNA detected is due to

virus shedding or just detectable RNA is to be kept under advisement and with aim

to avoid undue pressure on hospitals in otherwise well patients if still RNA positive.

• DI raised observations on less severe cases among children and KB noted that this

highlighted differing needs for management of paediatric and adult cases.

(b) Ethical issues during pandemic. Siobhan O’Sullivan Chief Bioethics Officer in DoH presented on Ethical framework for pandemics which was first developed in 2009 and who is now requesting guidance from EAG on developing the framework for the current situation. Developments since 2009 to be taken into account – new WHO guidelines developed, SARS-CoV2 is a novel virus, increased focus on solidarity as a community, and the addition of social media. Research being conducted during a pandemic needs to be addressed. Request for comments from EAG and plan is to bring COVID-19 specific ethics paper to the group for review. RG stated that if further legislative changes or implementation of successful international models were required for dealing with COVID-19, DOH would explore the options as now a here is now a Cabinet committee led by the Taoiseach who will meet weekly regarding situation. Further NPHET subgroups are being established: vulnerable people, medical devices, acutes capacity, work force. MC highlighted the importance of providing reassurances to HCW if they become sick due to risks at work. JCy consideration to detainment of patients if positive. Slides to be circulated after meeting. Action:

• EAG to provide input to updated COVID-19 specific ethical framework when prepared

(c) Review of current measures as part of current intense containment phase. CdG raised

point about testing for COVID-19 as part of surveillance activities, such as integration into IlI sentinel surveillance (although numbers are likely to be small as now at the end of flu season) or ICU surveillance. There was broad support for expansion of COVID-19 testing and integration into current surveillance activities. The current flu surveillance activities are due to continue past the end of flu season and into the summer. Note: there is flexibility regarding testing outside the algorithm according to clinical judgement. Action:

• CdG and DI to prepare paper on what surveillance piece would look like.

• DI and Joan O’Donnell to link in with AC on surveillance system that might work in ICU.

(d) Forward look to next phases – deferred until next meeting due to time constraints.

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4.

New Irish guidance/queries (a) Algorithms:

Testing algorithms were approved with key amendments and decisions as follows:

• If tested positive for SARS-CoV-2 patients should not self-drive to hospital but don’t necessarily need to be blue-lighted in – some alternative transport option should be found.

• If patients turn up to GP surgery they should travel home to await NAS home assessment but should not travel by taxi, public transport or walking.

• Attended healthcare facility abroad.

• Increased emphasis on consideration to test for COVID-19 in cases of severe acute respiratory infection without epi criteria.

Queries about whether there was any IT support available for communication of negative results. These may be put in place when new process is bedded down. Recommendation that samples for testing taken by NAS and delivered to receiving hospitals for dispatch to NVRL should link in with the courier systems already in place in hospitals. NAS will keep records on samples taken which will need to be signed off by the receiving hospital laboratory when accepting the samples from NAS. JOG and MC reiterated appreciation of NAS for implementing new testing model at short notice and acknowledge there will be teething period as with all new processes.

(b) Testing and management of asymptomatic close contacts: DI presented a paper prepared by LH summarising scientific evidence of virus detection in different specimen types and viral load throughout natural course of infection. A lot of evidence of asymptomatic infection has been shown but the evidence of asymptomatic transmission has been limited. Paper also looked at advice from key organisations (ECDC/WHO) on asymptomatic spread and Ireland put request into EWRS to ask other countries what they were doing in terms of testing and management of asymptomatic close contacts (summarised in paper). Italy had reported last week that majority of identified cases were asymptomatic but this morning reported via EWRS that over 95% of asymptomatic tests were negative so stopping asymptomatic testing due to difficulties in timing and requirement to follow up for 14 days post exposure anyway. Agreed that EAG does not support for testing of asymptomatic close contacts. Action: CdG to reply to NPHET that EAG recommending against testing of asymptomatic close contacts at present.

(c) Review of management of returned travellers incl. HCWs from affected areas: Agreement to prospectively exclude HCWs returned from expanded list of affected areas from work for 14 days (list expanded to now include the 4 regions of Italy: Lombardy, Piedmont, Emilia-Romagna and Veneto. Reiteration that this message will require a clear communication about the reasoning for expansion and the decision not to apply exclusions retrospectively. Draft paper on pregnant and vulnerable HCWs presented to group. Decision to use NIAC definitions of vulnerable and immunosuppressed persons and to use the NIAC guidelines as framework for the paper. These amendments are to be added to the draft document for further review next week. Action:

• MC, JOG and HM to revise paper on pregnant and vulnerable HCWs for sign-off next week.

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• All to send any additional comments on pregnant and vulnerable HCW paper before meeting next week.

(d) Irish involvement in clinical trial of therapy with remdesivir:

JM presented a paper on potential therapeutics for COVID-19 and a summary of the current landscape of investigational therapies and vaccines that are being fast-tracked by the WHO R&D blueprint group – some are re-purposed and some novel. Two promising candidates to date are Remdesivir (new nucleoside inhibitor by Gilead) and Kaletra (approved medicine for HIV treatment). If desire to access Remdesivir for patients in Ireland there are 2 available routes – cinical trials or as exempt medicinal product (EMP). Re. Kaletra there may be issues with supply and procurement. Questions for EAG consideration: 1) Could someone lead on a clinical trial? 2) What will be the criteria for inclusion in the trial? Action:

• ID physicians to set up an EAG subgroup and discuss options for clinical trial or COVID-19 treatment if not pursuing clinical trial route.

• DH to request procurement to purchase additional Kaletra.

(e) Autopsy guidance: Action: Interim Irish guideline to be developed based on RCPath one but accounting for differences in IPC.

(f) IPC guidance for non-acute community healthcare setting: Signed off by EAG.

(g) Hotels guidance: Action: Any comments to be sent by Friday 6th and document would then be signed off.

5


As above

6


None

7

AOB

• GOC queried if members of group are invited to give interviews or statements etc. in role as member of EAG, whether this should be flagged with group – agreed this should be flagged through department.

• Remote solutions for management of patients will need to be addressed in future meeting.

8 Date of Next Meeting March 11th 2020; 2pm to 4pm

Abbreviations: AGPs Aerosol Generating Procedures AMR Anti-Microbial Resistance AMRIC Antimicrobial Resistance and Infection Control CDC Centers for Disease Control and Prevention CMO Chief Medical Officer COVID-19 Coronavirus Disease 2019 DOH Department of Health

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EAG Expert Advisory Group ECDC European Centre for Disease Prevention and Control ED Emergency Department FAQ Frequently Asked Questions HCAI Healthcare-Associated Infection HCW Health Care Worker HPSC Health Protection Surveillance Centre HSE Health Service Executive HCID High Consequence Infectious Disease ICU Intensive Care Unit ID Infectious Disease ILI Influenza-Like Illness IPC Infection Prevention and Control MOU Memorandum Of Understanding NAS National Ambulance Service NI Northern Ireland NPHET National Public Health Emergency Team NVRL National Virus Reference Laboratory PH Public Health PHE Public Health England PPE Personal Protective Equipment RCPI Royal College of Physicians of Ireland WHO World Health Organisation

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Title of Meeting: COVID-19 Expert Advisory Group Meeting (Special Meeting 2)

Location of Meeting: Department of Health, Dublin

TOR of group



Dr Cillian de Gascun (CdG) Director NVRL, Consultant Virologist (Chair) Dr Vida Hamilton (VH) National Clinical Advisor and Group Lead, Acute Hospitals Dr Derval Igoe (DI) Consultant Public Health Medicine, NVRL/HPSC Prof Martin Cormican (MC) Consultant Microbiologist, National Clinical Lead HCAI/AMR Prof Karina Butler (KB) Chair, National Immunisation Advisory Committee, Consultant Paediatric ID Mr Robert Glennon Immunisation Policy Unit Department of Health (Admin Secretary) Dr Ciara Martin (CM) Consultant Paediatric Emergency Physician Dr Lynda Sisson (LS) Consultant in Occupational Medicine, Dean of Faculty of Occupational Medicine, RCPI Professor Aurelie Fabre (AF) Consultant Histopathologist Dr Elaine Breslin (EB) Health Products Regulatory Authroity (Alternate for JM) Dr Heather Burns SpR, Public Health Medicine, HPSC

Teleconference:

Dr Gerard O’Connor (GOC) Consultant Emergency Medicine, Mater Hospital Dr Aoife Cotter (AC) Consultant Infectious Diseases, National Isolation Unit Dr Sean Gaine (SG) Consultant in Respiratory Medicine Dr Colman O’Loughlin Consultant in Intensive Care Medicine, Mater Hospital Dr Margaret O’ Sullivan (MOS) Chair, National Zoonoses Committee, Consultant Public Health Medicine Dr John Cuddihy (JCy) Director, Health Protection Surveillance Centre Helen Murphy (HM) Infection Prevention and Control Nurse Manager, HPSC Prof Colm Bergin (CB) Consultant Infectious Diseases, St James’s Hospital Dr Regina Kiernan (RK) Consultant in Public Health Medicine, HSE West

Apologies:

Dr Jeanette McCallion (JM) Health Products Regulatory Authority Dr Jeff Connell (JCo) Head of Testing, UCD NVRL Ms Josephine Galway (JG) Director of Nursing for HCAI/AMR, AMRIC Team, HPSC Dr David Hanlon (DH) HSE National Clinical Advisor and Group Lead for Primary Care Dr Joanne O’Gorman (JOG) Consultant Microbiologist, HPSC and Rotunda Hospital Dr Ronan Glynn (RG) Deputy CMO, DOH Dr Laura Heavey (LH) SpR Public Health Medicine, HPSC (Medical Secretary)

Observer:


Time: 3pm to 5pm

Prepared by: Dr Aoife Colgan, Surveillance Scientist, HPSC Date Circulated:

10/03/2020

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Wed 11/03/2020; 2pm to 4pm

Item No.

1.


Minutes accepted

2.

NPHET letter (07/03/2020) and new requests:

a) Question 1. HCW guidance:

DI presented on Interim Irish Occupational Health guidelines and options for stratification by risk as

per CDC and UK guidance.

LS provided an update of recent situations in Irish hospitals that resulted in follow up of a lot of

HCWs that were considered close contacts of a confirmed case. The burden of the work to interview

and establish if contact/risks was very intensive and undertaken by Occupational Health and Public

Health, highlighted that one index case results in a lot of additional work for those involved in

contact tracing and monitoring of contacts so anything more complicated will be difficult to

implement. Additionally, feedback from Unions is that there is no appetite to have asymptomatic

close contact HCWs return to work due to unacceptable risk to colleagues and patients. To date

none have been asked to return to work due to possibility of re-deployment of staff from other

areas.

CdG and MC reiterated role of EAG to give best and reasonable advice but operational side re.

dealing with unions is not within EAG remit.

VH reiterated the need clear communication about what constitutes AGP and that the absolute

minimum of staff should be present when AGP is ongoing as well as the PPE necessary while

performing AGP. MC indicated that much of this detail is available from the draft AGP document –

on agenda. Reiteration that risk is doing AGP and having a PPE breach but HCW wearing appropriate

PPE are not deemed close contacts.

Discussion on the literature about HCWs infected in other countries highlighted that highest risk

among HCWs was in those that used FFP3 and non-ID specialists that were not used to using PPE.

The WHO joint report on mission to China traced back that majority of HCWs infected were infected

at home rather than nosocomial acquisition and in Singapore reports that no HCW were infected in

first 6 weeks of outbreak attributed to PPE.

MC highlighted importance of good IPC practice so risk of transmitting should be mitigated even if

these people are shedding while asymptomatic. The PPE being recommended now is the same as is

recommended for management of patients with flu and for AGP of patients with any viral respiratory

tract infection but the IPC precautions are not always practiced under these circumstances. So the

message re IPC precautions needs to be communicated in a single succinct message as a refresher.

MC indicated that Chief clinical officer is due to send letter out about importance of PPE and IPC

precautions.

To summarise, guidance around PPE for HCW in this setting already exists and doesn’t need to be

changed. Symptomatic HCWs should stay off work in line with current guidance. Asymptomatic

HCWs with no exposure may return to work if deemed essential. Suggestion to categorise a new

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group of HCWs currently asymptomatic but had performed AGP without correct PPE or with a PPE

breach. EAG recommendation for this group would be that they stay out of work for 14 days after

exposure but these would be second line group to be asked to return to work if demand on the

services increases. If asked to return to work, this group should have twice daily monitoring for

symptoms, the importance of hand hygiene and a high level of awareness of symptoms should be

promoted among this group and the symptom monitoring should be supported by line managers

and Occupational Health. To respond to letter from NPHET, EAG do not recommend risk based

categorisation of HCWs as this process may get too complicated. This group can be kept off work if

possible but may be asked to return if service demand becomes too high.

In situation over weekend no HCWs were asked to return due to local mitigation measures that were

put in place but feedback was that they were grateful to have the guidance and option to bring staff

back if necessary, even if not implemented.

b) Question 2. Use of respiratory masks:

This is already provided in the IPC guidance. Guidance that masks should be changed if they become

wet and after 4 hours. Concern that there will be a shortage of masks so in some settings can ask

patients to hold tissue over nose and mouth e.g. in GP settings or if masks not available. Importance

of focussing on IPC practice was again reiterated and highlighted that wearing PPE is only a small

part of this. COG highlighted that the more sick patients in ICU will be less able to tolerate masks,

particularly if supplemental oxygen is required – therefore important to point out that masks should

only be used if clinically tolerated. VH suggestion that these patients be asked to wear oxygen masks

to minimise droplet spread.

EAG advise that in cases where supplemental oxygen is required that it should be supplied by oxygen

mask rather than nasal cannula.

Action: Response on these topics to prepared ahead of meeting of NPHET tomorrow.

3.

Draft aerosol generating procedure

Draft paper on AGPs has been prepared and it provides the list of relevant procedures. MC suggested amendments to the paragraph on nebulisation to be phrased more positively and highlight the evidence that nebulisation is not associated with risk rather than lack of evidence that it is associated with risk. VH highlighted that this information not widely known and needs to be communicated more widely. Action: MC to make minor amendment to draft paper and finalised paper to be brought back for sign off.

4.

ICU Surveillance options:

There is already a plan in place to build on influenza surveillance and include surveillance of COVID-

19.

CdG posed two questions for consideration by EAG: 1) whether a once off screen for SARS-CoV-2 of

patients currently in ICU that may not have been captured if admitted earlier than change in testing

pathway. Any new admissions should be captured due to change in testing pathway. This may

already be happening informally and broad agreement that would be a good idea to implement

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immediately as will give a baseline about current situation in Ireland. AC suggestion that screen

should be of all ICU admissions and not just those with infectious pathology as pathology may

evolve.

Action: Individual centres do not need to await EAG approval to commence ICU screening. COG will

communicate message to broader ICU community but screen should be discussed with patient

family in advance. Mater planning to do screen tomorrow and will have preliminary details available

for next EAG meeting on Wednesday.

NVRL are now prioritising SARS-CoV-2 testing and other centres will be coming online in the coming

days/weeks. The request to inform PH in advance has been removed but good idea to flag cases if

there are cases with a high index of suspicion. Also good idea to flag with Cillian or lab if all ICU

screening samples are being batched and sent together.

2) Whether there is a need for community surveillance now as the situation evolves? CM suggestions

that this would have to go hand in hand with a change to model of care allowing relatively well SARS-

CoV-2 patients to remain at home to avoid pressure on receiving hospitals. MC agreed that

development of Flu influenza surveillance would be a good option but not currently feasible to

implement screening of all respiratory infections in the community. MC also suggested provision of

pathway for GPs to communicate with ID or micro physician if necessary if moving to a community

screening model.

Feedback on algorithms:

• KB and MC provided feedback on new algorithms that the new testing pathway is very

difficult to implement in both paediatric and adult settings.

• “HOSPITALISED PATIENTS” should be added to clinical criteria in receiving hospital algorithm.

• Highlight that if testing for surveillance purposes, PPE is only necessary from time of positive

test unless there is a high index of suspicion.

• Should provide numbers for lung function

• Important not to focus just on receiving hospitals now that case definition has broadened,

patient could arrive at any hospital.

Decision to wait until Wednesday to make further changes to algorithms when everyone’s

opinions can be provided.

5

Remaining agenda items

Other agenda items were deferred until next meeting on Wednesday March 11th as shouldn’t make

any further changes/decisions without more people present and due to teleconferencing difficulties.

6

AOB

• Question on when can COVID-19 positive HCWs return to work. The same approach for HCWs as members of the public because at present all positive cases are admitted to hospital.

• The Occupational Health guidance currently on HPSC website will need to be amended – Deborah and Regina to link in with HPSC on this. Guidance is to be flagged as “under review” for the moment.

• Pregnant HCWs document is coming back to EAG for agreement on Wednesday.

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• Document on Immunosuppressed patients and contacts management from Cancer Control Programme to be circulated and signed off at Wednesday meeting.

7 Date of Next Meeting 11th March 2020; 2pm to 4pm

Abbreviations: AGPs Aerosol Generating Procedures AMR Anti-Microbial Resistance AMRIC Antimicrobial Resistance and Infection Control CDC Centers for Disease Control and Prevention CMO Chief Medical Officer COVID-19 Coronavirus Disease 2019 DOH Department of Health EAG Expert Advisory Group ECDC European Centre for Disease Prevention and Control ED Emergency Department FAQ Frequently Asked Questions HCAI Healthcare-Associated Infection HCW Health Care Worker HPSC Health Protection Surveillance Centre HSE Health Service Executive HCID High Consequence Infectious Disease ICU Intensive Care Unit ID Infectious Disease ILI Influenza-Like Illness IPC Infection Prevention and Control MOU Memorandum Of Understanding NAS National Ambulance Service NI Northern Ireland NPHET National Public Health Emergency Team NVRL National Virus Reference Laboratory PH Public Health PHE Public Health England PPE Personal Protective Equipment RCPI Royal College of Physicians of Ireland WHO World Health Organisation

of 5



Location of Meeting: Department of Health


Dr Cillian de Gascun (CdG) Director NVRL, Consultant Virologist (Chair) Dr Derval Igoe (DI) Consultant Public Health Medicine, NVRL/HPSC Dr Jeanette McCallion (JM) Health Products Regulatory Authority Prof Karina Butler (KB) Chair, National Immunisation Advisory Committee, Consultant Paediatric ID Dr Colman O’Loughlin (COL) Consultant in Intensive Care Medicine Dr Gerard O’Connor (GOC) Consultant Emergency Medicine, Mater Hospital Dr Vida Hamilton (VH) National Clinical Advisor and Group Lead, Acute Hospitals Prof Martin Cormican (MC) Consultant Microbiologist, National Clinical Lead HCAI/AMR Damien Nee (DN) Patients for Patient Safety Ireland Dr Ciara Martin (CM) Consultant in Paediatric Emergency Medicine Dr Joanne O’Gorman (JOG) Consultant Microbiologist, HPSC and Rotunda Hospital Dr Aoife Cotter (AC) Consultant Infectious Diseases, National Isolation Unit Ms Josephine Galway (JG) Director of Nursing for HCAI/AMR, AMRIC Team, HPSC Dr Lynda Sisson (LS) Consultant in Occupational Medicine, Dean of Faculty of Occupational Medicine, RCPI Helen Murphy (HM) IPC Team, HPSC Mr Robert Glennon Immunisation Policy Unit Department of Health (Admin Secretary)

Teleconference:

Dr David Hanlon (DH) HSE National Clinical Advisor and Group Lead for Primary Care Dr John Cuddihy (JCy) Director, Health Protection Surveillance Centre Dr Margaret O’ Sullivan (MOS) Chair, National Zoonoses Committee, Consultant Public Health Medicine Prof Aurelie Fabre (AF) Consultant Pathologist, St. Vincent’s Hopsital

Apologies:

Observer:

Date/Time of Meeting: Monday 16/03/2020

Time: 8.30am to 10.30am

Prepared by: Dr Aoife Colgan, Surveillance Scientist, HPSC Date Circulated:

18/3/2020


Wed 18/03/2020; 2pm to 4pm

Item No.

1


Minutes of meeting on 11/03/2020 and 12/03/2020 were agreed and no matters arising.

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2

Urgent questions from NPHET: Due to the time sensitive nature of the questions from NPHET, these

were addressed as soon as the meeting was convened

Q1. A general recommendation has been made that members of the public who have “flu-like”

symptoms should self-isolate for 14 days. Is there a case to be made for a different requirement to

be applied to HCWs and, if so, what criteria should dictate their return to work?

Q2. Clarification also needed about whether statement applies to persons who have COVID-19 or

to all with respiratory symptoms

• Individuals who have symptoms and are confirmed positive for COVID-19 should self-

isolate for a period of 14 days

• For people who have tested and were COVID-19 not detected – stay off work for 2 days

after full recovery from respiratory symptoms

Answers to questions 1 and 2: HCWs who are symptomatic should be treated the same as general

public: if tested when symptomatic and have a COVID-19 not detected test result they may return to

work when they have been asymptomatic for 48 hours. If HCWs were close contacts, they revert to

relevant close contact protocol 48 hours after symptoms resolve within the 14 day period.

Table on EAG report to NPHET on 10th March 2020 will need to be expanded to include new criteria.

AC suggested 2 frameworks: One for ideal situation if no pressures on workforce, which must remain

unchanged. The second is the derogation framework for when there are gaps and pressures on

system.

Q3. Can the advice that recommends HCWs returning from Italy and Spain are excluded from work

be reviewed in terms of impact to the service versus risk of infection? If exclusion remains hospital

management will need system to monitor who cannot attend and for how long. And Occupational

Health capacity to be assessed if can return with active monitoring.

Due to difficulties in ascertainment of cases in some countries, defining areas affected and

maintaining an up to date list of countries, EAG recommend that anyone returning to the island of

Ireland from international travel (including UK but not NI) should self-isolate and not return to work.

Previously discussed derogations apply as necessary for HCWs. NPHET would need to agree same

with NI counterparts for NI borders.

Occupational Health will actively monitor in HCWs returned from higher risk areas but those

returned from low risk areas will need to monitor themselves.

Additional question about whether asymptomatic close contact HCWs should wear masks when they

return to work. There were discussions around the difficulties in procuring masks, even for those

self-isolating at home, so beginning to move away from guidance recommending masks at home and

looking at other options for IPC in the home. Everyone in broad agreement that masks should be

procured for HCWs but agreement that masks are not required for derogated HCWs returning to

work.

Q4. For preventing the spread of infection from someone with symptoms, should a distance of 1m

or 2m be used? This varies in different guidance from DOH and HSE.

MC highlighted that there is a continuum in size of droplets and distance travelled by droplets of

differing sizes and also highlighted that he has not found conclusive evidence that there is increased

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safety at a distance of 2 metres compared to 1 metre. 2 metres may be difficult to implement,

particularly in hospital settings and most protocols are currently built around guidance stating that 1

metre distance is sufficient. For Public Health purposes, contact tracing for those within 2 metres has

been clearly set out as a precautionary approach. Agreement that language used in previous versions

of algorithms re. close contact definitions was most suitable and should be added back in to

algorithms.

Answer: Advice from EAG is to remain at least 1 metre and 2 metres if possible for someone who is

symptomatic, especially in community settings. In healthcare settings, apply standard precautions. It

is important to give reassurance to people where 1 metre is only option either in healthcare or

community settings.

3

Draft revised acute hospital algorithm for review

The case definition for testing was revised based on decision at NPHET meeting on Thursday 12th but

decision not to make this change in hospital algorithm ahead of the weekend. This now needs to be

looked at to come in line with national policy.

Agreed also to remove policy of phoning NVRL in advance of sending samples from algorithm but

may be local policy if advice needed re sending samples.

The low and high risk streaming strategy was found to be unworkable in many centres and there are

difficulties in now asking people to reduce necessary PPE while caring for suspect patients. KB

suggestion that IPC precautions could vary based on procedures carried out rather than index of

suspicion of patient. IPC team are currently working on a paper and will bring to group when ready

before next meeting which will base PPE on activities/procedures done and will incorporate a matrix

for all points of contact throughout hospital pathway.

COL and MC to link in re interim guidance for critical care patients for today.

It was also agreed that case definition needs to be agreed and changed immediately to come in line

with national policy and can’t wait for next meeting on Wednesday.

Broad agreement that algorithms should contain decision point for whether patient is suitable for

hospital admission or community testing/home isolation. VH highlighted importance of re-iterating

not to call 999 or 112, which need to be kept for emergencies and people should be referred back to

the community through their GP or COVID care line to refer people for appointments at testing hubs.

KB highlighted the difficulties in paediatric settings if patients have already been waiting a long time

and concern they may not want to link in to another healthcare setting. VH highlight requirement for

clear messaging around phoning into system to avoid overcrowding and to support social distancing.

Need for testing algorithm not as necessary anymore but clear pathways of referral are more

important now. Small group to meet on algorithm now after meeting.

Decision that small group should meet after main meeting to discuss pathways for preliminary

algorithm incorporating new case definition, decision point for hospital admission/community

testing and pending changes to IPC guidance. This will be circulated to group today with tight

turnaround for review and will be uploaded to HPSC website tonight.

Actions:

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1. COL and MC to link in re interim guidance for critical care patients for today.

2. Small group to meet about hospital algorithm and new version to be uploaded to HPSC

website today.

4

Additional NPHORT question

Is there any basis for extending contact tracing back e.g. to day -1 or day -2 (currently tracing from

onset of symptoms)?

CDG has received an offer from HIQA to synthesise evidence on topic of asymptomatic transmission.

This will be reviewed again on Wednesday

5

AOB

1. VH would like EAG to look at distribution of COVID-19 patients in acute hospitals and

whether hospitals that aren’t suitable for COVID-19 work could continue with other non-

COVID work and if staff could be re-deployed between hospitals. Broad agreement for this

suggestion. VH has prepared a paper on the topic and will send to CDG to bring to NPHET.

2. Funeral directors requesting more clear guidance. MC asked for them to send specific

questions/problems to be worked on. Will be discussed in more detail at next meeting on

Wednesday.

3. VH requested group to consider HCWs upskilling to perform intubations which is putting

them at higher risk so suggestion of dedicated team to perform these procedures – for

discussion at next meeting on Wednesday.

6 Date of Next Meeting 18th March; 2pm

Abbreviations: 2019-nCoV 2019 novel Coronavirus AMR Anti-Microbial Resistance AMRIC Antimicrobial Resistance and Infection Control CDC Centers for Disease Control and Prevention CMO Chief Medical Officer COVID-19 Coronavirus Disease 2019 DOH Department of Health EAG Expert Advisory Group ECDC European Centre for Disease Prevention and Control ED Emergency Department FAQ Frequently Asked Questions HCAI Healthcare-Associated Infection HCW Health Care Worker HPSC Health Protection Surveillance Centre HSE Health Service Executive ICU Intensive Care Unit ID Infectious Disease ILI Influenza-Like Illness IPC Infection Prevention and Control MOU Memorandum Of Understanding NAS National Ambulance Service NI Northern Ireland NPHET National Public Health Emergency Team

of 5

NVRL National Virus Reference Laboratory PH Public Health PHE Public Health England PPE Personal Protective Equipment RCPI Royal College of Physicians of Ireland WHO World Health Organisation

of 6




Members/In

attendance:


Dr Alan Smith (AS) Deputy CMO, DOH

Helen Murphy (HM) Infection Prevention and Control Nurse Manager, Lead

Nurse AMR HCAI Response Team

Damien Nee (DN) Patients for Patient Safety, Ireland

Dr Joanne O’Gorman (JOG) Consultant Microbiologist, HPSC and Rotunda Hospital

Dr Gerard O’Connor (GOC) Consultant Emergency Medicine, Mater Hospital

Dr Derval Igoe (DI) Consultant Public Health Medicine, NVRL/HPSC

Prof Martin Cormican (MC) Consultant Microbiologist, National Clinical Lead HCAI/AMR

Prof Karina Butler (KB) Chair, National Immunisation Advisory Committee,

Consultant Paediatric ID

Mr Robert Glennon Immunisation Policy Unit Department of Health

(Admin Secretary)

Prof Colm Bergin (CB) Consultant Infectious Diseases, St James’s Hospital

Dr Colman O’Loughlin (COL) Consultant in Intensive Care Medicine

Prof Sean Gaines (SG) Consultant in Respiratory Medicine

Dr Ciara Martin (CM) Consultant in Paediatric Emergency Medicine

Teleconference:

Dr Margaret O’ Sullivan (MOS) Chair, National Zoonoses Committee, Consultant Public

Health Medicine

Dr Lynda Sisson (LS) Consultant in Occupational Medicine, Dean of Faculty of

Occupational Medicine, RCPI

Dr Jeanette McCallion (JM) Health Products Regulatory Authority

Dr David Hanlon (DH) HSE National Clinical Advisor and Group Lead for Primary

Care

Ms Josephine Galway (JG) Director of Nursing for HCAI/AMR, AMRIC Team, HPSC

Dr Mairin Ryan (MR) HIQA

Prof Aurelie Fabre (AF) Consultant Pathologist

Dr John Cuddihy (JCy) Director, Health Protection Surveillance Centre

Apologies: Dr Aoife Cotter (AC) Consultant Infectious Diseases, National Isolation Unit

Dr Vida Hamilton (VH) National Clinical Advisor and Group Lead, Acute Hospitals

Observer: Aoife Colgan Surveillance Scientist, HPSC

Date/Time of Meeting:

Wed 18/03/2020

Time: 2pm to 4pm

Prepared by:

Dr Laura Heavey, SpR Public Health

Medicine, HPSC

Date Circulated:

20/3/20

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Date/Time of Next

Meeting:

Wed 25/03/2020; 2pm to 4pm

Item

No.

1


SG wanted to add his apologies to the minutes for the last meeting. Due to the late distribution of

the minutes from the last meeting, members will be allowed to send their amendments via email.

GOC made a request that the modelling group’s projections be shared with the EAG.

GOC also requested that guidance on the clinical management of patients with COVID 19 be signed

off by the EAG.

COL updated the group on the development of national guidance on pre-op assessment.

Action:

• CDG to ask NPHET to share reports from modelling group with EAG

2


International: The latest Eurosurveillance article was discussed in detail. All countries are following

the same trajectory as Hubei in terms of the increase in cases of COVID 19.

National: LH provided an update on the latest epidemiological date on Irish cases. MC, GOC and COL

all requested that this data be shared more widely across the health care system. COL also requested

more data on the underlying conditions of cases, especially those in ICU. GOC requested more

information on the extent of community transmission. MC suggested a separate epicurve for those

cases due to community transmission. GOC also asked about the location where the HCW cases

were infected. JCy will share this request with NPHET. The EAG were in agreement on the need for

all HCWs to be kept informed of the Irish epidemiology.

Action:

• JCy to ask NPHET re possibility of sharing more detailed epidemiological information with

the wider health care system and the public

3

Governance

The latest governance structures for the COVID 19 response in the Department of Health’s action

plan were discussed. GOC wondered if we are under NPHET or working alongside them. CB

requested that we see the TOR of all the other new groups that are part of the response. DI asked

for more clarity on the governance and how these groups can complement each other and avoid

duplication of work. The TOR of the EAG were clarified. It is clear that the EAG can make

recommendations to NPHET, even if they have not been asked a specific question on that issue.

There was then a general discussion about whether the current measures in place to reduce the

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spread of COVID 19 are adequate. DN was concerned that the public are not following the

recommendations re social distancing. GOC asked what more could we do, especially taking into

consideration has been modelled in the paper from Imperial College. LH added that restaurants and

cafes could be closed except for take away, all public gatherings could be banned or we could ask

NPHET to urgently consider cocooning measures for those in high risk groups e.g. over 65,

immunocompromised, etc. DH asked for more information on what cocooning would involve. MC

and COL expressed concern re ‘compliance fatigue’, especially if these measures are in place for

months. MC also mentioned the civil unrest in France after the lockdown there, which included the

looting of shops. MC also advised re the danger of fear. Social cohesion is vital for this response to be

successful. MC cautioned re the risk of collateral damage i.e. people dying from strokes or MIs

because they are too afraid to attend the hospital or because staff are too afraid to treat them until

they have a negative COVID 19 test. SG and MC agreed that all EAG members need to work on this

issue in their own hospitals. DI added that, based on the Ferguson paper, these more extreme

measures may need to be implemented intermittently when ICUs are at capacity and need a

reduction in cases urgently.

DN also mentioned Perspex slots in pharmacies for delivery of medicines and reduction of customer

contact. MC and HM said these are not recommended and there is IPC guidance on the HPSC

website for pharmacists.

KB expressed concern that outside of the major hospitals, there is not the same level of

preparedness in the smaller hospitals. GOC requested that we design an algorithm outlining a

pathway of care for COVID 19 cases to help the smaller hospitals prepare. MC agreed more

education is required on IPC in all hospital settings.

4

Healthcare worker issues

LS provided an overview of the latest tables on management of HCWs with a history of symptoms or

exposure to COVID 19. Feedback from the EAG was noted but the overall messages in the table were

agreed by the group. LS said there is no occupational health on call service at night so a line manager

will have to be responsible for active monitoring of HCWs allowed to work because they are

essential. They should measure the HCWs temperature and ask for symptoms. The EAG agreed that

HCWs with mild COVID 19 disease did not need repeat testing before they return to work. They

could return to work 14 days after symptom onset and 5 days with no fever.

KB asked if all HCWs should be wearing masks routinely. CB mentioned some centres are already

providing masks for all staff. MC mentioned that in some hospitals where this is ongoing, HCWs are

pulling them up and down and not wearing them appropriately. MC was clear that there is no

evidence for routine mask wearing and it could actually be dangerous if they are not worn properly.

He felt we could not recommend the use of a critical resource without good evidence that it would

reduce the spread of infection. The EAG agreed that the routine use of masks is not recommended at

this point.

DI provided an update on the preliminary summary from HIQA on the evidence for asymptomatic

transmission. 5 studies suggest asymptomatic transmission. The research team felt the quality was

low and therefore the level of evidence was low. It is unclear if it is a significant driver of

transmission. There will be no change to the start of contact tracing of cases i.e. contact tracing will

start from the onset of symptoms in the index case. The EAG will await the full evidence synthesis on

asymptomatic/pre-symptomatic transmission before reviewing this again.

JOG gave an overview of the new IPC guidance. COL said he was getting a lot of queries from ICU

staff. He also mentioned that many staff are not aware of the HPSC site. MC agreed that there is

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more education to be done on IPC.

Actions:

• MC agreed to get out the message out that routine use of masks is not necessary

• LS to make the changes suggested by the group on HCWs guidance before uploading to the

HPSC website

Algorithms

The testing algorithm has now morphed into an assessment pathway. GOC felt this is necessary to

guide smaller hospitals that are not as prepared yet for cases.

SG raised the issue of not using NIV for suspect or confirmed cases. He is working on that issue and

will update at next meeting. COL mentioned that HFNO2 can also be useful for case management.

SG also raised concerns about those waiting for test results not getting their treatment in a timely

manner.

KB asked to clarify the case definition on hospital algorithm. The group agreed there is no specific

combination of symptoms that means COVID 19 is more likely. Not everyone has fever or cough. The

EAG recommended that cough be removed. Then the clinician could decide if there were symptoms

or signs of a respiratory tract infection present using their clinical judgement.

DI wants to remove the GP algorithm as it is now about operational issues. DH concerned there

would be a gap for GPs. MOS advised that the algorithms should clearly state that the clinical

content has been approved by EAG but not the operational set up.

Actions:

• DI and JOG to work on hospital assessment and testing pathway to reflect new IPC guidance

• DI to update algorithm for hospitals and GPs

• CDG to bring recommendation regarding removal of cough to NPHET

5


(a) Duration of self-isolation for cases of COVID 19 – decision on hold until next meeting when

evidence synthesis from HIQA is complete

(b) Duration of self-isolation for close contacts

KB emphasised that household transmission rates are high and we must be clear on isolation

of household contacts. For households with multiple members, the EAG agreed that the

‘clock must be reset’ if a second/third/fourth/etc member gets sick after the index case i.e. it

would be 14 days of self-isolation from the date of symptom onset for the most recent case

in the house for other asymptomatic household contacts.

(c) Handling of remains

HM raised some new questions around mass casualties and palliative care in the home and

residential setting. DH mentioned that emergency planners have given some consideration

to mass casualties.

AF and VH are still engaging with funeral directors. There is now some guidance on the HPSC

website. AF asked if any patient who dies needs to be considered as a possible COVID 19

case. AF asked for direction from NPHET on this. Usually the GP should decide if a death is

due to COVID 19.

Action:

• AF, DH and JOG, HM will liaise re the issues of the handling of remains.

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HPRA update

JMC gave an overview of the concerns re ibuprofen. The fake news on paediatric cases of COVID 19

in ICU in Cork after taking ibuprofen was discussed. The Safety team in HPRA have looked into the

safety of ibuprofen. No adverse outcomes related to ibuprofen have been reported to the EMA. The

French agency cannot verify the possible adverse outcomes reported in the media in 4 French

patients. The HPRA have created a statement for their website. This has been issued to the ICGP and

IMC. The EMA have also released their own communication today. KB noted that the BMJ paper did

not contain any evidence, just quotes from ‘experts’. The HPRA will follow up the issue with the BMJ.

Currently, the EAG will not change their recommendations on the use of ibuprofen and is in

agreement with the HPRA statement.

Research subgroup update

CB discussed the proposal to establish the research sub group. There will be a number of

workstreams. Individuals who have the expertise in an area will lead the relevant stream and provide

feedback to EAG, who will then feedback to NPHET. CB emphasised that RCTs are critical. He

mentioned some new data on drugs targeting IL6. DN mentioned reports from Japan regarding the

use of the antiviral Favipiravir. CB discussed the challenges in identifying drugs with real promise.

There is lots of noise but not much evidence for many drugs, except for case series. He has a list of

drugs and the research group are evaluating which ones have the most evidence for their

effectiveness. COL asked about indemnification for physicians using these medicines in a critical care

setting in an effort to preserve life. COL mentioned the family members of the cases had been

consented for the administration. The State Claims Agency is aware of this scenario.

MC and DI discussed serosurveillance and the importance of a biobank. The legislation group are

looking at what would be required for a biobank. MC emphasised serosurveillance must use residual

samples from a population sample, rather than cases of COVID 19 only.

Action:

• CB to update again at next meeting

6


Nil

7


Nil

8

AOB

KB raised the issue of community testing for children. Testing children of HCWs is particularly urgent.

Current community testers are not comfortable testing children.

DN made a request for more openness and transparency regarding the response to COVID 19,

particularly regards the numbers and details of Irish cases being available to the public. He also

mentioned the option of temporary accommodation for staff adjacent to hospitals, to reduce the

risk that they will spread COVID 19 to their families.

of 6

KB raised a query from the IDSI re transfer of critically ill patients for example those with

neurosurgical needs, where there might not be time to do an adequate risk assessment for COVID

19. She asked how to manage them in terms of IPC precautions. MC was clear that patients must not

be denied care because receiving units are afraid. MC requested that there is a clear message from

the HSE on this.

JOG asked CDG to raise the issue of guidance with NPHET. There are a number of groups now

creating guidance and there is confusion in the healthcare system. CM expressed concern that some

guidance is not following EAG recommendations. JOG requested that DOH would create a central

repository for guidance and that all HCWs are made aware of this.

AS raised a query re dental practices. MC has now discussed the IPC issues with the lead for oral

health.

Actions:

• CM following up with NC re community testing for paediatric patients.

• CDG to raise concerns re guidance with NPHET

9 Date of Next Meeting

18th March 2020; 2pm to 4pm

Abbreviations:

2019-nCoV 2019 novel Coronavirus

AMR Anti-Microbial Resistance

AMRIC Antimicrobial Resistance and Infection Control

CDC Centers for Disease Control and Prevention

CMO Chief Medical Officer

COVID-19 Coronavirus Disease 2019

DOH Department of Health

EAG Expert Advisory Group

ECDC European Centre for Disease Prevention and Control

ED Emergency Department

FAQ Frequently Asked Questions

HCAI Healthcare-Associated Infection

HCW Health Care Worker

HPSC Health Protection Surveillance Centre

HSE Health Service Executive

ICU Intensive Care Unit

ID Infectious Disease

ILI Influenza-Like Illness

IPC Infection Prevention and Control

MOU Memorandum Of Understanding

NAS National Ambulance Service

NI Northern Ireland

NPHET National Public Health Emergency Team

NVRL National Virus Reference Laboratory

PH Public Health

PHE Public Health England

PPE Personal Protective Equipment

RCPI Royal College of Physicians of Ireland

WHO World Health Organisation

1



Location of Meeting: DOH, Teleconference



Teleconference:

Prof Colm Bergin (CB) Consultant Infectious Diseases, St James’s Hospital Prof Karina Butler (KB) Chair, National Immunisation Advisory Committee, Consultant Paediatric ID Prof Martin Cormican (MC) Consultant Microbiologist, National Clinical Lead HCAI/AMR Dr Aoife Cotter (AC) Consultant Infectious Diseases, National Isolation Unit Dr John Cuddihy (JCy) Director, Health Protection Surveillance Centre Dr Lorraine Doherty (LD) National Clinical Lead for Health Protection Prof Aurelie Fabre (AF) Consultant Pathologist Prof Sean Gaine (SG) Consultant in Respiratory Medicine Ms Josephine Galway (JG) Director of Nursing for HCAI/AMR, AMRIC Team, HPSC Dr Vida Hamilton (VH) National Clinical Advisor and Group Lead, Acute Hospitals Dr Derval Igoe (DI) Consultant Public Health Medicine, HPSC Dr Ciara Martin (CM) Consultant in Paediatric Emergency Medicine Ms Helen Murphy (HM) Infection Prevention and Control Nurse Manager, Lead Nurse AMR HCAI Response Team Mr Damien Nee (DN) Patients for Patient Safety, Ireland Prof Michael O’Connell (MOC) Consultant Obstetrician and Master of Coombe Hospital Dr Gerard O’Connor (GOC) Consultant Emergency Medicine, Mater Hospital Dr Colman O’Loughlin (COL) Consultant in Intensive Care Medicine Dr Margaret O’ Sullivan (MOS) Chair, National Zoonoses Committee, Consultant Public Health Medicine Dr Lynda Sisson (LS) Consultant in Occupational Medicine, Dean of Faculty of Occupational Medicine, RCPI Dr Lelia Thornton (LT) Consultant in Public Health Medicine, HPSC

Apologies:

Dr Jeff Connell (JCo) NVRL Dr David Hanlon (DH) HSE National Clinical Advisor and Group Lead for Primary Care Dr Jeanette McCallion (JM) Health Products Regulatory Authority Dr Joanne O’Gorman (JOG) Consultant Microbiologist, HPSC and Rotunda Hospital Dr Alan Smith (AS) Deputy CMO, DOH

Secretariat: Dr Laura Heavey SpR Public Health Medicine, HPSC Mr Robert Glennon Immunisation Policy Unit Department of Health (Admin Secretary) Ms Antoinette François Department of Health

Observer:

Date/Time of Meeting: Wed 29/04/2020 Time: 2pm to 4pm

Prepared by: Ms Antoinette François, Assistant Principal, DoH and Dr Laura Heavey, SpR Public Health Medicine, HPSC

Date Circulated:

2


Placeholder for Monday 4 May at 2pm (bank holiday). EAG meeting may be scheduled if required. Secretariat will advise members.

Item No.

1


The minutes from Monday 27th were accepted with some amendments as follows:-

Remove footer from document

Point 5 P3 – It was clarified that it had not been agreed that those with mild symptoms and a

negative test could return to work. No change made in this scenario.

2

Mask wearing in the community The Chair referenced the HIQA evidence synthesis document that had been shared prior to the meeting and the proposed draft wording of EAG advice to NPHET in relation to mask wearing in the community. Under the proposed text members of the community would be advised, rather than mandated, to wear a mask in certain settings when physical distancing could not be maintained. There was a detailed discussion on this issue with members offering differing views. The supply issue in respect of surgical masks was highlighted – maintaining availability for HCWs is essential. The lack of evidence supporting the use of home-made face masks was also highlighted and any recommendation on this would disregard the scientific component. There is a need to explain the logic behind mask use – that it is to prevent a person from infecting others rather than providing protection to the wearer i.e. source control. There is a need for absolute clarity on what kind of mask is being recommended and when use is advised. If supply is not an issue, the evidence reinforces the use of surgical masks rather than cloth masks. Any recommendation would need to be backed up by a comprehensive public information campaign, including TV advertisements and posters, on correct use of masks. Single use of a surgical mask in shops and on public transport with immediate disposal afterwards seems sensible and there is some limited evidence to support this. There was a suggestion of evidence that cloth masks can reduce aerosols. While not perfect, home-made masks may give some level of risk reduction for the general public in the interim. It was recognised that many members of the public are already using masks and that as the virus is likely to remain an issue for some time, guidance would be useful. It was suggested that if the use of home-made face masks were to be recommended, advice would need to be provided on the correct material to use and the age that would apply for wearing them. There was general agreement that any recommendation should stress the continued importance of hand hygiene and address the issue of gloves. The group considered that strong advice should be issued against the use of gloves as this can increase the risk of infection rather than reduce it. Action:

• Chair to share draft wording of recommendation with the EAG for comment and agreement before sharing the recommendation with NPHET.

3

Acute hospital preparedness This featured as item 4 on the agenda but it was agreed that it would be taken as item 3 at the meeting. Restarting non-COVID related health care VH gave an overview of the proposed guidance on managing patients attending hospital for planned essential non-COVID-19 care which has been drawn up by the Acute Hospital Preparedness

3

Subgroup. Draft guidance documentation in relation to day case procedures (non-aerosol generating and aerosol generating/anaesthesia involvement) and outpatient appointments, including pre and post admission/attendance arrangements and use of PPE were outlined. It was recognised that treating patients in this way would take longer and patient throughput would be reduced as a result. Extended days and longer shifts may be required and new staff roles identified – this will require a huge amount of work in the area of workforce planning. It was agreed that the purpose of these documents is to provide a high-level framework which could be tailored to the local healthcare context, including adaptation for the paediatric setting and maternity services. It was also recognised that implementation will be challenging – advice will be needed from NDTP, RCPI, etc.

The pathway for management of inpatients who develop a fever while in hospital (inpatient pyrexia algorithm) was discussed. SG mentioned that a CTPA may be useful to differentiate between COVID-19 and another cause of fever, if PCR testing for COVID-19 is negative and there is high clinical suspicion of COVID-19. It can be useful to differentiate between a PE and an infective cause for the fever as well. For the in-patient pyrexia algorithm, it was agreed that contact tracing would not be initiated if SARS-CoV-2 was not detected, and there was an alternate clinical diagnosis.

The pre-work screen for HCWs (HCW algorithm) was also discussed. Use of thermal screening would be a matter for individual hospitals. Need for rapid turn-around times testing for HCWs was stressed.

Importance of surveillance of patients and HCWs to ensure that patients are not acquiring COVID-19 in healthcare settings was noted - need follow up for 14 days after discharge. Some feedback was given on the draft guidance documents. IPC input is required on the PPE required – IPC team will incorporate this into existing guidance. VH will update the documents as per feedback received and proposal is that these will be shared with NPHET this coming Friday as key enablers to restarting scheduled activity. VH also asked for comments on whether the metric “Total no. new cases over past 14 days/100,000 population” could be a useful metric for comparison purposes both nationally and regionally. JCy indicated that the HSPC will look into this.

Action:

• It was agreed that the revised documents on restarting routine non-COVID-19 care in acute hospitals could be shared with NPHET.

4

Occupational health issues in nursing homes This featured as item 3 on the agenda but it was agreed that it would be taken as item 4 at the meeting. The situation in relation to HCWs who test positive as a result of the testing sweep of nursing homes was clarified. In effect, there are two sets of positives as follows:-

• staff members (symptomatic or asymptomatic) who receive a positive test for COVID-19 for the first time as part of the nursing home screening. These staff should remain off work for 14 days.

• staff members with a history of COVID-19 infection who have finished 14 days of self-isolation and have the retested positive as part of the nursing home testing programme. These staff can work if they are well, even if they receive a positive COVID-19 test as part of

4

the screening. The HIQA review Preliminary evidence summary of the immune response following coronavirus infections was referenced. There is no evidence of re-infection so early after infection. It is most likely a re-detection of non-viable virus materials, rather than a new infection. Advice to NPHET to this effect will issue from EAG in order to provide clarity on the matter.

The EAG does not have a clear picture of the actions being taken to mitigate staffing risks in nursing homes. The issue of childcare for health workers is also impacting on staff availability. Confirmation that the arrangements for public sector workers in relation to childcare and working from home also apply to front line health care staff may further aggravate the situation. There was also a discussion on whether asymptomatic staff with positive test results should ever be permitted to work with COVID-19 positive patients in settings where there is sustained transmission, if no skilled staff who are familiar with the patients are available and when the only other option would be to transfer residents to an acute hospital. Many members could not agree to this in any circumstances and the strong opposition from NPHET was also noted. Other members indicated that this should only be considered in the most extreme situations and when all other options had been exhausted. This was not put to the group for agreement. Action:

• It was re-iterated that any staff member (symptomatic or asymptomatic) who receives a positive test for COVID-19 for the first time as part of the nursing home screening should remain off work for 14 days.

• It was agreed that HCWs, with a history of COVID-19 infection who finished 14 days of self-isolation and who have then retested positive as part of the nursing home screening, can work if they are well. This advice will be forwarded to NPHET.

5.

Lifting of restrictions in May Deferred.

6

Immunity to COVID-19 This issue was discussed under agenda item 4 - Occupational health issues in nursing homes

7

Issues referred by NPHET Nil

8

AOB The issue of retesting of patients in acute hospital who have recovered from their illness but where positivity with PCR testing for COVID-19 is persistent was discussed. There was a previous EAG recommendation that patients could not be transferred to a residential facility without 2 negative tests for COVID-19. It was acknowledged that the logic for the recommendation initially was there was limited community transmission at the time. Some older patients have persistent shedding. They may not be receiving the MDT care they need while cohorted on an acute COVID-19 ward. The EAG recommended that for those patients with a persistent positive PCR test for COVID-19 after 14 days in hospital, IPC precautions should be kept in place for another 7 days and then removed, provided the patient has no symptoms consistent with ongoing COVID-19 infection. No further retesting is required as the risk of spreading infection is extremely low at this point. The patient can be discharged to a residential facility at this point if they are well enough for discharge. Action: This advice will be forwarded to NPHET.

5

There was a short discussion in relation to the 2km radius, lifting measures related to sports and differences in COVID-19 cases in Cork (given that they have less BCG vaccination). VH raised again the issue of the 14 day cumulative incidence/100,000 population as a potential useful metric for hospitals.

8 Date of Next Meeting: placeholder for Monday 4 May at 2pm (bank holiday). EAG meeting may be scheduled if required. Secretariat will advise members.

Abbreviations: COVID 19 2019 novel Coronavirus AMR Anti-Microbial Resistance AMRIC Antimicrobial Resistance and Infection Control CDC Centers for Disease Control and Prevention CMO Chief Medical Officer CCO Chief Clinical Officer COVID-19 Coronavirus Disease 2019 CTPA Computed Tomography Pulmonary Angiography DOH Department of Health EAG Expert Advisory Group ECDC European Centre for Disease Prevention and Control ED Emergency Department FAQ Frequently Asked Questions HCAI Healthcare-Associated Infection HIQA Health Information and Quality Authority HCW Health Care Worker HPSC Health Protection Surveillance Centre HSE Health Service Executive ICU Intensive Care Unit ID Infectious Disease ILI Influenza-Like Illness IPC Infection Prevention and Control MDT Multi-disciplinary team MOU Memorandum of Understanding NAS National Ambulance Service NI Northern Ireland NPHET National Public Health Emergency Team NVRL National Virus Reference Laboratory PCR Polymerase Chain Reaction PE Pulmonary Embolism PH Public Health PHE Public Health England PPE Personal Protective Equipment RCPI Royal College of Physicians of Ireland WHO World Health Organisation

1



Location of Meeting: DOH, Videoconference

Members/In

attendance:


Teleconference:





Dr Aoife Cotter (AC) Consultant Infectious Diseases, National Isolation Unit


Dr Lorraine Doherty (LD) National Clinical Lead for Health Protection





Care

Dr Derval Igoe (DI) Consultant Public Health Medicine, HPSC


Ms Helen Murphy (HM) Infection Prevention and Control Nurse Manager, Lead


Mr Damien Nee (DN) Patients for Patient Safety, Ireland


Dr Joanne O’Gorman (JOG) Consultant Microbiologist, HPSC/Rotunda Hospital



Health Medicine

Dr Alan Smith (AS) Deputy Chief Medical Officer, DOH



Dr Lelia Thornton (LT) Consultant in Public Health Medicine, HPSC

Apologies: Dr Jeff Connell (JCo) NVRL

Prof Michael O’Connell (MOC) Consultant Obstetrician and Master of Coombe Hospital

Secretariat: Dr Laura Heavey SpR Public Health Medicine, HPSC


(Admin Secretary)

Ms Antoinette François Department of Health

Observer:

Date/Time of Meeting: Wednesday 06/05/2020 Time: 2pm to 4pm

Prepared by:

Ms Antoinette François, Assistant Principal,

DoH and Dr Laura Heavey, SpR Public Health

Medicine, HPSC

Date Circulated:

2

Date/Time of Next

Meeting:

Monday 11/05/2020 2pm to 4pm

Item

No.

1


Minutes from meeting on 29/04/20 were agreed and accepted by the Group.

The Chair advised the Group of the requirement to publish the minutes of the Group’s meeting on

the Department of Health website. In order to give members the opportunity to review the minutes

before publication, the Secretariat will circulate the minutes to members as soon as possible.

Members were requested to respond with comments by cob Friday 08/05/20.

Prof. Cormican indicated that the HSE Governance Group on Infection Control is looking for

clarification on one of the recommendations of the EAG.

2

Epidemiological Update

It was agreed that this item will now be taken as a standing agenda item at EAG meetings on

Mondays.

3

Mask wearing in the community

The Chair provided an update on NPHET’s consideration of the issue at its meeting on Friday

01/05/20. The EAG presented its advice to NPHET in relation to the wearing of face masks in the

community. NPHET acknowledged the advice but believes medical grade face masks should be

prioritised for HCW at this time. NPHET would like EAG to look at the role for non-medical grade

masks in the community. A draft NPHET document in relation to the use of face masks/coverings in

the community was circulated to the Group in advance of the meeting to inform discussion. The

Chair asked the Group whether any further EAG opinion should be offered to NPHET in relation to

mask use in the community. There was a general discussion on the issue in which the following

points were made:

• There is insufficient evidence to recommend mandatory or universal cloth mask use in the

community.

• Some members believe masks should be used when social distancing cannot be maintained in

areas like supermarkets.

• Even if they are not 100% effective, a 10-15% reduction in transmission could have an impact.

• There is an absence of robust evidence to support community mask use and there is a lack of

consensus among experts regarding the potential benefit; modelling suggests even partial

protection with a mask can have a real impact on transmission.

• Some of the impact is potentially related to the timing of the introduction of community mask

wearing.

• Given that many people are already using cloth masks, efforts should be directed to making sure

they are being used as safely as possible and providing advice on cleaning and donning and

doffing.

• It was suggested that it is not the remit of the EAG to give advice on how to safely make a mask

at home.

• The community wearing of masks would most likely be one of the first measures to be lifted as

soon as community transmission is no longer widespread.

• Mask wearing is not a substitute for other measures such as hand hygiene and physical

distancing.

3

There was agreement that characterising the wearing of cloth masks in the community as ‘an act of

solidarity” could be problematic. The aim of appropriate mask wearing is for infection control and

not for solidarity. It may give the impression that those not wearing masks are disregarding the

welfare of others which could give rise to social tensions. In addition, there will be some people who

will find it difficult to wear masks, such as those with communication difficulties and younger

children.

Action:

• EAG notes its previous advice to NPHET on the use of surgical masks in the community – this

has not changed.

• Given that many people are choosing to wear masks, the HPSC infection prevention and

control team will prepare guidance on how to do this in a safer manner and will bring this

back to the EAG for review.

4

Immunity to COVID-19

A number of questions referred by Public Health for EAG advice were outlined. The most recent

(final draft) of the HIQA evidence review Evidence summary of the immune response following

infection with SARS-CoV-2 or other human coronaviruses has been circulated to the Group. HIQA has

identified evidence that shows neutralising antibodies last for at least 8 weeks. It may be longer but

there are no studies yet that have a follow up duration of greater than 8 weeks. It was acknowledged

that sterilising immunity would be unlikely. A person may be protected from severe disease but as

yet the potential for reinfection is unknown. The uncertainty around this needs to be acknowledged.

As community prevalence falls, the possibility of a false positive tests increases. This is potentially

most problematic in the context of widespread testing of asymptomatic persons – someone may

have had a false positive test and believe that they are immune and so would need careful advice to

watch for symptoms. If they develop any symptoms, they must be re-tested and excluded.

HIQA did not identify any evidence for reinfection with SARS CoV 2. The studies identified were likely

detecting persistent shedding of non-viable viral material. The Group acknowledged, however, that

there was insufficient evidence to completely rule out the possibility of reinfection. After

discussion, the EAG made the following recommendations:

• Anyone with a confirmed COVID-19 infection who has recovered and completed their 14

days of isolation, if they are re-exposed to a case of COVID-19:- can be considered immune

for 12 weeks from the start of their symptoms and can continue to work. However, they will

need careful advice to continue to self-monitor for symptoms. In the event of new symptom

development, they should be re-tested for SARS CoV2 and other respiratory pathogens and

excluded from work. This will need to be kept under review as more studies with a longer

follow up on the persistence of antibodies are published.

• Someone with a history of COVID-19 who has recovered but who develops new symptoms

consistent with COVID-19 and has a positive PCR test for COVID-19:- an investigation for

other respiratory viruses should take place and the CT value of the COVID-19 PCR test should

be discussed with a microbiologist and/or virologist. If re-infection cannot be excluded, then

it cannot be assumed that the case is not infectious. Current contact tracing guidelines will

apply.

• If a HCW is asymptomatic and tests positive but subsequently gives a history of symptoms

consistent with COVID 19 in the days prior to the test:

(a) If they report symptoms consistent with COVID-19 within 14 days prior to the test - they

must remain off work from the date symptoms commenced

(b) If they report symptoms consistent with COVID-19 more than 14 days prior to the test-

they must remain off work for 14 days from the date of the test

4

Action:

• The recommendations will be shared with the HSE.

• The issues will be kept under review and HIQA will be asked to update the evidence reviews

on immunity in 3 weeks’ time.

5

Clinical definition for COVID-19

The EAG did not feel the current clinical definition needed updating, now that the requirement to fall

into a priority group has been removed. In addition, there is sufficient provision to allow for testing

outside of the definition on the HPSC website if clinical suspicion is high.

6

Vulnerable groups

There was a discussion regarding patients waiting for dental treatment prior to receiving

chemotherapy or to undergoing essential cardiac surgery on foot of a request from the HSE CCO.

Action:

• These individuals should be added to the priority list for testing.

The Chair received a question regarding the wearing of masks by prison officers in the prison setting.

There is IPC guidance available to guide those working in the prison setting. There have been a small

number of prison officers infected with COVID-19 in prisons.

Action:

• The HPSC IPC team will follow up with the Clinical Director of the Irish Prison Service.

7

Lifting of restrictions on May 18th

Deferred due to time.

8

Update from the research subgroup

Prof Colm Bergin reminded the Group that the subgroup was established in late March and initially

advised and reported to EAG of 5 prioritisations – clinical trials, national bio-registries, national viral

genome sequencing, testing and immunology, biobanking infrastructure.

Two papers have been submitted on clinical trials and testing/immunology to the EAG and

forwarded to NPHET. The paper on data registries/ biobanking is to be undertaken and will be

brought to EAG for review.

The subgroup is finalising a research paper on COVID19 strategy and funding and has sought input

from Chairs of NPHET subgroups and from Government Departments. The subgroup proposes to

have this paper submitted to the EAG meeting on Wednesday 13/05/20.

The subgroup has been working with the NREC to create a knowledge repository of COVID19

research being undertaken (funded and unfunded).

SFI and HRB COVID19 research awards announced last Wednesday.

Progress continues on the WHO Solidarity trial. UCC will act as sponsor. The research subgroup

proposes to undertake a self-review/reflection as it finalises the remaining papers referenced.

In the Q&A membership of the committee was requested - the present group is

Prof Cliona O’Farrelly, Prof Orla Feely, Prof Ivan Perry, Prof Stephen Kinsella, Prof Mark Ferguson,

Dr Anna Terres, Dr Mairead O Driscoll, Dr Siobhan O Sullivan, Dr Teresa Maguire and

Prof Colm Bergin. The group is supported by Sarah Gibney (DoH secretariat).

5

EAG also noted a brief update on the seroprevalence study that is being developed between HPSC

and NVRL which had been circulated in advance. It was clarified that there are no plans for

development of a bio repository in this surveillance focused study.

9


Nil

10

AOB

Correspondence received from Organ Donation & Transplant Ireland in relation to three further

steps for the organ transplant service to restart. This was discussed by the Group. Issues raised

included whether those waiting for transplant would need to cocoon in order to stay on the waiting

list for active transplant, the length of time this might involve and balancing the risk of contracting

COVID-19 versus the risks of waiting until there is a vaccine available to receive their transplant.

Many members felt a recommendation on cocooning was not within the remit of the Group. It was

suggested that it would be a matter for the individual patient, based on a risk assessment of

transplantation and cocooning with their clinician.

Action:

The Chair will draft a proposed response for review by the Group at the next meeting.

A query from the NPHET Testing Subgroup in relation to the testing of close contacts, in the context

of increasing testing was discussed i.e. at what point/day should the close contact be tested and

how many times? Day 0 and day 7 was proposed if the contact does not develop symptoms, and

anytime if they develop symptoms, was proposed. The median incubation period is 5-6 days.

Another member proposed day 14 to pick up all cases. However, there are issues of feasibility and

compliance to be considered with regard to serial testing.

If only 1 test is feasible, day 7 would probably detect the most cases. While it would not pick up all

cases, it would pick up more asymptomatic cases of infection than not testing contacts at all. The

impact on overall spread if the close contacts are already in isolation was also raised. A positive test

result may make contacts more compliant with self-isolation while a negative one may give a false

sense of reassurance. As NPHET do not require an immediate response, it was agreed to review

again after feedback from other countries on their contact testing strategies is available. In this

regard it was noted that within the European Early Warning System (EWRS), a question on testing of

asymptomatic contacts was asked this week by a Member State and the responses will be collated

and shared.

Action: the issue will be discussed at a future EAG meeting when feedback from other countries is

available.

11 Date of Next Meeting: Monday 11th May 2pm to 4pm

Abbreviations:





CCO Chief Clinical Officer


6

Ct Cycle threshold

CTPA Computed Tomography Pulmonary Angiography







HIQA Health Information and Quality Authority



HRB Health Research Board






MDT Multi-disciplinary team

MOU Memorandum of Understanding


NI Northern Ireland



PCR Polymerase Chain Reaction

PE Pulmonary Embolism

PH Public Health




SFI Science Foundation Ireland

UCC University College Cork


1




Members/In

attendance:


Teleconference:







Prof Sean Gaine (SG) Consultant Respiratory Physician


Care









Dr Joanne O’Gorman (JOG) Consultant Microbiologist, HPSC/Rotunda Hospital



Health Medicine

Dr Eibhlin Connolly (EC) Deputy Chief Medical Officer, DOH (on behalf of Dr Alan

Smith)


Apologies: Dr Jeff Connell (JCo) NVRL

Prof Michael O’Connell (MOC) Consultant Obstetrician and Master of Coombe Hospital



(Admin Secretary)


Observer:

Date/Time of Meeting: Monday 11/05/2020 Time: 2pm to 4pm

Prepared by:



Medicine, HPSC

Date Circulated:

2

Date/Time of Next

Meeting:

Wednesday 13/05/20 2pm to 4pm

Agenda

Item

No.

1


A number of amendments to the minutes from EAG members were proposed and discussed. The

agreed changes will be incorporated into the approved version of the minutes.

Prof. Cormican indicated that the HSE Governance Group on Infection Control is looking for

clarification on one of the earlier recommendations of the EAG (recommendation of EAG of

29/04/20) in relation to patients in acute hospitals whose illness has resolved, but in whom SARS-

CoV-2 RNA remains detectable after 14 days. Members called for consistency in guidance across

all settings – acute hospitals, nursing homes, etc.

The updated HIQA review on viral shedding reports no evidence that live virus is shed after day

8/9. Ct values were discussed – issues with different Ct values with different tests used. The Group

agreed that, based on the evidence available from the HIQA evidence review and experience on

the ground, any patients who have made a complete clinical recovery from COVID-19 at day 14

from symptom onset and who have had no fever for 5 days, do not need to be tested again for

COVID-19 in order to prepare for discharge from hospital or any residential setting or transfer or to

remove IPC precautions. It was agreed, however, that there may be certain situations where

repeat testing would be of use and where clinical discretion should be applied e.g. patients with

cognitive impairment, older persons with subtle symptoms or where Ct value above 34 is

declining. In general, high CT values, e.g. above 34 in the absence of clinical symptoms are unlikely

to indicate infectiousness

Action: it was agreed that a wording in respect of this recommendation would be drafted and

circulated to the Group for comment before being tabled for agreement at a future EAG meeting.


This item was not included in the original agenda, however a draft document prepared by the

HSE IPC team on the use of face masks by the general public was discussed. The aim of the

document is to provide information about the use of face masks in everyday life and not in

healthcare settings. The draft document avoids the use of technical language in the interests of

making it easily accessible. The document provides information on the role that masks may play

in stopping the spread of the disease and features a “Do’s and Don’ts” section on mask wearing.

The guidance also stresses the importance of other measures including self-isolation, social

distancing and hand hygiene and touches on the skin irritation that can arise with mask use.

Prof Cormican presented the document but indicated that it does not reflect his views with

regard to the use of masks in the community.

The Group welcomed the document and provided some initial feedback on it.

Some members discussed the availability of surgical-type masks in the shops – these may not be of

the highest standard and most likely are not as effective as masks used in the healthcare setting. It

was suggested that the DoH may need to provide advice for the public on this. The observations

of one member in a hospital clinic setting suggest that people can find masks uncomfortable and

repeatedly touch their faces, while those not wearing masks focus more on hand hygiene. The

requirement to wash masks at 60 degrees might be an issue although the use of a hot iron might

be an alternative. The requirement for guidance on how to make cloth masks was noted, as poorly

3

made and ill-fitting masks lead to poor infection control. The issue of mask wearing by children

was discussed and a number of members had concerns in this regard, including the fact that they

would be a choking hazard for younger children. It was agreed that children less than 13 should

not use masks.

While there is no majority consensus within the EAG for a recommendation on the use of cloth

masks in the community in instances where social distancing cannot be maintained, it was agreed

that advice should be provided on how people who choose to wear masks in the community can

do so in a safe manner. Members will respond with comments on the document directly to

Prof Cormican and a revised draft of the document will be tabled for agreement at the next EAG.

Action:

• EAG will provide feedback on the draft guidance document on use of face masks by the

general public.

• The revised document will be tabled at the next EAG meeting for approval.

2

Epidemiological Update

A brief overview of epidemiological situation including outbreaks in residential settings and

regional variation in COVID-19 cases was provided.

3

Viral shedding and infectivity

Two questions which had been referred to the EAG by Public Health were raised and were

discussed. The discussion was informed by the updated HIQA review on viral shedding.

The first question related to the removal of IPC precautions in nursing homes. An earlier EAG

recommendation was made in relation to HCWs – however this question relates to patients. It was

noted that there has to be an understanding within the system of the rationale behind the

recommendation and why a positive test can be treated differently in certain specific situations.

Action: It was agreed that residents of a nursing home with a history of COVID-19 infection who

have recovered completely and been discharged from hospital with 2 negative test results for

COVID-19, if these patients receive a positive test for COVID-19 as part of the nursing home testing

programme within 12 weeks of the start of their illness, but are currently clinically well, this can be

considered persistent detection of virus material, rather than re-infection.

The next question related to ending isolation for immune-compromised patients with COVID-19.

The basis of a wording was agreed whereby patients who are immune-compromised with COVID-

19, can leave isolation 14 days from symptom onset provided they have made a clinical recovery

and have had 5 days without fever and are symptom free. It was noted that many may not have

had fever. However, caution was advised as regards the transfer to inpatient wards with other

immuno-compromised patients.

Action: It was agreed that a draft recommendation on this issue would be drawn up and

circulated to EAG members for comment.

4

Lifting of social distancing measures

Deferred to next EAG meeting

5

Kidney Transplant Query

This item was not discussed. The Chair will respond directly to Organ Donation Transplant Ireland.

4

6 Issues referred by NPHET

Nil

7

AOB

The issue of reporting suspected cases, that are being treated as COVID-19 cases, but with not

detected test results, to the HPSC was raised. Some may have abnormalities on CT. There is a lack

of clarity about the number of such cases. The HPSC advised that these would be clinical

notifications and depend on the clinician reporting theses cases to their local public health

departments. HPSC to circulate a reminder re the procedure for notifying clinical notifications.

One member suggested that EAG should look at the issue of childcare and whether there might

be scope for a recommendation from the Group in this regard. The Chair indicated that the HIQA

review on transmission of COVID-19 from children would be discussed at the next EAG meeting.

The timelines for availability of antibody testing was also raised and the Chair provided an update.

The issue of trying to find earlier cases of COVID-19 that may have been missed in Ireland before

the first known case in February was discussed. The Chair noted that 400 tests for COVID-19 were

done in Ireland before the first positive result. It is possible that there were undetected sporadic

cases before the first known case and this would be of interest from an academic and surveillance

perspective. The issue of testing those who have died is different and may be justified if there is no

alternative diagnosis to explain the death.

8 Date of Next Meeting: 13/05/20 2pm to 4pm

Abbreviations:







Ct Cycle threshold



















NI Northern Ireland




5


PH Public Health






1




Members/In

attendance:


Teleconference:








Prof Sean Gaine (SG) Consultant Respiratory Physician









Dr Joanne O’Gorman (JOG) Consultant Microbiologist HPSC/Rotunda Hospital


Dr Alan Smith (AS) Deputy Chief Medical Officer, DOH

Apologies:

Dr Lorraine Doherty (LD) National Clinical Lead for Health Protection


Health Medicine






(Admin Secretary)


Observer:

Date/Time of Meeting: Wednesday 13/05/2020 Time: 2pm to 4pm

Prepared by:



Medicine, HPSC

Date Circulated:

2

Date/Time of Next

Meeting:

Monday 18/05/20 2pm to 4pm

Item

No.

1


The minutes from Monday 11 May 2020 were approved with a number of textual changes on pages

2 and 3. Prof Cormican also asked that it be noted in the minutes that, although he was involved in

preparing the guidance on mask wearing in the community, the document does not reflect his views.

2

Lifting of social distancing measures

This featured as item 3 on the agenda but was taken as item 2 at the meeting.

There was a brief presentation on the HIQA review of the role of children in transmission of

COVID-19. The report indicates that from the small number of studies available, it appears that

children are not substantially contributing to transmission of SARS-CoV-2 in their households or

schools. Members discussed the potential re-opening of schools. The data are reassuring but limited

and raises the question as to whether schools could reopen sooner than planned. It is a case of

balancing the risks. Of particular concern are children with special needs and their families. Classes

for these children are already smaller and there would appear to be a low level of risk. It was

stressed however that congregation of adults at school drop off and collection times would pose a

risk of transmission and this would need to be managed carefully, particularly in the greater Dublin

area. Clear messaging would be needed here. A rise in the reproductive number to 1.2 could lead to

a significant increase in hospital admissions and the requirement for ward and ICU beds. The needs

of teachers and staff who are in the cocooning cohorts require consideration. Members discussed a

phased re-opening starting with primary schools. It was felt that social distancing is not possible

with younger children and could be distressing. There should be a focus on practical measures such

as hand hygiene, use of hand gel, clean toilets.

More general issues in relation to the increased movement of people around the country, including

attendance at funerals were discussed. An area of focus should be the rotation of NCHDs in July and

how to manage this. A proposal for testing rotating NCHDs was considered. The potential challenges

and pitfalls of testing of NCHDs and other HCWs were discussed. There was no consensus that

testing was appropriate. It was agreed that if a testing programme was introduced the consequences

of testing need to be thought through in advance.

Action:

• It was agreed that the EAG is supportive of the re-opening of schools, especially primary

schools and schools for those with special needs. Draft wording will be circulated to the

Group this evening for comment and then brought to the next NPHET meeting if possible.

• It was decided to continue the discussion on the possible testing of HCWs, including NCHDs.

This will be put on the agenda for the next EAG on Monday.

3


This featured as item 2 on the agenda but was taken as item 3 at the meeting.

The updated guidance prepared by the IPC team which provides advice to the public on the safe use

of masks in the community was discussed. The changes made since the last iteration were outlined.

The Group provided some feedback on the document. Members can revert with further comments

by tonight.

3

Action:

• It was agreed that members would revert with comments on the guidance document by

tonight in order for the document to be submitted to NPHET tomorrow.

4

Update from research sub-group

Prof Colm Bergin gave an update on the work of the research sub-group. The minutes of its

meetings have been formulated and are available to be put into the public domain. The subgroup’s

research paper on COVID19 strategy and funding has been submitted to the NPHET sub-groups and

will be submitted to EAG next week. The subgroup is a standing item on the agenda for EAG

meetings on Wednesday.

Action:

• Research subgroup to submit its research paper on COVID19 strategy and funding for review

by EAG next Wednesday.

5


Nil

6

AOB

The query from the Testing Subgroup in relation to the optimum day for testing of asymptomatic

close contacts, in the context of an increase in testing capacity, was discussed. A short paper was

circulated to EAG in advance and the issue will be considered by NPHET tomorrow. The ECDC has

included the testing of asymptomatic contacts as one of its contact tracing steps, where resources

allow. Only three other EU countries are doing this – Luxembourg (Day 5), Slovakia (Day 5) and

Denmark (Day 4 and Day 6). The Testing Subgroup would like the views of EAG. Any eventual

decision in this regard will be kept under review.

The Group discussed the matter and a number of points were raised. It was confirmed that Day 0

for testing relates to the date of last contact with the case. The Group had some concerns in

relation to how this would impact the health service in terms of exclusion and how to make the best

use of testing capacity. The challenge of performing this test on children was also noted, as well as

the discomfort and inconvenience of repeat testing. A negative result may lead to a reluctance by

close contacts to self-isolate. Some members in the group were not in favour of testing

asymptomatic contacts – there is an existing EAG recommendation against testing asymptomatic

contacts. The benefits of testing close contacts where they are already self-isolating was

questioned. The Chair outlined how it could be beneficial in aggressively suppressing infection.

Testing capacity is increasing and there is potential to understand more about asymptomatic

infection driving the pandemic. In this regard, testing at day 0 could help identify the potential

source. The possibility for testing of close contacts to reduce the time spent in isolation was

considered. An example from the US was given – test at day 7, result at day 9, if reported as virus

not detected, contact released from quarantine. The need for a national strategy on testing in order

to make the best use of available resources was also raised. The Testing Subgroup will bring the

suggestion to NPHET that if NPHET decide to test asymptomatic contacts day 0 or day 5 may be

options. The group will also share the views of the EAG in relation to testing of asymptomatic

contacts.

A query was raised on whether there is guidance on testing staff who move from one part of a

hospital (e.g. ICU) to another part of the hospital, such as theatre. It was established that this is not

recommended in current HPSC guidance.

4

There was a query on whether and how the HIQA findings on immunity to COVID-19 are being

communicated to the public. It was noted that HIQA has recently discussed the findings of the

review in the media and referred to evidence of neutralising antibodies being present for 8 weeks.

The HPSC will update its website in this regard and will raise the issue at NPHET for information.

The issue of a possible roadmap for the resumption of hospital visits was raised, particularly for

those patients with non-COVID diagnoses, patients with stroke, those with long admissions and

patients with dementia.

• Action: It was agreed that the topic will be added to the EAG agenda next Monday.

An EAG member asked that EAG advice to NPHET be shared with EAG members. The Chair agreed

that these could be made available on Sharefile.

• Action: EAG advices to NPHET to be made available on Sharefile.

7 Date of Next Meeting: Monday 18/05/20 2pm to 4pm

Abbreviations:







Ct Cycle threshold



















NCHD Non-Consultant Hospital Doctor

NI Northern Ireland





PH Public Health






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