NPHET Advised Against Border Quarantine When We Needed It Most - Part 1

On the 25th of February 2021, the Dáil voted to require all travellers coming to the country from high-risk regions to complete a mandatory 14 days of quarantine.

A border quarantine is a standard public health policy in a period of contagion, as it helps to suppress the outbreak by keeping the infected away from the susceptible. Quarantines have been used throughout history, including by governments all over world during the current pandemic. Indeed, the countries that were the quickest to implement border controls, were also the most successful at protecting their citizens form the virus.

Unfortunately for the Irish, it took 400+ days for their government to implement what should have been a straightforward piece of public health policy. In that time, there have been several million arrivals into Ireland’s airports, a couple of hundred thousand confirmed cases of COVID-19, and 4,500 official deaths. So, while the announcement of this policy change was ostensibly a step in the right direction, it really does come quite a bit too late, and, like the ‘Green List’, may simply be another box-ticking exercise that will fade into the background noise once the news cycle has moved on.

Had the border quarantine been implemented in February last year, the Irish would have had good reason to feel optimistic. The measure would have stemmed the flow of the virus into the country, just as the global outbreak was beginning to build momentum. With no curve to flatten, the health care system wouldn’t have been thrown under the bus and the government wouldn’t have resorted to prolonged, civilian-level restrictions.

Ireland could, and should, have implemented a border quarantine in February 2020, and it should be a matter of national inquiry that we did not.

But to be clear, I am not arguing that in hindsight it would have been better if we had established a border quarantine last year (though clearly, it would). No, my point is that a border quarantine was actively considered by NPHET in February 2020. If NPHET thought it was an effective way to protect the public health from a deadly and contagious virus, NPHET was free to make the recommendation to the government.

In the end, NPHET chose to reject the measure on the grounds that it would place a “disproportionate burden on the individual”. This article is the first of two that will attempt to explain how NPHET came to such a bizarre conclusion.

It might seem like a distant memory now, so let’s remind ourselves how the world looked at the early stages of the outbreak.

January 2020

The first day of 2020 brought with it news of a mysterious pneumonia-like disease in a Chinese city called Wuhan. The next few weeks saw a sharp escalation in global risk, and concerns were not assuaged by mixed messages from the WHO about the severity of the outbreak.

The true gravity of the situation was confirmed on the 22nd of January when the likelihood of human-to-human transmission was finally acknowledged by the WHO. The organisation immediately raised its global risk warning from ‘Moderate’ to ‘High’. A week later it would declare the outbreak a Public Health Emergency of International Concern.

The ECDC had been slower to react but by the end of January 2020, its assessment of the situation and its guidance was clearly in line with the WHO’s. The potential impact of the outbreak was high and further global spread was likely. If countries did not take major precautions or if they were too slow in reacting, then community transmission was very likely and the consequences could be disastrous.

By the first week of February 2020, there were over 20,000 cases globally spread across 23 countries, including Australia, the USA, the UK, and all of Ireland’s closest continental neighbours. The majority of new cases were still appearing in China, but the numbers in Europe told a clear story: the virus was here and it was spreading.

4 February 2020: NPHET’s 3rd Meeting

If the world was burning outside, they weren’t feeling the heat in Miesian Plaza, where NPHET was easing into a routine of weekly meetings. NPHET had also taken the sensible decision to establish a sub-committee called the Expert Advisory Group (EAG) on which NPHET could lean for expert advice.

On NPHET’s agenda that day, was a review of the international experts’ latest assessments of the outbreak. In its discussions, NPHET had noticed a point of distinction between the UK and the EU relating to the management of passengers arriving on repatriation flights from China.

Given that the passengers were coming from a region where the virus was clearly out of control, there was a real possibility that any one of these individuals could be carrying an infection in the country. In response, the UK had decided to impose a mandatory 14 day quarantine on returners to prevent any possible spread into the population. In contrast, the EU had made no statement or recommendation on the matter.

Which approach should Ireland follow? NPHET decided that this was an issue for the newly-established EAG to consider. Fortunately, the EAG’s first meeting was due to take place the following day, so NPHET wouldn’t have to wait long for a response.

5 February 2020: The EAG’s 1st Meeting

The 17 available members of the EAG met in the HSPC’s offices on Middle Gardiner Street. NPHET had referred the issue of border quarantine, requesting that the EAG:

“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”

(I think NPHET should have used “quarantine” instead of “self-isolation”, as a quarantine is for potential infections, whereas isolation is for confirmed infections.)

It was assumed that symptomatic individuals would be tested and managed within the health care system, but there was still the possibility of pre-symptomatic or asymptomatic individuals carrying the virus into the country. Should Ireland require all passengers returning to the country from China to quarantine for 14 days? Should a more comprehensive border policy be considered? What was the international best practice on the matter

These were the kinds of questions that the doctors, professors, and senior consultants of the EAG had been summoned to answer. And who better? Each and every member of the group brought with them decades of experience from a diverse range of specialities across the health care system. Ireland could not have assembled a group with greater medical expertise.

And yet, one might wonder whether the problem of border quarantine needed a team of PhDs and hospital consultants to solve. It seemed like a simple choice between two bad outcomes.

If quarantine was mandated for returning travellers who weren’t carrying the virus, then they would have been unnecessarily inconvenienced. On the other hand, if travellers were allowed into the country without a period of quarantine, then the nation risked a nasty outbreak that could infect tens of thousands of people.

The problem for the EAG was that there no way to address both risks. Minimising one, meant automatically maximising the other. If the border controls were total and complete, then the protection offered to the public health would be similarly robust, but some travellers might be disgruntled. No border controls meant no disgruntled passengers, but it also meant no protection for the Irish people.

The EAG had to decide which of these outcomes would present the greater threat to the health of the Irish people.

We should remember that the decision was being made in a moment of high uncertainty, and with limited data and no easy options. These are not the conditions in which good decisions are made. Fortunately for the EAG, there was a large and growing body of evidence from the international community to guide them.

By early February, scores of countries had found themselves in an identical situation and almost all had decided to err on the side of caution. They included Singapore, Taiwan, Vietnam, Australia, New Zealand, Indonesia, Israel, Tunisia, Guyana, the Bahamas, and Grenada, who had all established border quarantines. Dozens more nations had closed their borders – in part or in full – so it was quite clear that the international community was prioritising public health and border integrity, over supranational pleasantries.

Despite the fact that the EAG was responsible for researching and analysing the latest international developments and communicating them to NPHET, neither the logic of border quarantines nor the empiric reality that they were being implemented effectively all over the word, seemed to influence its reasoning. The EAG decided that a health policy which risked inconveniencing travellers was not one that Ireland should consider.

“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.”

Based on the information available at the time, that seems like a remarkably bad decision.

The global risks were growing by the day, the international evidence seemed to point in precisely the opposite direction, and given that the EAG was a group of health experts, providing health advice, during a public health emergency, one must wonder why it was ever concerned with the convenience of individual travellers. That issue was not within its remit – never mind its skillset – so why did the EAG think it was relevant?

We can’t answer that question. We don’t know what the EAG was thinking because the meeting minutes contain no further information on the matter. We are told that border quarantine was discussed, but we weren’t told what was discussed. We don’t know whether any research or data was presented, what arguments were made in favour or against the measure, or how the group came to its conclusion. Without this information, it is all but impossible to assess the quality of the EAG’s decision.

10 February 2020: The EAG Responds to NPHET

Dr. Cillian communicated the EAG’s decision to NPHET via a letter. This letter was notable for three reasons.

Firstly, it was written 5 days after the decision had been made, suggesting a distinct lack of urgency on Dr. Cillian’s part. In the time it took him to respond to NPHET’s request, global cases and deaths had doubled, to 40,000 and 1,000 respectively. Was he not aware of the speed at which this outbreak was growing, and the need for quick, decisive policymaking?

Secondly, the letter was written by Dr. Cillian on headed paper from the National Virus Reference Laboratory in UCD, and it was addressed to the CMO himself, not to NPHET or any of its members. Shouldn’t the letter have been sent on behalf of the EAG? Shouldn’t it have been addressed to NPHET? As things stand, the letter looks like it was part of a conversation between two individuals, not the official communication between the chairs of separate committees.

Finally, Dr. Cillian did not take the opportunity to explain or to justify the EAG’s decision, choosing instead to copy the exact words from its minutes into the letter. This was disappointing, and somewhat incongruous. The members of NPHET and the EAG had been selected, at least in part, for their scientific and analytic expertise. Surely a scientist’s natural instinct would have been to provide the data on which their conclusions had been reached? And where the scientist was the one in receipt of the recommendation, wouldn’t they want to review the evidence before committing to the suggested course of action? Yet neither party seemed to be concerned by the robustness of the EAG’s conclusion.

But, perhaps we are getting ahead of ourselves. It was quite possible that the letter was another box-ticking exercise and that the real discussion would be saved for NPHET’s next meeting. The EAG was set up to advise NPHET after all, and it was the members of NPHET who would have the final say in any communication with the government.

NPHET’s 4th meeting would take place the following day on the 11th of February 2020, and that is where the second part of this story will begin.