Professor Carl Heneghan:

That is not a problem.

I have heard the opening arguments. There are two schools of thought between endemic disease versus this strategy of elimination and I think it is incredibly important that the first thing one does is be very clear about what that actually means. Words like “suitable period of time” are unhelpful given the uncertainties, so one needs to be very clear about that definition. If one thinks about endemic, then it is a disease or condition that is regularly found among people in a certain area.

What we know is that this pathogen is now endemic in every part of the world. I will come back to New Zealand, but it is out there. The idea that we are going to eliminate it globally is a misnomer now. It is a problem if one is pursuing that path. When one refers to an elimination of a disease, then that is a deliberate effort that leads to a reduction to zero of the incidence of an infection caused by SARS in a defined geographic area. It is also important whether one is talking about Ireland or about southern Ireland. One can class elimination from a specific region without it being eradicated globally. There are examples of that like polio and measles, but it is important to understand that there are only two pathogens that can come under the list of where we have had complete global elimination of diseases: we have got smallpox and rinderpest. They have three things in their favour when one goes for elimination. They have an effective vaccine in place. They have no animal host as humans are the only vectors. Third, they have a political will globally to succeed in elimination. When I hear that school of thought around elimination I ask how are we informing this on what we have done previously. How are we considering that this is a zoonotic pathogen that communicates to animals and back, and has multiple routes of transmission?

The fact has been alluded to that lots of people use New Zealand as an example, and there are some helpful examples between it and Ireland. The countries have a very similar population of about 4.9 million, but in terms of density, we are talking about 15 per sq. km in New Zealand, whereas there is about a fourfold increase in Ireland. Ireland is much more densely populated than New Zealand. In addition, when one talks about New Zealand, one has to consider that its nearest neighbour is more than 1,000 km away, that is Australia, which is also one of the least densely populated countries in the world. I think that any comparison with New Zealand is unhelpful because not only is it locking down, it has to lock out. One cannot have a sort of all-or-nothing strategy.

There must be a strategy. Where countries have done this, such as in Hong Kong or New Zealand, we are talking about quarantine in hotels for two weeks and testing. Once people are let out, problems emerge. That is important.

With evidence gathering there is much uncertainty about what will happen next. We can look at the age structure of Ireland, for example, with a median age of 36.5 compared with 40.5 in the United Kingdom. We modelled this and examined deaths and there would be 10,000 fewer deaths because of that age structure. When people are doing comparisons, they must really bring in nuanced evidence to understand it.

We are talking about an elimination strategy and I have read the emails, and there is much emotion about such matters. We try to focus on the evidence. Whatever the strategy, and whether one is in the Sweden camp or the Spain camp, where they locked down very hard instead of keeping society going, there is the same problem that we have and that Ireland has. In Ireland, 62% of deaths were associated with care homes. It is still not clear to me why governments and their policy have not understood that this is where the problem is.

Looking at the age structure of who is affected by the disease, I have never seen a disease like it where age has such a major impact. We should remember that with influenza we saw many deaths in people under five but we are not getting that problem now. Fewer than 400 people aged under 50 with no comorbidities have died of Covid-19 in the United Kingdom. That is an incredibly small number. We can assume that the biggest problem in the middle age group is dealing with comorbidities and this is most important. The decision today if we go down the elimination strategy is to make it exactly clear what is being done, what evidence this is based on and, in doing that, what may potentially be ignored where the strategy is more important. I still do not see the urgency around protecting care homes and thinking through the issue.