Preparedness for Ebola Virus in Ireland – Joint Committee on Health and Children

Joint Committee on Health and Children Debate

Preparedness for Ebola Virus in Ireland: Discussion

Chairman: I remind members, witnesses and those in the public gallery to ensure their mobile telephones are switched off or in flight mode as they interfere with the broadcasting of this meeting and are unfair to members of staff. I welcome in particular viewers who are watching this meeting live this morning on Oireachtas TV on UPC and a variety of Sky platforms, as well as on the Oireachtas app and live online. They are all welcome this morning and I thank them for their presence. This is the second part of the joint committee’s meeting this morning. We had a good discussion earlier and I thank members for their participation in the discussion on stillbirth. I again pay tribute to and thank the witnesses who appeared before the joint committee.

I welcome to this meeting the Minister for Health, Deputy Varadkar, Mr. Michael Smith and Dr. Tony Holohan, chief medical officer, from the Department of Health; and Dr. Darina O’Flanagan and Mr. Gavin Maguire from the Health Service Executive, HSE. This meeting will deal with one issue only, namely, that of the Ebola virus. As members are aware, our quarterly meeting with the Minister for Health will be held next Thursday and I reiterate the only issue on the joint committee’s agenda today is that of Ebola. I thank the Minister and the chief medical officer for agreeing to the committee’s request of last week and thank Senator Crown for proposing the motion last Thursday. The joint committee will hear today from the Minister and the chief medical officer in respect of Ebola.

I remind witnesses they are protected by absolute privilege in respect of the evidence they are to give to the committee. However, if the witness is directed by the committee to cease giving evidence in respect of a particular matter and the witness continues to do so, the witness is entitled thereafter only to a qualified privilege in respect of evidence. Moreover, witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and are asked to respect the parliamentary practice that where possible they should not comment on, criticise or make charges against any person or entity by name in such a way as to make him, her or it identifiable. Members are reminded of the long-standing parliamentary practice or ruling of the Chair to the effect that members should not comment on, criticise or make charges against any person outside the House or an official either by name or in such a way as to make him or her identifiable.

For the information of members and those watching from home, Mr. Michael Smith is from the health promotion unit of the Department of Health, Dr. Darina O’Flanagan is the director of the Health Protection Surveillance Centre in the HSE, Mr. Gavin Maguire is the assistant national director of emergency planning in the HSE, Dr. Tony Holohan is the chief medical officer in the Department of Health and Deputy Leo Varadkar is the Minister for Health. I invite the Minister to make his opening remarks.

Minister for Health (Deputy Leo Varadkar):   I welcome the opportunity to brief the committee this morning on our preparedness for Ebola virus disease, EVD, in Ireland. I am joined by Dr. Tony Holohan, the Chief Medical Officer; Ms Darina O’Flanagan, the director of Health Protection Surveillance Centre, HPSC; Mr. Michael Smith, from the health protection unit of the Department; and Mr. Gavin Maguire from the HSE. In this statement, I propose to discuss high level arrangements that are in place to deal with public health threats and the major elements of our Ebola preparedness. We will be happy to take any questions the committee may have.

As of Monday, there were 4,033 confirmed deaths from Ebola and 8,399 confirmed, probable and suspected cases of Ebola in seven countries, although widespread transmission is confirmed to three – Liberia, Sierra Leone and Guinea. The number is doubling every three to four weeks and the UN has declared the outbreak to be an international public health emergency. As President Obama stated yesterday, the most effective thing we can do is to halt the rise of the diseases in west Africa. This is the single most effective thing we can do to prevent the spread of the disease to Europe and Ireland. That is why I publicly commend the volunteers, staff and aid agencies working on the ground in west Africa.

Ireland has pledged over €2.5 million to the effort of the International Medical Corps, IMC, Concern, GOAL, World Vision, International Rescue Committee and the Ministry of Health and Social Welfare in Liberia. We have also provided 42 tonnes of equipment, including blankets, tarpaulin, tents, nets, soap and water tanks. My Department has deployed two public health specialists to work with the World Health Organization, WHO, in Liberia and Nigeria.

The European Centre for Disease Prevention and Control, ECDC, in its latest risk assessment on 13 October, concluded that the risk of a case in the EU remains low. However, the increase in cases in the affected countries means that the risk of a case being imported into Europe has increased.

Environmental conditions in Ireland do not support the natural reservoirs or vectors of any of the viruses that cause viral haemorrhagic fever, VHF. Given appropriate infection control, the risk of transmission of Ebola in Ireland is considered very low. Should a case occur, it is likely that the case will be somebody who has been evacuated into Ireland. There may be one or two cases and in those circumstances, they can be handled in the national isolation unit in the Mater hospital. There is no reason to believe that emergency departments will be swamped or services overwhelmed. This has not happened to date in any Western country, and indeed, in more developed African countries, such as Nigeria, where an outbreak was successfully contained. That is not a reason to say that there will not be several suspect cases and we need to be prepared for them and learn from experiences emerging in other countries. As everyone will appreciated, this is very much an evolving situation and our response, and the level of our response, must evolve as the situation does.

The committee will be aware that the Minister, Deputy Coveney, in his capacity as Minister for Defence, chairs the Government Task Force on Emergency Planning which comprises Ministers and senior officials of Government Departments and public authorities, senior officers of An Garda Síochána, the Defence Forces, and officials of other key public authorities which have a lead or support role in Government emergency planning. The Government task force is the top-level structure which gives policy and direction, and which co-ordinates and oversees the emergency planning activities of all Departments and public authorities. It promotes the best possible use of resources and compatibility among different planning requirements.

Preparedness for major public health emergencies is a critical function of the health service and of the whole of Government. Emergency planning in Ireland is structured around the “lead Government Department” principle. There are currently 41 emergency types, each with a lead Department set out in annex A of the strategic emergency planning guidance. The Department that is responsible for an activity in normal conditions retains that responsibility during a major emergency. In accordance with established procedures as agreed by Government, the lead Department is responsible for co-ordinating the whole of Government response to a particular emergency and chairs the national co-ordination group in relation to that emergency.

The Department of Health is the lead Department for two types of emergency: pandemic influenza and other public health emergencies; and biological incidents, where incident is primarily a public health incident. A good example of this is the swine flu, where the response was managed and led by the Department of Health with input, where necessary, from others. Ebola virus disease is another example. The national response can be divided into two components: first, the health service response which will be the main subject of my opening statement; and, second, other specific elements of preparedness that are the responsibility of other line Ministers. Let me firstly deal with the latter.

My colleague, the Minister for Foreign Affairs and Trade, Deputy Charles Flanagan, has lead responsibility for emergencies abroad involving Irish citizens. His Department has issued detailed travel advice for the affected countries and continues to work actively with my Department, the European Union and international partners on contingency plans should an Irish citizens become infected abroad. In addition, the Minister of State, Deputy Sean Sherlock, through Irish Aid, has been managing Ireland’s development and humanitarian response to the crisis, and has been out to visit the region.

In relation to ports and airports, the port health group, in its role as medical officers of health, has had regular meetings with port authorities in its jurisdiction. Updates on the Ebola outbreak in 2014 have been sent to the environmental port health officers. Protocols are in place for viral haemorrhagic fever risk assessment by ambulance personnel at airports and shipping ports. The Minister for Transport, Tourism and Sport, Deputy Paschal Donohoe, has specific responsibility for ports and has assisted in ensuring that information requirements at both sea and airports are in place in line with the international advice provided.

The health service response is the major element of Ireland’s national Ebola preparedness. First, it provides the expert advice and guidance to other Departments. Second, it puts in place the specific arrangements for an appropriate public health and clinical response to any case that might arise in this country.

It may be helpful for me to go through the major elements of our Ebola preparedness. Firstly, the epidemiological situation is assessed on a continuing basis using international data from ECDC and from the WHO. This information helps to inform both the international risk assessments conducted by ECDC and also the national level risk assessments that are specific to Ireland.

The EU decision on serious cross-border threats to health, agreed under the Irish Presidency, came into force in November 2013. The decision provides a coherent framework for tackling all serious cross-border public health threats by addressing three main areas: first, preparedness and response planning; second, risk monitoring and assessment; and, third, risk management and crisis communication. Ireland is represented on the EU Health Security Committee, which was set up to co-ordinate health threats at EU level, by officials from the Department of Health. This is chaired by the EU Commission and all 28 member states are represented. Teleconferences have been held regularly on Ebola since April 2014, with the latest held on 14 October.

The Health Service Executive Emerging Viral Threats Group and the Ebola Scientific Advisory Group have met recently to review the situation and approve national guidance for Ebola and other emerging viral threats to health. Late last week, the CMO chaired a meeting of the National Public Health Emergency Team, NPHET, to discuss the issue. In addition, the office of the CMO has been in regular communication with colleagues in Northern Ireland and Britain to discuss national and international developments.

The matter was also discussed in Milan last month at the informal Council of Ministers meeting, which I attended. The Health Protection Surveillance Centre, HPSC, has issued guidance to hospitals and GPs, including an algorithm for the assessment of VHFs and clinical assessment forms and advice for health care workers. These include humanitarian aid workers, returning or coming to Ireland following travel from an area affected by the Ebola virus.

Extensive information has been provided for hospital clinicians, general practitioners and other health care workers to enable rapid identification of suspected Ebola patients in other settings, and their urgent management by the HPSC. Health care staff in the national isolation unit and hospitals around the country have received information and advice on identification and management of Ebola.

There is also extensive guidance relating to infection prevention and control which clearly describes the steps that staff must take to ensure that they protect themselves and other patients in the event of the presentation of a case or suspected case of Ebola. The HSE has distributed personal protective equipment packs to GP practices, out-of-hours services and ambulances, and many will have them anyway from previous threats.

The HSE has been active in informing the public about the disease. It has produced specific information for travellers and those who have returned recently from affected areas and information posters are on display in airports. Advice has also been distributed to airports and ports and to educational settings.

The issue of airport screening has been raised. This has been the subject of extensive discussion at EU and international level. At the most recent meeting of the EU Health Security Committee, a number of options for inward screening at airports for Ebola were discussed. It remains the view, based on advice from ECDC and the World Health Organization, that it is far more effective to support the implementation of exit screening in affected countries. However, it was noted that the provision of clear information to passengers from affected countries, particularly on symptoms and how to access health care, are important measures in preventing the spread of the disease.

I would specifically like to address the concerns raised by unions in recent days. It is reasonable that health care workers would be concerned about the risk of transmission to them of infections as virulent as Ebola, and although it is unlikely, it is possible. We have seen a number of health care workers being infected in Spain and in Texas. For this reason, we need to step up our preparedness. This will involve training, in particular at hospital level, dry runs and the provision of further equipment.

It is also vital we have the co-operation and commitment of our front-line health care professionals to enable us to respond appropriately. Meetings have been arranged with the HSE. In fact, a meeting took place yesterday. It is hoped the concerns can be allayed and further actions taken and we can all reassure the public that Ireland is prepared.

Considerable public health planning is under way with a range of bodies and professionals about the implications of the Ebola emergency in west Africa. My Department will continue to work closely with the HSE, other Departments, EU member states and the World Health Organization to co-ordinate measures to tackle the Ebola epidemic and to protect Irish citizens.

Chairman:   I thank the Minister. Dr. Holohan will not make an opening statement but will take questions. Will members be specific with their questions and precise and concise in their presentations because a number have already indicated their wish to speak? I call Deputy Kelleher.

Deputy Billy Kelleher:   I thank the Minister for outlining—–

Chairman:   Members have four minutes each.

Deputy Billy Kelleher:   I will stick to questions. Has the task force met at ministerial level to discuss this issue and outline the contingency plans that would be in place in the event of a suspected case or a live case arriving on our shores? Have there been any suspected cases of Ebola to date in this country? If so, did the response follow through as if it was an actual case?

Concerns have been raised by health care professional representative groups, including the IMO and others, in regard to the preparedness of Ireland in the event of a case in this country. The Minister alluded to the risks to health care professionals. The level of contraction of the disease by health care professionals in west Africa is quite alarming. We saw the transmission of the disease in Texas and Spain. There are legitimate concerns among health care professionals. Is the Minister satisfied everything is being done to address the concerns raised by union representatives and individuals who have expressed concerns about our preparedness?

Two issues strike me as a lay person. If a person is suspected of having Ebola, he or she should present himself or herself at a GP surgery. I am a little confused as to why that is the place to go. Should there not be a more formalised place to which he or she could present himself or herself?

I refer to the national isolation unit in the Mater hospital. I know we have the best equipment and isolation units in place and we have negative pressurised chambers and so on, but at the same time, should we not learn from others that taking people who have Ebola to high density places is not the best practice? Is that not something that should be looked at, not only in the context of Ebola but other diseases which may arrive on these shores from time to time?

I do not want to be overtly political on this but the health care professionals have legitimate concerns. I do not know whether they are playing politics with this, to which the Minister alluded, but I know one thing for sure and that is that two health care professionals in Texas and a nurse in Spain contracted Ebola and the priest who brought it to Spain died. The very localised nature of this indicates that the health care professionals are the ones most likely to contract Ebola. They have legitimate concerns. Rather than having megaphone diplomacy or otherwise on this, we should have real engagement to ensure their concerns are alleviated and addressed. Some GPs have informed me that the pack being sent may not be sufficient in terms of information and the protocols to be put in place to transfer a suspected case onwards to the national isolation unit. The equipment itself, in terms of gowns, masks and gloves, could be expanded.

Deputy Caoimhghín Ó Caoláin:   I have a number of questions. Only a couple of days ago, one of the national newspapers highlighted commentary from the IMO – I know a meeting was held with the IMO yesterday – which indicated some GPs had still not received the safety suit and goggles. Will the Minister indicate he is 100% certain all GP practices, out-of-hours services and the presentation areas within our hospital sites have not only received the protective equipment but have actually had instruction on its use? In the first instance, I would think how the protective equipment is put on is hugely important but, in the context of a case presenting, its removal would be of great importance also. Will the Minister elaborate on this?

I note that the medical director and head of the emergency department in St. James’s Hospital has confirmed that it has carried out several practice runs to prepare for a potential Ebola patient presenting. Is that practice in train across all of the sites where it should take place?

Other than the situation in regard to doctors in GP settings and hospital settings, what about nursing staff and other staff, including GP and hospital reception staff? Are we ensuring all those who could be – I emphasise “could be” – exposed to a case presenting are being properly advised and given the essential training as to how to deal with it? Will the Minister elaborate on the capacity of the Mater hospital isolation unit, its current utilisation, if any, and its preparedness?

In the course of my recent priority question to the Minister, where this matter was first addressed in an exchange between us in the Dáil Chamber a number of weeks back, I asked him about advances in terms of treatment and I queried the whole situation in regard to ZMapp. Does the Minister have an update on developments on treatment for Ebola? What is his Department’s most up-to-date information in regard to the speculated medical response to cases presenting?

The IMO issued a statement following yesterday’s meeting in which it highlighted a number outstanding concerns. It is questioning the wisdom of advising patients displaying Ebola symptoms to visit GP surgeries. It does not believe that is an appropriate setting. There is also the issue of robust protocols in terms of emergency department settings in our hospital sites. Again, these are very legitimate concerns which members and the wider public have.

I mention the imperative of training sufficient numbers of hospital staff, which goes to the wider aspect of this, to which I referred, the shortage of public health doctors in general, and the critical need for agreed arrangements to deal with circumstances where medical staff must deal with a patient displaying symptoms of Ebola.

I have a specific question which I am not at liberty to pose in a public engagement with the Minister, but I would like to ask about any concerns in regard to people arriving on our shores, or coming back here, having visited any of the countries where cases have presented.

The advice is simple and understandable but there are real concerns within cohorts around any such given presentation. Does the Minister consider that is enough? Does he really believe that self monitoring is sufficient in that instance?

Senator John Crown:   Go raibh maith agat. I welcome the Minister. It is very likely that all the reassurance we are getting is entirely correct. It is most unlikely we are going to see any kind of apocalyptic scenario such as has been portrayed by Hollywood with respect to newly emerging viral illnesses. However, it is very plausible that we will get a few cases. It does not require any kind of conspiracy theory or apocalyptic bent to imagine that happening. I do think it makes sense because of the potential catastrophe that arises with respect to this infection that we prepare for a scenario somewhat worse than is likely. It may not necessarily be a question of preparing for the worst but we should prepare for something which is a little worse than is likely. Merely preparing for the likely is not enough.

We are hearing a lot of the word “evolution” but this has moved very quickly. There were no infections in western health care workers two weeks ago, and now there have been three and they have occurred in very sophisticated medical scenarios, not in places where people did not realise they were looking after somebody who potentially had Ebola, but in places where they did. We have already seen the most sophisticated and very successful international infection control organisation, the CDC, being somewhat flat-footed and finding itself behaving two days ago a little bit like a deer caught in headlights and suggesting there must have been a breach of protocols when somebody became infected and then understanding that it was quite possible that the protocols themselves were adhered to but were inadequate. We have not got clarity on the issue yet, but what we do know is that the CDC itself has ramped up the level of scrutiny and the level of intervention it is carrying out. Its “hit squads” will go around the country and are now advising a higher level of personal protection. We must understand without being alarmist that there is a possibility that the situation will be somewhat worse than it was.

I have a number of specific questions for the Minister, one which was mentioned by Deputy Ó Caoláin. We need clarity on the advice given to GPs because it looks like the original advice was to visit and that has now been downgraded to contact. If someone does contact his or her GP, what is the specific instruction the GP will be given if an issue arises? Could the Minister please tell me how many doctors we have employed in the specialty of public health in Ireland, a rough idea of how that compares to international standards, and how many of them are doing front-line public health jobs and how many are in administrative roles?

I could get emotional talking about the medical experts dealing with the crisis. To date, 10% of the deaths have been among doctors and nurses. That has never happened before. There has never been such a disease in modern times, where the people who get the sickest are the most infectious; that the people who need health care most pose the greatest threat to the nurses and doctors who treat them. They are great people. How many Irish nurses, doctors, missionary workers and aid workers are involved who are potentially going to get infected? Do we have a policy? Will the routine policy be that people will be repatriated? If they wish to be repatriated, will we have the facility to repatriate? Do we have the facilities in place for safe containment? I am fully supportive of any Irish person who gets the illness being repatriated.

Amplifying a little on the questions Deputy Ó Caoláin asked, what is the containment level and what is the personal protection level we are using in the Mater hospital unit at the moment? Is it level 4? From what is coming out of the CDC it looks like it is a moving target right now. The CDC is ramping up its own recommendations. Do we have pressure suits and, if so, how many?

With the current staffing and equipment level, how many simultaneous cases of Ebola can be handled in the Mater hospital unit? Do we have provision for staffing to recant from the buddy system everybody is recommending right now, which is effectively double staffing on an hour on and hour off basis? Can we cope with that? Do we have the ICU beds? What level of training has been given and what is the specific plan to increase the level of training? This is a very important undertaking. I hope it is an example of something we will never need to use but we might, and we need to be ready.

Another scary element is that a vastly larger number of people is infected with the virus right now than has ever occurred previously. The number of virus particles in humans right now is probably ten or 20 logs higher than it ever has been before. As the capacity for a mutation is possibly greater than it has been before we do need to keep ahead of this one.

Senator Colm Burke:   I thank the Minister for his presentation this morning. I wish to raise three issues. One relates to people returning home from countries that are affected. Is the Minister satisfied that proper protocols are in place for monitoring and dealing with those people when they return home? I refer in particular to perhaps three weeks before the symptoms are identified. What protocols are in place, and are we satisfied they are correct? How will the situation be monitored?
If an Irish person contracts Ebola abroad, what procedure will be followed? Will the person be treated in situ or will he or she be returned home and we will assist in the provision of the necessary care and support?
Is the Department satisfied that the aid agency that has agreed to get involved in the provision of medical care in countries affected by the outbreak has the capacity to adequately train people? Has it the capacity to provide the necessary supports? This is something new for the aid agency concerned to be involved in. A considerable amount of State money is being provided to the agency. Are we satisfied that protocols are being followed correctly and appropriately and that the necessary training will be provided by the people the agency will assign to the projects?

Deputy Leo Varadkar:  There are a lot of questions. I will not be able to answer them all but I will answer as many as I can and then I will hand over to Dr. Holohan. The task force has met at ministerial level. We met about two weeks ago. At the time we decided not to issue a statement or hold a press conference as we did not want to unnecessarily heighten concern. The task force expects to meet again at ministerial level.

I was asked about having a suspect case, which we have. Members will be aware of a person who died in Donegal over the summer who had been to the region and had to be tested for Ebola post mortem. The person did not have Ebola. One or two people have presented in usual scenarios claiming they have Ebola but they have never been to the region or been in contact with anyone from the region. None the less, one cannot dismiss such cases and they must be taken seriously. There have been approximately a dozen cases, only one of which could possibly have been Ebola, in the sense that the person concerned was in the region or was in contact with someone from the region. My colleagues might provide more information on the case.

It is important to point out that there is a difference in what we can learn from West Africa to what we can learn from Texas and Spain. Speaking to people on the ground, including the Minister of State, Deputy Sherlock, it appears that health services are virtually non-existent in that part of Africa. We often hear people talk flippantly about the Irish health service being “Third World”, but it certainly is not. Liberia has the same population as the island of Ireland and a total of 60 doctors. That is what people are dealing with. They do not have proper hospitals even in the capital city. Not too far away in Nigeria, which is a much more developed country, there was an outbreak of Ebola. There were 20 cases which resulted in eight deaths but no deaths have occurred in recent weeks. The situation has been contained there. In between those West African countries and Nigeria is Côte d’Ivoire, Ivory Coast, which has had no case at all. It is important to point out that what is happening in West Africa is first related to the fact that they are war-torn countries with effectively no health care infrastructure and they are countries in which the virus thrives because of the environmental conditions.

We can learn a lot from Texas and Spain. If Ebola does appear in Ireland it is much more likely to be along the lines of what happened in those places, namely, affecting somebody who has been repatriated or has come back independently and ends up in an isolation unit. We are still learning. What seems to have happened in Spain and Texas where health care workers got infected has been around the degowning procedures. They are now recommending that people should be observed as they degown and gown. We would not have known that a few weeks ago.

The situation is evolving and we need to learn from what is happening and adapt to it. I am satisfied that we are ready but the situation is escalating and we need to escalate our response to it from now on. We must also be ready to de-escalate it should the outbreak be contained in west Africa. If somebody who is being repatriated is taken to the national isolation unit, he or she will be taken in a sealed pod. Dr. Holohan will elaborate on that later.

I was asked to respond to some of the concerns that have been raised about staff. The concerns that have been raised by trade unions about their members and staff are entirely reasonable and legitimate. I should point out that any staff infected in the western world have been isolation unit staff, and not routine or emergency department hospital staff or GPs, but it is still a matter of concern. Concerns like that are best addressed through the regular meeting that we have. It is very important that we support the front-line health care professionals and that we use their networks to get the message out to health care professionals, some of whom might be a little sanguine about this and are only waking up to it in the past couple of days as it developed as a media story. By and large, I would prefer that when it comes to a public health emergency of any sort that we set aside normal politics and that applies to all of us around this table and our different political parties and it applies to everyone in the health sector as well. When it comes to a major public health emergency or the risk of a major public health emergency, we should set aside normal concerns about normal politics and normal debates and get behind the effort that must be taken.

I have not read the IMO statement but my understanding is that the advice is not to go to the GP’s surgery but to call a GP. A GP or a well trained practice nurse would be able to triage a patient. One cannot expect patients to know about Ebola but GPs and practice nurses would be able to identify very quickly as to whether there is any possibility that the person could have Ebola. They would be able to triage a patient and then deal with it from that case. There will be people who have a high temperature and be concerned that they have Ebola, even though they have never been to the region or never been in contact with anyone who had Ebola.

When it comes to aid workers and people returning from that region, they are well briefed and well trained on what they should and should not do. They are asked to contact the public health department on the Health Protection Surveillance Centre, HPSC website, which is very good. It is worth looking at all the algorithms and protocols on it. There are telephone numbers as to whom a concerned GP can contact, as well as telephone number that a person coming home from the region can contact and get advice from a public health specialist so that the person is directed to the right place. One thing we may have to consider and which we are already considering, is putting together a team that can move in and go into a hospital if there is a suspected case and help the hospital to deal with it, if the staff of the hospital are not able to do it themselves. When it comes to practice runs, they have happened in some hospitals, but I know for a fact that they have not happened in other hospitals. We need to ensure that dry runs and practice runs happen in every hospital. That has to be led by the infection control and emergency staff on the ground, but we will be doing texts to ensure that has been done.

I cannot say for certain that every practice and out-of-hours service has got the equipment but I know that 5,000 packs have been issued and there are not 5,000 GPs and out-of-hours services in the country. If anyone does not have them, they need to let the HSE know and we will ensure they get them.

On the national isolation unit, NIU, I have all the details on the number of beds. I am not sure if members want me to go through the figures as it will take time to go through the details. I will leave that to my colleagues.

There is no vaccine for Ebola. The drug ZMapp is an experimental medicine and is only made as it is requested. We do not know if it works. The treatment for Ebola is supportive measures and also very tight infective control around it. I do not know off the top of my head the number of public health doctors in the country but I can get the figures for members.

I do not know the exact number of Irish aid workers specifically on the ground but there are 54 Irish citizens in those three countries and they are accounted for and registered with the Department of Foreign Affairs and Trade. To the best of my knowledge it is not correct to say that 10% of the deaths from Ebola are doctors and nurses, it is about 5%. When it comes to the repatriation of an Irish person overseas, that is something that will have to be considered at the time. Ireland does not have the capacity to repatriate somebody from west Africa, most small European countries do not, and what is happening at foreign affairs level is that efforts are being made to put together something on a European level, which is of particular interest to smaller European countries that do not have a big airforce and are not able to do what the British, French or the Italians could do.

If there is an Irish citizen overseas, consideration will have to be given to the scenario. One will have to consider if the patients is well enough to be transported, as sometimes they are not. Consideration has to be given as to whether they can be treated on the ground in theatre. If they can be treated well on the ground that would make more sense that taking the risk of repatriating them. We need to bear in mind that by its nature, evacuating somebody into Ireland does bring the disease into Ireland. It is a difficult to think about out but it is true, the only reason that the Spanish and American health care workers have been infected is because people were evacuated to America and Spain. From a very heartless epidemiological point of view one is helping to spread the virus through repatriation. At the same time I cannot possibly countenance the idea that we would leave an Irish citizen without care in the theatre. That is an issue we will have to consider on an individual case basis, should it arise. The NHS is trying to establish its own hospital in the region to help treat aid workers should they become infected.

Senator Burke asked a pertinent question about the different aid agencies certainly Médecins Sans Frontières, MSF and the International Medical Corps are well used to dealing with situations like this – I cannot say for certain about the others – aid agencies can help in different ways. They would not all be treating patients, some of them would be proving logistical support and other things that are often just as important, helping out the governments on the ground and the general government that barely exists in west Africa. People who criticise democracy and politics and everything else can see what the alternative to government and politics is. This is very evident now in west Africa.

I will ask Dr. Holohan to fill in some of the gaps.

Dr. Tony Holohan: The gaps are few but I will clarify from my information that the number of people in whom suspicions have arisen and where testing has taken place is 14 and about 23 tests done in the 14 people. That is the number we have dealt with so far.

Deputy Ó Caoláin asked about non-medical workers who might be at risk, it is important to stress that risk only arises in the case of contact with symptomatic individuals or individuals after they have died. There is no risk in contact with individuals during the pre-symptomatic phase. If an individual is symptomatic it still requires contact that can lead to transmission of bodily fluids. Ordinary contact that administrative staff have is not likely to lead to situations where—–

Deputy Caoimhghín Ó Caoláin:   What about nursing staff?

Dr. Tony Holohan: Nursing staff are in a different situation. Clearly nursing staff are in a situation where they have direct and intimate contact with symptomatic patients and there needs to be—–

Dr. Darina O’Flanagan: I wish to clarify the point raised. Is Deputy Caoimhghín Ó Caoláin referring to practice nurses in general practice?:

Deputy Caoimhghín Ó Caoláin:   In any setting?

Dr. Darina O’Flanagan: We would not advise that nurses in general practice assess a possible Ebola case. We would advise in that case the person would be assessed by a GP.

Dr. Tony Holohan: To go back to what the Minister said, our advice now is that people make contact with their GP. The GPs have a very simple algorithm that will enable them to make an assessment of an individual’s travel history and their symptoms and to make an appropriate recommendation to an individual as to whether he or she requires further assessment at hospital level. We must provide GPs with the information were a situation to arise that somebody simply arrived into a GP surgery. Let us be clear that we are not directing people, whom we believe to be symptomatic potentially with Ebola or such conditions to general practice surgery as the place for that assessment.

A question was asked about the containment facilities in the national isolation unit. Currently there is a capacity of 12 beds and there are plans in place to double that capacity.

An active plan is being developed through the hospitals division in the HSE to consider expanding that capacity in the event that it is needed. As Senator Crown rightly stated, it is a question of identifying what is likely in terms of provision and going one step further to ensure that we are in a position to—–

Chairman:   What about outside the Mater? It is an unlikely event, but could still happen.

Dr. Tony Holohan: Through their existing emergency preparedness arrangements, individual hospitals have a means of identifying their isolation facilities. They must treat their patients in accordance with those arrangements. If a case is identified, an assessment will be made on its merits as to whether the most appropriate course of action is to have the individual transferred to the national isolation unit in the Mater. It might not happen in every situation because it might not be clinically appropriate for that individual. We can discuss principles, but the assessment of any individual in the context of repatriation or movement within the country must take account of the clinical situation and the public health implications.

Unless I am mistaken, I believe I have—–

Senator John Crown:   My question was on facilities in the Mater’s unit and—–

Deputy Caoimhghín Ó Caoláin:   Regarding self-monitoring—–

Chairman:   I am sorry, but four other members wish to speak.

Deputy Caoimhghín Ó Caoláin:   I have just one point to make about self-monitoring. For people presenting in this country, whatever the circumstances, I understand that the current advice is to encourage them to self-monitor.

Dr. Tony Holohan: A specific arrangement is in place and advices provided, for example, to volunteers returning to Ireland who are at high risk or have had high-risk contact. The advice is that they should first identify themselves to their local public health departments and that, on a twice daily basis, there should be a recording of temperatures and symptoms. This is the mechanism that has provided for that high-level surveillance. Like every other arrangement that is in place, we would never say that our plan is static. We respond to the intelligence we receive from the international community, continually assess it and feed it into the adaptations that we might need to make to our plans, for example, the novel arrangements that are now being pursued in the US to provide for support teams from the Centers for Disease Control and Prevention, CDC, to help hospitals in handling infection control procedures that authorities there probably imagined were fit for purpose but have turned out not to be as robust as they might have liked. Every country must be able to respond dynamically to evolving information. If we find that our plans and procedures need to be strengthened further, that is exactly what we will do. However, our current arrangement is in line with what will happen internationally. Dr. O’Flanagan may have something to add.

Dr. Darina O’Flanagan: I agree. As to the question of aid workers returning, it depends on their level of exposure, whether they have been in contact with Ebola cases and whether they have been exposed to bodily fluids. If they have, there will be active monitoring. In other words, public health staff will organise to have them telephoned twice per day to check that they remain asymptomatic. If they have not had high-risk exposures, they will be asked to notify, take their temperatures twice per day, self-monitor and report if they develop fevers. It depends on their level of exposure in the country in question.

As Dr. Holohan stated, we are constantly considering our protocols for contact tracing. We are learning from the experience in the US. We will review that and the experience in Spain to determine whether our protocols need strengthening. In addition, the European Centre for Disease Prevention and Control, ECDC, has guidance on contact tracing and the appropriate steps to take. We follow that guidance closely.

Chairman:   I will call the following four members – Deputies Fitzpatrick, Conway—–

Senator John Crown:   I would like an answer to another question.

Chairman:   I will allow the Senator back in at the end. In fairness, four members have not spoken yet.

Senator John Crown:   I will ask on air later.

Chairman:  I will call Deputies Fitzpatrick and Conway, Senator MacSharry and Deputy Healy in that order. I will allow Senator Crown to contribute again if his question has not been answered by then. The members who have been present all morning also deserve a chance to be heard.

Deputy Peter Fitzpatrick:   I thank the Minister and his Department for their excellent presentation. As the Minister knows, many Irish people are concerned about the high risk of the Ebola virus spreading globally. He answered many of my questions in his presentation. I welcome the fact that the Health Protection Surveillance Centre has issued guidelines to hospitals and general practitioners, GPs, but were they issued to all hospitals and GPs? Cases might present anywhere.

What extra surveillance has been put in place at ports and airports? Do we have qualified personnel? If someone presents, what is the protocol? Many families in Ireland have relatives in Liberia, Sierra Leone and Guinea. Are these families being monitored or have they been contacted? Has any of them been on holidays in the last three to four weeks or is any out there currently?

This morning, the Minister stated that no one in Ireland had Ebola, but I also heard on my local radio station of a suspected case in my county. I want to stop the scaremongering.

Deputy Leo Varadkar:   There was a suspected case yesterday, but not anymore.

Deputy Ciara Conway:   Many questions have been asked about the distribution of packs for front-line health care workers. Having read a little about how the workers in America are dealing with the situation, I would like to focus on the issue of the disposal of such garments. Where patients were treated effectively in the US, a significant amount of resources and specialised equipment was used in the decontamination of equipment before it was transported by waste management companies. For example, industrial autoclaves operating at very high temperatures were used to treat disposable garments before they were put on the “Federal highways”.

The Minister referred to repatriating someone with the disease. We have a free travel area arrangement with the UK and there are frequent ferry services. If a person appears in Rosslare, is treated there and undergoes an assessment to determine whether he or she should be brought to the Mater, what of the equipment used in Rosslare? Has thought been given to this issue and how will we deal with it? While it is good to know that the packs have been distributed, if one or two cases arise in Ireland, how will we ensure that standards are met, in light of the fact that most of our waste disposal services are private? How are we engaging with those providers with a view to ensuring that this disease is cut off at the earliest point?

Senator Marc MacSharry:   I thank the Minister, Dr. Holohan and his team for their presentation. The Center for Infectious Disease Research and Policy, CIDRAP, at the University of Minnesota has just advised the CDC and the World Health Organization, WHO, that the aerosol transmission of small or large particles is possible. The WHO has stated that face masks should be worn and the Department has sent those to GPs. During the 1998 situation, however, the WHO called for the use of respirators, in particular powered air purifying respirators. We know of some definite means of transmission, but we do not know them all. Increasingly, CIDRAP’s research is showing that aerosol transmission is possible. Have we powered air purifying respirators? How many do we have? Where are they? If we have none, how much are they and should we be buying some? CIDRAP has advised the US Government to make resources available immediately so that such respirators can be on hand. The WHO has stated on its website that standard masks are okay when dealing with viral haemorrhagic fevers, but it also recommends the use of respirators.

[Senator Marc MacSharry:  ] I accept that we are somewhat prepared for the unlikely event of an infection happening here. If it did, how prepared are we in terms of respirators and other things? Let us say this has evolved from the Zaire strain which was the first, through the Congo and now we have today – call it what one will – the Liberia strain. Has it evolved to the extent that it is much more infectious from aerosol? For example, sneezing or even flushing a toilet can put pathogen-laden aerosols into the air.

While I do not want to go into crude detail, the Center for Infectious Disease Research and Policy suggests that a health professional without a respirator attending an infected patient who has had an episode of diarrhoea is not safe. Albeit unlikely, and as Senator Crown has said and the Minister has agreed with him, let us see what the risks are and go one step further. Maybe we need to go a few steps further. I ask for a response on the respirator issue.

Deputy Seamus Healy:   I thank the Minister, Dr. Holohan and the officials for the briefing. Obviously, it is very important for us not to be alarmist on the issue. However, we need a high level of preparedness. For clarification, as we have already said, we need to say very clearly that suspect cases should not attend their general practitioners. I take it that also means they should not attend accident and emergency departments. What is the procedure for a possible case? How does that case get from the initial situation to the isolation unit in the Mater hospital? It is clear that screening at airports in west Africa is being recommended. Is there a case for a belt-and-braces approach for airports here at home?

Deputy Catherine Byrne:   Many questions have been asked. I thank the Minister and the officials. I believe the Minister mentioned triage nurses and the lady at the end of the phone. I say this as a layperson with no medical experience. Why would we not use a special isolation unit outside a general hospital rather than bringing people into a general hospital? Could some other space not be used?

Many of the comments, particularly on television, have centred on people being buried. Why are people with such infectious diseases not being cremated?

Regarding the screening, if somebody develops symptoms at home, how do they make initial contact? Is information being given out through the media, including television and radio? I know many people might think they have it. How is that information given out? Is there a public awareness issue?

Chairman:   Senator Crown indicated he had a question unanswered.

Senator John Crown:  I just want a bit of clarity. It is all very well to say we have 12 isolation beds. Since I asked my question, I have received a message stating that two of them are the highest-level containment beds with negative pressure; four others are standard ICU, still negative pressure; and six are in shared rooms. That partially answers the question I was asking. However, what level of containment do we have for the staff? How many patients can be looked after simultaneously if we go with what looks like the revised CDC recommendation of going beyond mask, gloves, boots, etc., and actually going to pressurised suits? How many people could we cope with at the moment with that?

Chairman:   I call the Minister and then Dr. Holohan.

Deputy Billy Kelleher:   I wish to reiterate a question I asked earlier. Have we any other isolation unit equivalent to that in the Mater hospital in any other region or could one be prepared in short time?

Deputy Leo Varadkar:   Many of these questions are quite sectoral or scientific. I will answer the ones I can and then hand back to Dr. Holohan and Dr. O’Flanagan.

Exit screening is in place in the airports of the three most affected countries. Of course it is never possible to be sure that it is 100% up to scratch; that is the nature of these things. So far the only airport in Europe that has decided to carry out entry screening is Heathrow, which has direct and connecting flights to the region. However, it is something we need to keep under consideration.

The general WHO advice is not to do it on the basis that people who are asymptomatic – a person is asymptomatic for 21 days by and large – will not show up. What will show up are many people with coughs and colds and other illnesses, who have a temperature, but not Ebola. The only real benefit in it might be contact tracing. We need to keep it under consideration. To date, the advice is not to do it and to assist with the exit screening rather than doing entry screening in other airports. Even in the UK, although it is being done at Heathrow, it is not being done at any other airport. For the ports there is a protocol and I can send on those details.

The advice for the public is important. The HPSC website is very useful in this regard. The aid workers have all been told to register with their local public health department and all the numbers are there. They are told how to monitor in the first 21 days. For other people, the website states, “If you have had no contact with Ebola patients or articles potentially contaminated by them then you do not need to take any precautions as you are not at risk”. However, if a person has been in contact with Ebola patients and in contact with potentially contaminated items, the website recommends that a person becoming ill within 21 days of return from the region “should contact your doctor for assessment and let him/her know of your recent travel history”. What is envisaged in the guidelines is that a person would contact, presumably by telephone, his or her doctor who can then follow the protocol and assess if the person needs further action.

The IMO statement, which is in front of me, questions the wisdom of advising patients displaying Ebola symptoms to visit their GP. The guidelines do not state “visit”, but state “contact”. However, that may need to be made more clear lest there be a misunderstanding there. I can clarify that the guidelines do not suggest that people visit their GP. They suggest the circumstances under which they should make contact with the public health doctors or their GP.

Deputy Catherine Byrne asked about specialised units outside a general hospital. I do not fully know the answer to that question, but I imagine the reason they are in a major hospital is that they would need close access to other hospital facilities, such as ICU, radiology and laboratories. Without that there would be all the risk of transferring a patient and his or her samples to and from a hospital.

Deputy Conway’s question related to the disposal of garments. That certainly could arise if we had a confirmed case. That relates to the issue of category A waste. I might let the CMO speak on that because he has been doing some work on that today.

Deputy Kelleher asked about other parts of the country. We will be asking hospitals to identify which isolation bed they will use if they suspect a case. All the acute hospitals would have isolation facilities. To the best of my knowledge, none of them would be up to the level of the national isolation unit, but that is the nature of a national isolation unit; it is at a different level. It is the kind of thing of which each country – or each state in a large country – would have only one.

I will also ask the CMO to speak on the issue of aerosol transmission. GPs obviously would not be doing aerosolising procedures in their surgeries, but there are other ways to create aerosols as the Senator pointed out.

Deputy Healy asked about the different patient scenarios. There are many different scenarios. When we had the emergency task force meeting two weeks ago, we started to come up with different scenarios. All sorts of scenarios could arise and we have gone through some of them. Again, I might ask my colleagues to comment on them further. There is obviously a huge difference between somebody who we know has a confirmed case of Ebola who is brought into the country and a suspected case that may just turn up somewhere.

We have had a couple of them already.

Dr. Tony Holohan: I will take Deputy Conway’s questions on the disposal of the waste. The waste is termed “category A waste”. It is highly infectious and there needs to be specific arrangements in place for its disposal. It is generated largely through the secretion of bodily fluids which, unfortunately, are secreted in copious amounts by individuals when they are symptomatic. Obviously, all the materials used form part of that waste so, in the first instance, it has to be handled appropriately and, in the second instance, it has to be disposed of appropriately. The arrangements the Deputy referenced in the US, in terms of industrial autoclaves and so on, are the kinds of appropriate arrangements, including things like incineration, to dispose of that waste.

There is an ongoing discussion on arrangements for that. There are two potential methodologies. We are in discussion with the Environmental Protection Agency, through the HSE, around the licensing of an appropriate facility to provide for disposal of that waste in this country, should the need arise and, in the interim, to provide for a mechanism, should it be necessary, for it to be disposed of through international agreements – essentially, its exportation out of the country through channels that are appropriate to handle that form of waste. It is an important consideration in the context of the handling of these issues.

To go back to Senator Crown’s question, I think his information is correct in terms of the current designation of those beds but again I stress the point that this is a dynamic situation and I go back to swine flu, for example. We had a static capacity in terms of ICU. It became clear, in the context of that particular epidemic, that it was not sufficient and a plan was put in place to ramp up that capacity very quickly. Extra machines, ventilators and so on were required and new areas were identified within our hospitals to allow them to ramp up that capacity quite quickly. On that basis, similar discussions are beginning to happen with the Mater hospital about what would be the eventualities if there was pressure on that existing static capacity. How would it ramp up that procedure? How would it commission and bring into effect other areas that could operate to the same standard of isolation? That is a discussion that is going on between the HSE and the people in that particular unit. We would not sit here and say this is the static capacity and it will always be sufficient for any given scenario. We have to be able to adapt, based on what we get.

I will also go back to the discussion around repatriation. When we have a question that may arise, in the context of repatriation, there will, in spite of our need to have in place agreements and mechanisms to repatriate individuals when that need might arise, still have to be an assessment on the basis of the clinical status of that particular individual as well as all the considerations like, for example, capacity, which I mentioned, around the repatriation of that individual at that point in time. This is important in terms of people who might be making decisions about going to these areas and potentially becoming involved in activity which involves high risk. We would not for a moment say that people should not do that. It is a very appropriate and worthwhile thing for people to do, but they should do it in an informed way. Some of the information we have provided, through the Department of Foreign Affairs and Trade and the aid agencies, deals with some of this and reminds people of the importance of understanding that even if they do not pick up Ebola but become ill in some other way or injured and find themselves using health care facilities in these affected countries, they will become exposed to these viruses. That is a specific risk of which they need to be aware. The repatriation of those individuals in those situations could be challenging.

Chairman:   Do we have any plans or procedures in place for aid workers returning home from these affected areas?

Dr. Tony Holohan: We have specific information which is directed and supplied to them as to their understanding of the nature of the risk and their ability to be able to self-monitor and report or, if necessary, participate in active surveillance when they come back.

Dr. Darina O’Flanagan: On the question on respirators and the evidence of airborne transmission, the only studies that have shown airborne transmission were done in animal testing. There has never been any evidence of airborne transmission of Ebola between humans. Previous studies have looked at family members and at who got it and who did not and it is the people who have direct contact with the bodies and bodily fluids. All the evidence points to direct contact.

The only time we are worried about aerosol is, as Dr. Holohan said, in relation to aerosolising procedures, like intubating the patient. Those procedures are not done in general practice. Respirators and FFP3 masks are available in hospitals where there is the potential for aerosolising procedures. The FFP3 masks stop aerosols just as much as powered hoods. Staff have FFP3 masks. If they wish to use a powered hood, that is possible, but is not necessary according to guidance from CDC, the WHO, etc. Obviously, the transmission in the recent cases in Texas and in Spain has caused concerns among health care workers, so CDC is very carefully looking at where there was potential breakdown in regard to personal protective equipment, PPE. These issues will be fully examined and lessons will be learned, but the initial information coming out is that it may have been more a problem when people were taking off the PPE rather than the effect of the PPE when they were actually wearing it. The most dangerous time for a health care worker is actually taking off PPE.

The other thing I would like to stress is that patients become more infectious the more the disease progresses. When patients present to GPs or in emergency departments, they do not have the same viral load they have when the disease progresses and they are extremely ill. The greatest risk to health care workers is when caring for cases in extremis. People have to be aware of that. I can understand the concerns of health care workers but where we need to make sure people have this right is in terms of health care workers who are handling the extremely ill patients who, as Dr. Holohan said, are producing copious amounts of bodily fluids. That is the time when they are most infectious.

As was said, people are using the buddy system and are making sure that when they take off the PPE, they are doing so appropriately. Those systems are being practised and are being put in place for those who will handle the really critically ill patient.

Chairman:   Are we training paramedics who may be put in that position?

Dr. Darina O’Flanagan: The national ambulance service has training. I understand that, this week, it is making another video to use with the ambulance personnel. It has had practice runs for the transport of patients many times.

Mr. Gavin Maguire: If I may add to that, obviously members are getting some kind of a flavour today of the broad range of activities being undertaken in the HSE to date to prepare, and there are more. We are acutely aware of the concerns of front-line health care workers, as expressed today. As Dr. Flanagan just pointed out, there is ongoing familiarisation training and exercises occurring right across the ambulance service, in hospitals and among GPs and others involved. We realise we have to escalate that and ensure that reaches more, and we are focusing on that right now.

To pick up on another general point made earlier, this is moving very fast, as Senator Crown mentioned. We are adapting, changing and strengthening our algorithms and guidance in accordance with international learning, as one always does, but we are also conscious of listening to our own staff, and we are doing that. We are also engaging with other stakeholders. As mentioned earlier, we met the IMO and a couple of unions yesterday. We will meet other unions next week. We are eager to engage with all stakeholders involved in this and to learn from international developments. We will adapt and strengthen our approaches as a consequence of those engagements.

Dr. Tony Holohan: I will make one additional point that arises in the context of the discussion around training, and the Minister referenced it earlier in the context of people being sanguine. As part of our plans, we provide training on an ongoing basis, but the engagement of people with training has to be greater as we get closer and as the risk changes. As we become more concerned, the level of understanding, but also concern, rises. It would be challenging for us to run training programmes for GPs if there was no Ebola. The likelihood is that we would get very little in the way of attendance from individuals who did not perceive that there was some risk. There is always a point in time at which it is appropriate to step up arrangements, including training arrangements, and so on and that is one of the things we are doing, as Mr. Maguire said.

The principles behind a lot of what it is we do is that we have good and clear governance around how we make our decisions and how we assess our evidence. It is based on good information, good surveillance, good practice and dry runs of our procedures and arrangements.

I think Deputy Healy asked for a walk through from the point at which a person presents through to the Mater hospital.



Chairman:   Simulation.

Dr. Tony Holohan: I ask Dr. O’Flanagan to take that question.

Dr. Darina O’Flanagan: The questions were how a patient might present and how they would be referred. A patient can present in two ways. As we have said, if a patient returns, they can see on the posters that if they have recently come back from an affected area, they should phone their GP. If they do so their GP will take their history, see what the symptoms are and decide either that they are at high risk or they are not. If they are at high risk, the GP will telephone the hospital to arrange a referral and he or she will be told where the patient is to be sent.

Next the patient goes for an assessment in the hospital. There is a risk assessment form they complete within the hospital to assess if they are high risk. Then they get a lab test taken which is sent to the National Virus Reference Laboratory. If the test is positive, the clinician phones the national isolation unit to discuss transfer to it and the national isolation unit contacts the National Ambulance Service to arrange the appropriate transfer.

The other issue raised was what happens if a case arises abroad but is repatriated. In that case it is a question of arranging the transfer from the airport where they land to the national isolation unit. Those protocols are in place with the National Ambulance Service to arrange that transfer.

Deputy Billy Kelleher:   I wish to ask a brief question.

Chairman:   Three other Members wish to ask a follow-up question. We also gave the Minister a commitment that he could go to another event and Deputy Ó Caoláin wants to raise a matter in private session. Therefore, I ask Members to be concise in their remarks.

Senator Colm Burke:   We have focused on Irish people travelling abroad. What about the scenario of non-Irish doctors coming here to work? Have we put new protocols in place to deal with the issue? It is a fairly remote scenario but we need to keep it in mind. On the first day or first week of January, new people could come in from abroad. New protocols must be put in place to ensure we have all the checks in place to deal with the issue.

Deputy Ciara Conway:   I am glad the Department is exploring the issue of waste disposal. It is in the nature of Ebola for a person to suffer vomiting and diarrhoea and thus lose a huge amount of body fluids. There will be a huge amount of waste created even if only one person is affected. Dr. Flanagan has said that the biggest risk to health care workers is when they de-robe as they may make contact with waste. Should we shore up our plans for waste disposal? How wise is it to export this waste? Is there a potential to endanger our European neighbours?

Senator Marc MacSharry:   I thank the delegation for the answers. I am not trying to scaremonger here but ask the delegation to apprise itself with the University of Minnesota’s paper.

Dr. Darina O’Flanagan: I am familiar with the university’s findings.

Senator Marc MacSharry:   That is fine. I have read the paper and it does not correspond with Dr. Flanagan’s assessment.

Deputy Billy Kelleher:   A person who suspects that he or she may have Ebola is supposed to contact his or her GP. Then the GP runs an algorithm which assesses the risk and if a person is found to be high risk, he or she is referred to a hospital. Is that not weak link? Should the GP go to the residence of the person in the first place to conduct a full assessment as opposed to referring a person to a hospital? Otherwise it is possible that an infected person could wander into a hospital. Will the delegation to clarify the matter?

Chairman:   I will allow one other person to contribute before returning to the panel. I call Deputy Fitzpatrick and ask him to be quick.

Deputy Peter Fitzpatrick:   Can the panel elaborate on the suspected case announced yesterday?

Chairman:   I suggest Dr. Flanagan starts by answering the direct question from Deputy Kelleher.

Dr. Darina O’Flanagan: The Deputy mentioned a GP referring a patient to a hospital where that patient may be a possible case.

Deputy Billy Kelleher:   That is what Dr. Flanagan said, yes.

Dr. Darina O’Flanagan: The vast majority of people who come back with a fever from these affected countries will not have Ebola. The vast majority will have illnesses like malaria and typhoid. Therefore, it is appropriate these people are assessed in a hospital, tested and the appropriate people who need care, because they tested positive, are referred to the national isolation unit. It would be inappropriate not to test these people in hospital. They cannot be properly assessed in their homes. They need to go to hospital for the appropriate investigations.

Deputy Seamus Healy:   Is it appropriate for them to go to an accident and emergency department?

Dr. Darina O’Flanagan: That is the issue. Hospitals are being asked to identify the most appropriate location within the hospital. There may be an isolation ward located in their emergency department. That is an issue for each hospital to determine.

Deputy Seamus Healy:   All the general hospitals of which I am aware take admissions only through their emergency departments. I do not know whether that is a good system.

Chairman:   Not in all cases.

Mr. Gavin Maguire: In terms of the algorithm in this case, and we have done this before in relation to the initial contact, specific arrangements are made for the patient to enter the hospital in a controlled fashion based on the plan of each hospital. It is a change in protocol from the norm and the person is not going to the emergency department.

Dr. Tony Holohan: Just to stress the point. Hospitals will have a capacity, via their emergency departments, if the need arises to isolate individuals for the purpose of assessing them. As Dr. Flanagan has said, the vast majority of these patients will not have Ebola but some other infectious disease. We expect that hospitals will be in a situation to conduct those assessments.

One of the things that is happening at the moment, and we have been talking about the HSE’s hospitals team about this, is that the assurance arrangements we need to have are in place and everything that needs to be done at the level of each hospital is being done and is in place. We have been working on those, and that checklists are going to hospitals to ensure they are doing all the things they need to do. That will include arrangements, such as the ones we have spoken about, to make appropriate assessments of individuals.

Chairman:   I remind the delegations that Deputy Conway mentioned waste and Senator Colm Burke commented on new doctors.

Deputy Leo Varadkar:   I will respond to the comment made about non-Irish doctors coming here for the changeover in January. We do not have any doctors coming in from west Africa. They need to remain where they are. We have doctors coming here from India, Pakistan, some of the Arab countries and Sudan. To the best of my knowledge, there have been no cases of Ebola in any of those countries. There is no reason to impose obligations on them that we would not impose on anyone coming from anywhere else.

I can confirm to Deputy Fitzpatrick that there was a suspected case in County Louth yesterday but that has since tested negative. For reasons of patient confidentiality, I cannot give him any further information. Even as Minister for Health I know very little about individual patient cases. People often assume I am able to look at people’s medical records and investigate their individual circumstances. I cannot because doctor-patient confidentiality applies even to politicians.

Dr. Tony Holohan: In response to the waste issue, I ask Mr. Maguire to supplement what I said earlier.

Mr. Gavin Maguire: As the chief medical officer outlined, we are discussing with the HSE and EPA arrangements in this area. There are two aspects to waste. First is the holding and management of the waste on site. Second, as the CMO outlined, there is the disposal of that waste.

We are working with the Health and Safety Authority, and we expect a result fairly quickly, on optimum waste and hope to store it initially pending transportation and disposal. We are exploring two options. As the CMO outlined, one is exporting the waste and the other is working with the EPA to see if there are other options related to incineration in the country. Both options, in terms of transport and containment, would be undertaken under very controlled conditions which would have to be complied with.

Deputy Ciara Conway:   Is it correct that there is nowhere licensed to dispose of this waste?

Mr. Gavin Maguire: That is correct.

Deputy Ciara Conway:   There is nowhere in Ireland licensed to dispose of this waste.

Mr. Gavin Maguire: Correct.

Dr. Tony Holohan: There is an active discussion taking place, which is expected to yield something in days, between the HSE and the EPA. That is my information. Although what the Deputy has said is correct, we anticipate that will no longer be the situation in the next few days. That is yet another example of our dynamic response to the issues as they arise.

Deputy Catherine Byrne:   I wish to ask a layman’s question. Why are people with Ebola buried and not cremated?

Dr. Darina O’Flanagan: We have guidelines, agreed with the coroners, on the handling of dead bodies. In relation to dead bodies abroad whom people wish to repatriate, the Deputy is right that cremation is a good idea. There are guidelines for the safe disposal of bodies.

Chairman:   I thank the Minister and his officials for their very active engagement in this public part of the meeting. I also thank members of the media and Oireachtas staff for their interest.

The joint committee went into private session at 1 p.m. and adjourned at 1.20 p.m. until 9.30 a.m. on Thursday, 23 October 2014.