Official Report: Minutes of Evidence

The Chairperson (Mr Gildernew): I welcome Ms Olive MacLeod, interim chief executive; Professor Hugo van Woerden, director of public health; Dr Jackie Hyland, consultant in public health; and Dr Brid Farrell, assistant director of service development, safety and quality. You are very welcome to the meeting this morning. I now invite you to brief the Committee, please.

Ms Olive MacLeod (Public Health Agency): Good morning. Thank you for the opportunity to update you on the contact-tracing programme that we are developing here in the Public Health Agency (PHA).

The Chairperson (Mr Gildernew): Olive, we are having difficulty hearing you. Can you move closer to a phone or speak up a little, please?

Ms MacLeod: Yes. Can you hear me now?

The Chairperson (Mr Gildernew): That is better, yes.

Ms MacLeod: OK. I will shout a little.

Thank you for the opportunity to speak to you this morning and to update you on the Northern Ireland contact-tracing programme. The purpose of the programme is to slow the spread of the COVID-19 pandemic in Northern Ireland and to lessen the impact on health and social care (HSC) services by preventing the community transmission of COVID when social-distancing measures are relaxed. We will do that by identifying cases of COVID, tracing their contacts and offering them testing and, if they are symptomatic, public health advice.

Our purpose is to establish a large-scale contact-tracing programme for cases of COVID-positive commencing next week, from 11 May. The objective is to deliver a contact-tracing programme in a number of locations in Northern Ireland. We are confirming the service model. We are recruiting and training suitably experienced staff. We are working to provide appropriate IT platforms to support the work. We are identifying and securing other resources, including finance, to support this work, and we are arranging appropriate governance, programme management and administrative support.

The work is being led by Dr Jackie Hyland. Jackie has much experience in contact tracing, and we are very pleased that she is leading this work for us. I will pass over now to Jackie to describe the work, the project, the initial pilot and the forward programme that we have prepared. Thank you.

Dr Jackie Hyland (Public Health Agency): Thank you. I will describe how we moved into the position that we are in, which is the public health management of a large incident such as a pandemic. To give you some context, everybody became aware of this in January, and we started to receive information through the World Health Organization (WHO) about the infection and the novel approach that it was taking. At that point, we started the usual public health contact tracing by understanding the kinds of risks that people might put themselves at, with the result that they become infected.

The initial contact tracing was based on the fact that anybody who came from Wuhan and had a temperature, breathlessness and a cough could be suffering from COVID. At that point in Northern Ireland, very few people fitted that criteria, so it was relatively easy to do contact tracing for their contacts. It became a little bit more extended when we passed on to understanding that it was affecting Hubei province, and, again, we were looking at people who had the symptoms of a temperature, cough and breathlessness. However, it rapidly expanded across the world, with the first big cases arising in Italy. On that basis, the definition had to be changed again to include a wider group of countries. It then became even more difficult to follow the contacts, because, as you can imagine, as soon as we looked at people who came from Wuhan and Hubei and passed them, other people had come in from, for example, Italy, Germany and Austria who had not been part of that definition and had started to spread the infection. Only then, when we were informed that those countries were also infected, was the definition expanded. As many countries in Europe then found, the disease had spread so quickly that it was no longer possible to contact all the people who had been there.

The difference between us and other countries such as Korea is that Korea had some experience through the SARS incident several years ago, in which it set up very rapid testing procedures. With its ability to scale up testing to the thousands within weeks of the process, its case definition included a positive test, so it could whittle down all the people who had come from infected areas and had the symptoms of a cough, temperature and breathlessness. Those are very broad symptoms, but it could test them quickly and pin down specifically only those who were likely to be ill and only those who were likely to be their contacts. However, in the rest of Europe and other parts of the world, because the testing was very new and the systems were not up and going, we were totally reliant on the definition of the symptoms.

The only other way to manage the spread of disease in those cases is very crude, and it is to close down the whole society and isolate everybody, assuming that everybody possibly has the infection, in order to break the chain of infection. That is what happened when we had the lockdown. We have to go through that until the levels of infection throughout the community slow down, because people are not connecting and the disease is no longer being spread. When we see that happening, as we are beginning to see now — Northern Ireland has been quite successful in getting to that position relatively quickly because people have been listening to the messages — we have to start releasing social isolation because of other consequences, such as economic and social well-being. We are now at that stage.

A few weeks ago, seeing that this was coming in Northern Ireland a little bit earlier than in other places and given our relative success in managing the outbreak because of people's adherence to the guidance, we started looking at setting up a pilot for contact tracing. The aim of the pilot is, when people start moving around, to stop any little clusters that start to evolve. When people go into workplaces, one or two people may still have the infection and may spread it to others. We need to get there very quickly to stop the spread in the workplace setting moving out into other parts of the community.

We started designing the pilot in early to mid-April. We started working together on about 15 April to look at the four key things that we needed to develop to start the contact-tracing centre. The first and main thing that we needed to do was to recruit people into the place and to get them appropriately trained. The second thing was creating a training package by looking at all the guidance at the moment and making sure that we were in line with World Health Organization and European guidance. The third thing was to get facilities that would keep people in a safe place. They had to have enough spacing between them, and we had to get equipment and IT for them. The fourth thing was to set up the database so that we can collect the cases and their contacts and very quickly identify any clusters that are evolving, either geographically or in certain social groups because of their behaviour.

The pilot started on 27 April, which was about 15 days after we started thinking about this. It came together very well because everybody really wants to make a difference here, and people moved mountains, to be honest, to get us going with databases and recruitment. We are piloting until 25 May. Some cases have started to come through the system. Individuals have been trained and are now using the system. We are contacting cases and their contacts, and we are providing them with advice on isolation. Any case who is symptomatic and in a key-worker grouping will be advised to get tested. If they turn out to be positive, they will come back into the system and we will be able to identify further contacts.

At this stage, the pilot is up and running. We are ironing out any problems. Problems specifically relate to issues such as bringing together IT systems that, historically, have always been fairly isolated or have evolved independently. People are making great moves to bring this together, but there is more to be done. The other issue that we have is making sure that we have contact numbers for everybody. The lab results that we get normally go to GPs or hospitals, and patients would be told the result by the clinician. That is no longer feasible because of the large numbers that we are going to see, so we are now trying to find ways of getting something as basic as phone numbers so that we can phone people back.

Those are the kinds of things that we need to work through in the pilot, and, once we sort them out, we will start running the full programme, taking every case, every day, and we will contact all the contacts within 24 hours to make sure that we are on top of things. Getting the contacts depends on two things: people answering their phone; and us having their phone number to start with. Those are the key, critical issues that we are working on at the moment. I am happy to take any questions.

The Chairperson (Mr Gildernew): Thank you. You are aware of the serious situation that is developing in care homes. I know that the Public Health Agency was previously involved in collecting and publishing the data. It is fair to say that you need information to be able to concentrate resources to fight this. It is also fair and very important to say that people who have loved ones in care homes are absolutely entitled to know what the situation is in the care home in which their loved one is living.

Can you give us your view on the need to publish accurate and meaningful data on time about the transmission, spread and extent of coronavirus in our care home sector, which is impacting some of the most vulnerable?

Ms MacLeod: This is Olive MacLeod. I am happy to start, and I will hand over to Hugo to answer, but, to advise you, all outbreaks must be reported to the Public Health Agency. Coronavirus is a reportable infection to us. On a daily basis, every home must advise us if they believe that they have patients with respiratory symptoms. If they meet the current definition, which is anybody with a respiratory illness, and if there is only one person, that person is swabbed. If there are two or more people, everybody in the home is swabbed, including the staff. We monitor that home on a daily basis, they send a return to us on a daily basis, and we speak to them on a daily basis. We provide those homes with advice and support, and we monitor them until the outbreak is over. The outbreak is over only when it has been 14 days since the last person had their last symptom. That home must then have what we describe as a terminal clean. That means that everything in the home is cleaned to a very high standard, and only then will the home be declared free of respiratory infection, or COVID, and allowed to take new patients in.

We are satisfied that we are actively monitoring and supporting the homes, as are the trusts, which commission the care, and the Regulation and Quality Improvement Authority (RQIA), which is the regulator and which, where there are concerns, goes out and inspects. It is doing a small number of inspections because of the risk in the homes. We monitor every home in Northern Ireland on a daily basis. We are satisfied that the home managers make sure that the families understand that there is an outbreak in the home and that the reason why they cannot visit is so that we can try to contain and control further spread of infection to this very vulnerable group of people.

The Chairperson (Mr Gildernew): What is your view about communicating the extent of an outbreak to families where there is one? The Committee has said in the past that every care home is vulnerable, and it is the view of many that the testing of staff and residents should be taking place across all our care homes. Is information sharing with families good enough?

Ms MacLeod: It is standard practice that, where there is an outbreak in a home, families are notified. There is flu every year, and families are notified. We contain any spread of infection by containing visiting and making sure that there are good infection-control practices in that home. That is tested when the RQIA is out on inspection. We have very close working relations with the homes, and I believe that it is up to a home to advise families where there is an outbreak and to help them understand all the measures that it is taking to keep their loved ones safe.

The Chairperson (Mr Gildernew): OK, I am going to take a quick round of questions from members on the care home sector in the light of the significant concern that there is out there. I want to also come back to the other issues about the arrangements that are in place for significantly increased testing and tracing, and I want to explore the mechanisms that are in place to do that. So, I am going to take a quick round of questions. If I could ask members to go with one question each on this issue, and we will come back for a second round. I have indications from Colin, Paula, Gerry and Alex at this stage, and then I will go to the phones.

Mr McGrath: Recognising the disturbing information that is coming out today about the care home sector and given that the PHA has health protection as its key aim, what has the panel specifically done to protect people in the care home sector given that, on the 20 February and 19 March, they had board meetings where they never once mentioned care homes? There are media reports today on one home where 17 out of 64 residents have passed away with coronavirus. That is over 25% — over one quarter — of the residents that have passed away with coronavirus. You are the Public Health Agency. What have you done, given that there is nothing in your minutes, to try to protect the sector?

Olive, you mentioned that the RQIA is undertaking visits. Around a week ago, I was informed by its chief executive that it was not doing that but was simply making phone calls and offering advice. Will you let me know when you were made aware of that change and that actual inspections are now taking place?

Ms MacLeod: Would you like me to answer that question now?

The Chairperson (Mr Gildernew): Yes. Go ahead. Please, Olive.

Ms MacLeod: We were advised this week that the RQIA is inspecting. It is part of the silver command and reports daily to us on the care home sector. That is where we got our information.

Professor Hugo van Woerden (Public Health Agency): If I might come in, I recognise that there are a significant number of frail and vulnerable patients in care homes. This is a time of significant anxiety for those individuals and their families, and we have a societal duty to do all that we can to care for our elderly, who have given to society over a lifetime. There is a passionate concern about that in the Public Health Agency and a recognition of the issue.

There has been a recognition from fairly early on that care homes would be a significant area in which there would be challenge and where there was likely to be a significantly higher fatality rate than in other parts of society. The PHA, in conjunction with the Health and Social Care Board (HSCB) and the trusts, has developed a regional plan with three main aims. The first is prevention, which is focused on testing, infection control training, enhanced cleaning, reduced footfall and on-site support for infection control that is delivered through nurses and, perhaps in due course, through some dentists, who, interestingly, have a strong focus on infection control. The second strand of that regional plan for mitigation is cohorting residents, which is about keeping those who are infected in one part of a home with one part of the staff. There is a virtual acute care support team that reaches into care homes through video linking etc to support them. The third strand of the plan is supporting care home continuity, which is focused on step-up and step-down alternatives and redeployment of trust staff into the care homes when the homes are starting to struggle in one way or another.

A lot of that work is being coordinated by the director of nursing, the director of social care and the health protection team in close conjunction with the RQIA. There is that coordinated regional response, and there are regular meetings. There is a meeting of the infection control leads across the system today.

I am trying to say that it is not that there is not a problem but that we recognise the problem. Intensive work is being done on it. It is an ongoing problem and is likely to be an ongoing problem for some time. In some ways, it may be replicated in the future in other settings where there are a large number of people living under the same roof. Hospitals, houses of multiple occupation and supported accommodation contexts are high-risk areas and are contexts that we are keeping a close eye on.

The Chairperson (Mr Gildernew): OK. Thank you. Will the panel members please identify themselves as they come in? It can be hard to distinguish witnesses on the phone. Will you also keep your volume levels up as high as possible, please?

Ms Bradshaw: Thank you, panel. I will not repeat the concerns that my Committee colleagues raised, so I will move on. I am, however, gravely concerned at the state of the support for our care homes.

I want to look at your report. On page 9, you refer to "staff shortages", "acute service pressures" and the:

Will you please comment on whether you feel that you have enough resources and are well-enough equipped to deal with the issue?

Professor van Woerden: It is Hugo here. The PHA is well set up as a central body that pulls together a multidisciplinary team. As I said, there is a director of nursing, and we work closely with the director of social care in the Health and Social Care Board.

No system across the world has a health protection team that is sitting waiting to deal with a global pandemic. Every public health team in every country across the world has been stretched by the pandemic, but people have risen to the challenge. We have managed to bring in some retired individuals to help us. We have reached out to other sectors where there is resource. We are linking to the voluntary sector side where appropriate. We are also using the contracts that we have on health improvement and promotion, and we are seeking to use the individuals, where we contract with those third-sector organisations, to focus their activity on helping society to respond to this huge challenge across all the dimensions of that challenge. We have spoken before about mental well-being, emotional support and wider societal needs, whether that involves getting food delivered to your front door etc. A huge response is going on across a whole range of dimensions, and, within the confines of what one would expect, we are reasonably resourced.

The Chairperson (Mr Gildernew): Thank you.

Mr Carroll: There is obviously a lot of concern about care homes, especially in recent days. A lot of the people I have been speaking to feel let down, and, to be frank, a lot of them feel that the PHA has taken its eye off the ball where coronavirus is concerned.

Olive, how many care homes have you visited since being appointed chief executive of the PHA? What planning are you aware of that took place in care homes in January and February, including any conversations with the Chief Medical Officer (CMO)?

Ms MacLeod: OK. It is Olive here. I have not visited any care homes since I came into the PHA. The PHA is not an inspectorate body — the RQIA is the inspectorate body — and, given the concerns about the transmission of infection, it would not have been wise for me to visit care homes. However, we have had a lot of communication with care home providers, who have sought advice and support from the PHA. I came from the RQIA, and we are all in this space helping and supporting them. It would not have been appropriate for me to visit a care home.

Your second question was about preparedness. Every nursing home has a business continuity plan and a winter preparation plan. Those were revisited with all the care homes last year, and workshops were provided so that homes could be prepared for the winter, which includes respiratory outbreaks and the support for them. Flu comes every year and can have a devastating effect, particularly on older people. There are flu plans, winter preparation plans and business continuity plans. Those are all in place. There is also daily active management and close monitoring by the PHA when an outbreak is declared to it. We manage those until they are finished and we are satisfied that it is safe to reopen that home.

Mr Carroll: With respect, Olive, a flu plan is a lot different from a plan to deal with a global viral pandemic. From your comments, it does not sound like there were any plans in place from the Public Health Agency's perspective to tackle care home infection rates.

Ms MacLeod: OK. I will pass to Hugo, who has some expertise in the area.

Professor van Woerden: What you are highlighting is that close communication with care homes is really important so that they feel supported

and are given appropriate expert advice. At the moment, the PHA is in contact with over 100 care homes each day through a variety of means, such as phone calls and emails etc. There is intensive input with the care homes and an open, strong working relationship with them at the level of the care home managers and the organisations that own the homes.

The Chairperson (Mr Gildernew): OK.

Mr Easton: Thank you for your presentation. I am deeply concerned about the news on the figures in the nursing homes. Can you assure me that all COVID-19-related deaths and the cases that are reported with residents that have it are being reported accurately on a daily basis and that those figures marry up with the Department of Health and the RQIA figures? Can you also tell us how many nursing homes across Northern Ireland have reported cases of COVID-19? I think that there are 484 nursing homes, so I would like to know that figure, please.

Ms MacLeod: I will cover the figures, and I will ask Hugo to cover the case definitions. Today, there are 110 open and active cases of reported respiratory illnesses that are being managed by the Public Health Agency. Of those, 35 are suspected possible COVID and 75 are confirmed COVID. Since the start of the pandemic, 16 care homes have had outbreaks conclude, and, since 16 March, 126 acute respiratory outbreaks have been reported to the Public Health Agency.

I will ask Hugo to speak about the reporting of the deaths and the cases and to cover the case definitions and what has been reported.

Professor van Woerden: It is Hugo here. I want to pick up on what Jackie said. We are in a situation where we have to rely partly on symptoms. We also use testing, but it is not a panacea, and a negative test does not always mean that an individual does not have the disease. The way that the swab is taken at the back of the throat or up the nose is not easy to do, particularly if you have, for example, an elderly person with some degree of dementia. That test is extremely difficult to undertake practically. One is then dependent on that swab having picked up some of the virus at the back of the throat, which, again, will vary from person to person.

I am trying to say that our focus is on mapping the trend and on working intensely with the care homes that have not so far had an outbreak as well as those that have had identified outbreaks. Prevention is at least as important as working with care homes that have had it. Our focus is on having a reasonably accurate number rather than a precisely accurate number.

The symptoms in older people can be quite nuanced. You could have an older person who becomes a little confused, goes off their food, has a bit of a fall or has some diarrhoea. All those symptoms could be symptoms of COVID as well as the classical symptoms of high temperature, coughing and shortness of breath, particularly in older folk. We are trying to encourage care homes to have a low level of suspicion and to ask for an individual to be tested if they have concerns that there is a possibility that the person is unwell.

Does that help to paint a little bit of a picture? We need to work with the care homes that have infection, but, in a sense, the care homes where we are seeking to prevent infection moving in are equally important.

The Chairperson (Mr Gildernew): OK. Thank you for that. I am going to go to a further round of —. Sorry, I said that I would go to the phones. I will go to Pam and Órlaithí on the phone. Pam, are you there at the minute?

Mrs Cameron: I am, yes. Thank you, Chair. I thank the panel for the presentation this morning. I understand that it is a very difficult situation, and we are all very concerned about our care homes in particular. I am more concerned after hearing how difficult it is to even be suspicious of COVID-19 in older people. It is quite obvious that it is not a simple task, and testing is also difficult. That is very much understood.

I want to ask about personal protective equipment (PPE) in care homes. We know that, in the past, there was difficulty in accessing PPE, and we hope that that is now well under control. I am concerned that there might not have been sufficient PPE in care homes since the beginning of the outbreak. Can you tell us whether all staff have received the full training required in the proper use of PPE? Whilst staff may have the appropriate PPE, we understand that they can easily infect themselves and others if it is not put on or taken off correctly. Could you tell us a bit more about the PPE?

I very much welcome the news that dentists and dental nurses are now involved in care homes. Can you tell us a bit more about what they are doing in the care homes?

Professor van Woerden: It is really important that we touch on PPE because it is absolutely key to keeping the residents and carers as safe as possible in the context of this pandemic. There are lots of different items of PPE. The basic PPE is gowns and gloves, and face masks and so on are used in appropriate situations. You are right that it can be difficult for care homes to wade through large quantities of guidance and to be really clear about it, so there has been an intense effort to provide care homes with access to information and to give them the capacity to speak to individuals from the RQIA, the trusts and the Public Health Agency who have relevant expertise so that any question that arises can be answered.

There have been instances when care homes have not fully understood at particular times. They have been on a learning curve in the use of PPE, and we continue to keep a close eye on that. We need to keep reinforcing the messages and to keep making sure that that training continues to be delivered. Our role is to support the management and leadership of care homes in their internal training. We are happy to go in and do any training in any way that we possibly can, but we also have to respect the management of the care home as the management of the care home. There is a balance, but I think that we have good relationships with all the care homes so that [Inaudible.]

The supply of PPE comes through the trusts from central supplies. Again, that is working better than it has at times, and some of that is a communication issue and is about an understanding of whom to ask and how to ask. There are clear single points of contact in each trust for care homes. If there are any problems with that, there are escalation routes as well.

Ms Flynn: Thanks to the panel. We have been told that the developments in testing have continued since the start of the pandemic, and the Research and Information Service (RaISe) paper stated that testing was stepped up particularly during April due to increases in capacity. Can the PHA share any documents detailing what those developments are, dating back to January or maybe to the first positive case in February? I am concerned that the testing strategy paper that the Committee received from the Department of Health on 6 April did not reference or map out any detailed plan for a wider community-testing and contact-tracing programme. The Department of Health's paper also stated that current testing capacity was "constrained". In your view, has the priority for testing and contact tracing in our care homes and, indeed, in the wider community taken so long to evolve due to that lack of capacity? Could that not have been addressed or planned for at a much earlier stage of the pandemic?

Dr Brid Farrell (Public Health Agency): It is Brid Farrell here. Can I answer the question on testing?

The Chairperson (Mr Gildernew): Go ahead, Brid.

Dr Farrell: Our testing capacity at the end of February was roughly 40 tests per day. The testing capacity that is currently available to Northern Ireland has come through two work streams, one of which is the testing capacity that is available through hospital laboratories and which now stands at 1,700 tests per day. Running in parallel, we also have a national initiative, which is responsible for the drive-through centres at the SSE, City of Derry rugby club and Craigavon MOT centre. That has a testing capacity of 750 tests per day.

In our plans going forward, we hope to further increase the testing capacity in our hospital laboratories and through the national initiative. Our hospital laboratories are part of an academic consortium that includes the laboratories in the Agri-Food and Biosciences Institute (AFBI) and Almac and those in the Clinical Translational Research and Innovation Centre (C-TRIC) in the west. We expect, as part of that, that, by the end of May, we will be able to increase our testing capacity by a further 2,000 tests per day. The other development in the national initiative is that, in May, we hope to have two mobile units that will be able to assist with the management of outbreaks in areas where there are clusters of infection. Each mobile unit will have a testing capacity of roughly 200 to 300 tests per day. So, in a relatively short period of time, we will rapidly increase our testing capacity.

The testing strategy document dated 5 April was from a point in time when our testing capacity in hospitals was extremely restricted and very much focused on hospitalised patients. The national initiative did not come on stream until the beginning of April. So, in a relatively short period of time, we have increased capacity, but it is also clear that we are now at a different stage of the pandemic than we were when the strategy was first issued. I can advise that we are updating the strategy to reflect the developments in contact tracing and the need to undertake more surveillance in order to get more information about what is circulating in the community. Hopefully, that updated strategy will be available in the next seven to 10 days.

Mr Sheehan: I concur with members' comments about the lack of preparation for this pandemic and the havoc that it was going to wreak in residential care and other healthcare settings. How many care home residents have been referred to hospitals since the first outbreak? Secondly, after speaking to staff in Muckamore Abbey Hospital, I have information that there is a serious situation there, with up to 20 staff having tested positive for COVID-19 over the last week or 10 days, and that there is still free movement of members of staff between wards. This is another setting where there are very vulnerable patients. What is the PHA going to do about that?

Professor van Woerden: It is concerning to hear that information. I am certainly concerned to hear about staff moving between wards.

Every effort should be made to keep staff linked to the same set of patients so that, if some spread does happen in a group of patients or staff, the situation is already as ring-fenced as possible. As you know well, the concept that underpins that is cohorting. It is concerning to hear that you are hearing evidence of cohorting not being followed. We want to try to do everything that we can to support any specific context in which that is not happening and to give advice to make sure that staff understand that not doing it is very high-risk.

There have been pressures on the number of staff available in some contexts, because of staff self-isolating, being unwell or having family members with whom they have to be at home. We recognise that some contexts have been under huge pressure. Of course, as I am sure that you are aware, the risk is that, when there is a reduced staffing quantum, staff are under increased pressure, so the quality of infection control can slip. That is why we are investing in the regional tier to support the hospitals, including an increase in cleaning and having staff go into specific homes that have shortages or problems of one sort or another. We have to be careful in doing that, because if the staff that we put in work across different contexts, they may also be causes of spread.

It is difficult to strike a balance between having peripatetic staff who wander around between different contexts, providing good advice, and limiting the contact between a group of patients and a group of staff. That would be my main focus in that context.

Mr Sheehan: What about the number of patients referred?

The Chairperson (Mr Gildernew): Hugo or any of the other panel members, what about the number of patients referred?

Professor van Woerden: I do not have that figure to hand. We could try to get an estimate, but that would be dependent on asking the trusts for the information. It therefore might take us a little while to get back to you on that, but we can come back to you.

The Chairperson (Mr Gildernew): OK. Thank you.

Mr Chambers: Has the PHA identified a common denominator in how the virus is getting into homes? Is it possible to exclude completely, on a continuing basis, the possibility of the virus getting into a residential home setting? Is there a difficulty that if you were to test all the staff and residents of a particular home today and the results were to come back clear, you could be facing an outbreak in that same home by the beginning of next week? Is that the case?

Professor van Woerden: Yes. You have articulated it very well. The difficulty is that a negative test today does not mean, as you said, that there would not be an outbreak in that home a week later. If you were to test every resident and every staff member every single day, it would tell you what is happening then, but, in and of itself, it would not prevent an infection coming into the home.

As you may be alluding to, once an infection gets into a home, it is remarkably difficult to eradicate. Homes are built to be homely rather than to be fortresses. As you know, visiting has been severely restricted and other measures have been put in place, but there needs to be a balance struck between locking every resident of a home in solitary confinement, as it were, for 24 hours a day, and, at the same time, giving them a homely environment, giving them a good quality of life, making them feel cared for and providing them with contact with other human beings. I think that you are pointing out that striking a balance is complex.

The Chairperson (Mr Gildernew): OK. Thank you.

Panel, we will ask a further round of questions, but, first, I want to address an issue. Sometimes, it feels as though there is a conversation happening about the easing of lockdown measures. I have observed that the amount of traffic is noticeably increasing. Jackie, you referred to the World Health Organization guidelines earlier. The very first thing that is referred to is that COVID-19 transmission must be controlled. That would mean that the hugely traumatic individual death rates that have such an impact on every family would be falling, but we are not seeing that. The other thing that we need to see is the outbreak in high-vulnerability settings being minimised. From the conversation that we have just had, that clearly is not the case. Here, we are still very much in the business of saving lives, and everything that is being discussed today is in that context. Brid set out a number of figures, and those are very welcome, but what is your assessment of the level of testing and contact tracing that we would need to be doing before we could consider easing the lockdown restrictions?

Professor van Woerden: I will try to pick up on a couple of your comments. You are right to say that the traffic on the roads has increased somewhat, and we have all noticed that. I recognise the potential factors that might be associated with that. You raised the issue of what we do to try to protect the care home sector. Can you articulate the question again for me?

The Chairperson (Mr Gildernew): You need to be in a position in which the risk in high-vulnerability settings is mitigated. It is very clear from the conversation here that coronavirus is widespread in the care home sector. We are looking at 25% at this stage, and that percentage is potentially rising. Do you agree with me that we need to be in a much different place before we consider easing the lockdown restrictions on working, social distancing and all of that? What I am asking you, Hugo, is this: how many tests would we need to be doing per day to be in a position to start lifting the restrictions?

Professor van Woerden: I do not think that there is a close connection between the two. We had some modelling evidence from England that suggested that the growth in the number of cases in care homes in England was rising exponentially. It was doubling, so it was going two, four, eight, 16, 32, 64, 128 etc. That was the type of growth being seen in care homes in England. We developed a regional plan, on which we have had an intense focus. As a result, we have not had that exponential growth in the care homes affected in Northern Ireland.

We have, by international comparison, done remarkably well. That does not mean to say that we have not got a rising number of affected care homes, but I think that, if you consider what one might have expected to happen, we have done quite well. We should be careful about counting our chickens before they hatch, but we have done quite well in that space to control the rate of the rise. We monitor the rate of the rise very carefully. Testing is now a very active policy in care homes, and that is important. I do not think that any rate-limiting step is being taken with testing in care homes. Brid may want to comment on that aspect.

Dr Farrell: I just want to reinforce what Hugo said. If there is an outbreak in a care home, all staff and residents are tested.

The Chairperson (Mr Gildernew): Do you not believe that we need to be testing in all care homes, given their vulnerability and the potential for every care home to become a site of further spread? What is the Public Health Agency position on why we are not testing staff and residents in all care homes?

Dr Farrell: That is a very good question, and it is one that we keep under constant review. Earlier, Hugo mentioned that you may have a negative result, because either the test has been done too early or has been incorrectly applied. You need to be careful with asymptomatic people that there is not an over-reliance placed on testing, because a negative result could be returned that gives them false reassurance, when, in fact, they are incubating the disease and will be positive in a couple of days. Our approach, which is kept under review, is that it is really important that homes that currently have no COVID-19 cases apply strict infection-proof procedures to reduce the likelihood of that happening. As I said, we are keeping the approach under constant review.

There is another broader issue. I mentioned our testing capacity.

If we went to the stage where we offered testing to everyone — we are not at that stage — in every care home, we would be able to do it only in a phased, cyclical way. I am not sure that the effectiveness of that has been established, and I am not sure that it would give us the impact that we might expect it to.

The Chairperson (Mr Gildernew): OK. That will continue to be an issue that we will come back to. The other part of my question was this: at what level does the Public Health Agency believe that we need to be case-finding and mass testing in the community? Where do you think that we need to be in that regard in order to safely start easing lockdown?

Dr Hyland: That is a good point. It underpins an awful lot of what we are going to do going forward. In the few areas where we have done contact tracing as part of the pilot, we are finding that some of the cases that have been reported to us as positive are asymptomatic people who have been in care homes. They may be positive because they have previously had the infection and they are just releasing some dead material up through their lungs; when they get tested, they may not be infectious, but they might get a positive result, so there is a little bit of complication there. However, the few that we have done just to test the system have demonstrated that their contacts are very few. That is incredibly important and very helpful, because it means that people in the community have been following the guidance not to mix with others. Therefore, when they become ill with it, they are possibly passing it on to only one other in the same household. Hopefully, they will not pass it on to anybody because, as soon as they become unwell, they self-isolate from other members of the household. When we get to that stage and continue to see that, we will get one person passing to fewer than one, which, as we know, is when it will be good to ease social distancing. However, easing social distancing does not mean that we change anything that we have advised so far. That has to come with the maintenance of the 2-metre distance between people. They must not spend more than 15 minutes within 2 metres without any sort of protection, whether out in public or in care homes. The key thing that we are finding about the care homes is that it may have got in there once, but people are still coming in and out from the community. As soon as we get community infection down, we will see the impact in the care homes.

Professor van Woerden: It is also fair to say that the decisions about lockdown are a policy matter that we, as PHA, are not in a position to comment on. The R number — the reproductive number — is believed to be below 1, so we are in a good position in Northern Ireland. There are lessons to draw from across Europe from the approaches that are being taken. That evidence is being considered; there is a scientific advisory group that reports to the Chief Medical Officer and gives him advice.

The Chairperson (Mr Gildernew): Sorry for interrupting you, Hugo. You said that that is a policy decision that it is not your role to comment on, but surely that policy should be informed by your expertise for the purposes of our population here. I repeat my question: what level of testing do we need to be at? When I say "testing", I include the case-finding and the tracing. What level of testing do we need to be at?

Professor van Woerden: I would not base it on testing, to be honest with you. It is more about the evidence around community transmission. The key metrics that are looked at in most international situations are the rate of admissions to hospital and the number of people in intensive care. We have done small studies in care homes, for example, to see how many people are infected. What I am trying to say is that one uses a triangulation approach, which uses multiple metrics to assess where we are in this wave of the pandemic. It is fair to say that most international

recognise that it is not impossible that there will be a second or third wave of the pandemic. We may have to live with COVID-19 for many years and develop mechanisms that allow us to do that.

The UK Government outlined five tests for lifting the lockdown: making sure that the NHS can cope; a sustained and consistent fall in the daily death rate; the rate of infection decreasing to manageable levels; ensuring that the supply of tests and PPE can meet future demand; and being confident that any adjustment would not risk a second peak. Different jurisdictions have come up with similar criteria, but the interesting thing is that none of them is relying on one single criterion. It is an opinion, at the end of the day, based on looking at a range of factors and the risks and the mitigation that can be put in place. As Jackie has been talking about, she is leading on this approach to contact tracing that allows us both to continue to keep a downward lid on the reproductive number in the community and to monitor the situation.

The other thing that will be key to monitoring is antibody testing on samples of the population. Antibody tests are only just beginning to appear on the market and have approval. The academic group has plans to undertake surveillance using antibody testing that will inform the picture of what is happening societally. We have a strong infrastructure that is tightly collaborating with the Republic of Ireland and other jurisdictions to be in a position to monitor as steps are taken to ease the restrictions and to do that in a dynamic way. I feel quite confident that the infrastructure is there to closely monitor that.

The Chairperson (Mr Gildernew): OK, I am going to move on for now. We all will be aware of the 'Contact tracing for COVID-19: current evidence' document released by the European Centre for Disease Control (ECDC). Within that, it says:

which is what we have been doing —

testing and isolating —

key —

I know that members have detailed questions, and I am coming to members soon, but one thing that I have not seen or heard of are the arrangements that have been made around isolating, because the purpose of testing and tracing is to identify who needs to be isolated. I want to know what arrangements have been made for isolating people who may need it, and that includes people travelling into the country. I am also very concerned — and I mentioned this to you the last time you were in front of the Committee — with the issue where a lot of foreign national communities here are working in quite congregated settings and living in high multiple-occupancy housing and may find it difficult to apply the isolation that is required. What support and recommendations is the Public Health Agency making to the isolation part of this strategy?

Professor van Woerden: You raise an important point. There are situations in which individuals may have personal circumstances that make their self-isolation difficult. That issue has been recognised, and there have been a number of contexts in which that has been considered. One context that came up early on was fishermen. Steps were put in place to identify contexts were individuals could be housed while they were required to self-isolate for 14 days. There are a number of groups where that possibility arises, including the ones that you have mentioned. That provision can be made in a variety of settings across Northern Ireland.

The Chairperson (Mr Gildernew): Is there adequate provision, Hugo? Is that already in place?

Professor van Woerden: Yes, it is. There is plenty of provision; there has been no way at all that that provision has been stretched.

The Chairperson (Mr Gildernew): What is your assessment of how many of those places will be required?

Professor van Woerden: The numbers are likely to be relatively small. It is an important consideration that we can provide support to any individual who needs it.

The Chairperson (Mr Gildernew): OK. I am going to go to members now. I will go to the phone first and then I have Gerry indicating, but I will go back to the phone. I will take Pam and then Órlaithí on the phone, please.

Mrs Cameron: Thank you, Chair, and thank you, panel, again. I have two parts to a question around the PHA and messaging and where you are going with that. It has been mentioned to me that, somewhere in amongst all that is going on, the message of self-isolating if you have symptoms is getting lost. That is part of what I want to ask. Also, I have been contacted by NI Chest Heart and Stroke, and it is saying that the statistics are suggesting that we have had eight non-COVID excess deaths every day for the last four weeks. So, should the PHA — this is the call, I suppose — be running a FAST — Face, Arms, Speech, Time — campaign in order to highlight that? We do not want people dying from COVID, nor do we want people dying because they are not accessing the services that they need to access.

Dr Farrell: Can I answer that question?

The Chairperson (Mr Gildernew): Yes, Brid. Go ahead.

Dr Farrell: We are aware that people have been reluctant to seek care, and we have seen a slight reduction in the numbers of people who receive thrombolysis or clot busters for stroke. It is very encouraging to note that the number of thrombectomies in Northern Ireland, which is where the patient is transferred to Belfast to have a clot retrieved by an interventional radiologist, has actually increased during the pandemic. That is really good to see, because it suggests that those sorts of assessments have been undertaken when people did present to hospital.

It is of concern. We have been talking to our communications people, and we are going to run the FAST message on our social media platforms first. We are also looking at putting up posters in public venues, including GP surgeries, supermarkets and other areas, to get people back to responding to the FAST message, because it is an incredibly powerful and easily understood message for the public, and people act appropriately when they see the four signs. We are aware of the issue. We will do some more publicity on social media, and we will keep it under review.

Mrs Cameron: That is very welcome. Thank you. What about the self-isolating message for those with COVID-19 symptoms?

Dr Farrell: Are you asking that question in relation to stroke?

The Chairperson (Mr Gildernew): In relation to COVID, what is the Public Health Agency doing about public messaging about the need for people to self-isolate if they are symptomatic?

Dr Farrell: I will hand that one over to the other members of the panel.

Professor van Woerden: I think that it is always helpful to get feedback and to hear from members if they recognise and feel that that message is not getting out as well as it should be. We take that on board. We are committed to continuing to put that message out loud and clear. Thank you for that.

The Chairperson (Mr Gildernew): OK. Thank you. I remind members that we are taking one question in this section. In the light of time moving on, can we keep questions and answers fairly succinct and direct, please?

Ms Flynn: My question follows on from Pam's points on public messaging. Similar to the feedback that we had on the excess non-COVID-related deaths, I have been picking up the same concerns right across the mental health sector, given that the number of crisis admissions to emergency departments is down and that community and voluntary groups have seen a reduction in calls. There is a real worry that people are at home, still battling with mental health problems, but not availing themselves of the services that are still there for them. Can you factor that in?

There is also growing concern about the increased consumption of alcohol. I am really worried that, when we come out of the COVID-19 pandemic, we will be dealing with a lot of mental health problems, and, with the increased amount of alcohol that people might be consuming, that will be an additional problem and pressure for the health service, so it would be great if you could factor that in to any public campaigns that you are doing.

The Chairperson (Mr Gildernew): OK. Thank you, Órlaithí. Rather than respond, can the panel note both those concerns? Are you aware of those concerns, panel?

Professor van Woerden: Yes, and it is helpful to have them reiterated. We are being asked to factor them in, and we take that message on board. Thank you.

Mr Carroll: Following on from one of your points, Chair, the panel may be aware that the World Health Organization has six requirements that have to be in place before lockdown should be lifted.

Is now not the time for the Public Health Agency, as the key influencers of public health policy, to go on the offensive to demand that no lifting of the lockdown should be considered until those six requirements are met? If not, why not?

Professor van Woerden: As you point out, there is no single requirement of which one could say, "On this single factor, we would lift the lockdown." We have a number of metrics that this needs to be measured against. One should look at the European picture as well, and the international evidence, as well as looking at Northern Ireland. It is a matter of the scientific advice being provided through the appropriate channel and a policy decision being made. It is trying to trade off individuals who have COVID-19, or who may have it, economic and social factors, and, as we heard earlier, mental health factors. There is a large number of factors to take into consideration. Inevitably, there will be a variety of opinions, as different individuals come together. Factors always come together slightly differently in a situation such as this. A consensus position needs to be reached.

Mr Carroll: With respect, I did not get an answer to my question.

Professor van Woerden: Do you want to clarify the point that you want me to answer specifically?

Mr Carroll: Yes, please. I said:

Professor van Woerden: I look at the data every day, and my personal view is that a significant proportion of those requirements are moving in the right direction. The data that I am looking at have provided me with a degree of reassurance that the direction of travel is consistent with what we see happening internationally. The trend continues in that direction, although, obviously, it needs to be closely monitored.

Mr Sheehan: The importance of testing and tracing has been highlighted this morning. Before I move on to my question, Olive, I would like you to clarify some remarks that you made the last time that you spoke to the Committee, on 16 April. You said that there were 500 people currently being trained for contact tracing. How is that training going?

Ms MacLeod: For clarity, we estimate that we will need to identify 500 people to be trained —.

Mr Sheehan: I am sorry for interrupting you, Olive. You said on 16 April, and I quote:

The Chairperson then asked you, "For testing." Ms MacLeod answered: "Yes, for testing." The Chairperson came back in, and said:

You said, "Yes, this is contact tracing." Are you now saying that there were not 500 people recruited, and there were not 500 people being trained on April 16 when you told us that?

Ms MacLeod: Thank you for that, Pat. I do not have the record in front of me.

Mr Sheehan: I do.

Ms MacLeod: I appreciate that. What we are saying in relation to contact tracing is that the environmental health officers could make 400 people available to us, and they have the skills for contact tracing.

Mr Sheehan: That is not what you said, Olive. You said that you had:

Ms MacLeod: Then, Pat, I spoke out of turn. That is incorrect.

Mr Sheehan: If you spoke out of turn, that is fair enough. I want to move on to my question. The decision was taken to end community testing and contact tracing on 12 March. I presume that that decision was relayed to the PHA from the Department, because it was the PHA that was responsible for contact tracing up until that point. What discussions took place with the Department about the ending of contact tracing? Did the PHA raise any objections? Did you raise the fact that the World Health Organization was advising on the need for community testing and contact tracing?

Dr Hyland: I can answer that one, if that is OK. Discussions on where we were with contact tracing were held not just with the Department of Health but across the UK. As I described, several criteria are required to contact-trace. We needed to know if the individual had a temperature, was breathless or had a cough. We were also working on the origin of their passage: had they come from Wuhan, elsewhere in China or from Germany, Italy or Austria? The number of people who were, potentially, carrying it became so big that it no longer became possible for us, as was the case with many other countries, to apply that non-test approach, because we did not have the testing. At that point, there was widespread discussion about the best way to approach it. On that basis, the only way was to close the area to stop further spread, as we do in normal health protection practice, and, because COVID was so widespread, we ended up with complete lockdown. As I said, that is a very crude measure of doing this. In other areas, we could have tested people to get the diagnosis at that time. There would have been a little bit less of a lockdown, but nowhere had that level of testing available. The safest thing to do, therefore, was the final stage in health protection outbreak management, which is to stop —.

Mr Sheehan: Sorry, Jackie, may I interrupt you? Why did contact tracing stop? What was the rationale for the stopping of contact tracing?

Dr Hyland: The rationale was the fact that so many people fitted the definition that it was no longer possible to find them, because it was everybody.

Mr Sheehan: So, it was a capacity issue.

Dr Hyland: No, it was the fact that we no longer had a definition that we could follow to contact everybody. We got calls from everybody about a temperature and a cough. That is practically everybody in the population. The country destination was no longer applied to it, because so many people had moved around that we only had a cough and a temperature to go on, and everybody had a cough and a temperature.

Mr Sheehan: You are aware, surely, Jackie, that the WHO and the ECDC advised to continue contact tracing, even where there is widespread transmission of the disease. They say that that is how to find out where it is, isolate it and continue the fight.

Dr Hyland: That is right. They advised testing, with contact tracing. To find out where it is, you cannot simply look at people who have a temperature and a cough; they need to have the test. Otherwise, it will be everybody who has asthma, chronic bronchitis or a winter cold. It is very difficult to tell. At that point, therefore, you have to break the chain of connection. Contact tracing stopped to break the chain of connection, and, at that point, we had to move to public messaging. Once we broke the chain and saw the numbers decrease dramatically , because it has been fairly successful in stopping the spread, we need to reintroduce contact tracing. We have had what is equivalent to a fire sweeping through the place, devastating everything; we have had to stop, with everybody indoors, and then we have to go back out and put out the little fires as they arise. That is the approach that we are now taking. Does that answer your question, Pat?

The Chairperson (Mr Gildernew): We will have to come back to that, because I want to move on to other members. There are remaining questions about that issue and about the decision-making and who was taking advice. We hear regularly about discussions taking place across Britain, but the Committee is interested in what steps were being taken to recognise the unique circumstances that we had here. We have a devolved Department of Health that can take its own decisions. That will continue to be an issue, I think, for the Committee.

Ms Bradshaw: This question is for Olive; it is non-COVID-19-related. Northern Ireland Statistics and Research Agency (NISRA) statistics show that there has been a rise, over the past five weeks, in the average number of deaths; they show that there have been about eight extra per day. What are you doing on public health messaging? Obviously, many of those deaths will have been from strokes, heart disease, heart attacks and issues that people should present with at emergency departments and GP surgeries. It is your responsibility to get those public health messages out. They are being drowned in the midst of all the other conversations about COVID-19. How do you plan to remedy that?

Ms MacLeod: Thank you for that question. We have a very active communication and engagement plan. We have daily rolling messages on all the issues that we have just covered: from maintaining good mental health to alcohol control; people with diabetes, specifically; and pregnant women. That programme is rolling out and those messages are being issued daily. We are using all the platforms and media available to us — Twitter, newspapers and television — in order to get those messages out. We are also using all our community contacts and programmes that we commission to ensure that people get the message to keep themselves healthy and that, if they are unwell, they must contact or attend their GP surgery.

It was apparent from the numbers that we monitor daily that people were not attending their GP surgeries or going to hospital, although we are beginning to see those numbers climb again. People are getting the message that they need to look after their own health. The Public Health Agency will continue to put out those messages. We will also do sensitivity analysis to see whether our messages work. We are looking at the hits on our website to ensure that the messaging is effective.

Ms Bradshaw: That will require a degree of creativity, because many of the people who need to receive those messages are not necessarily on social media all day or looking at your website. You need to be more involved in getting GPs to be proactive. A lot of work needs to be done on that.

Ms MacLeod: Thank you for that.

Mr McGrath: I make no apology for coming back to the issue of care homes. We have a global pandemic that, locally, is killing up to 25% of people in care homes. Through our conversation today, we identified that that has not been mentioned at recent board meetings in the midst of the pandemic. I am getting conflicting messages. In some of your responses, it seems as though you support testing; in others, you suggest that testing does not really achieve much. You mentioned a three-point plan for homes. One of those points is to wash your hands and another is to keep people out. There has been ambiguity in your remarks about whether there are inspections in care homes and when they started. Somebody mentioned that there is a role to map trends, which, rather than being proactive, is very much a retrospective piece of work. You remarked that the Public Health Agency does not comment on whether we should have lockdown. I am very concerned about the work that you are actually undertaking.

With regard to care homes, are you aware of any correlation between homes that are on, for example, an RQIA or other authority's at-risk register, which need to have an extra eye kept upon them and extra inspections done in them? Is there any connection between homes that are on that list and the outbreaks and, indeed, deaths in homes?

Professor van Woerden: I think that what you are pointing out is the importance of close working with the RQIA. Trusts will have a view, from their infection control perspective, as to whether they have concerns when they go into a home. At times, the RQIA will have concerns about particular homes. The health protection team will

have concerns from time to time. The infection control and prevention group, which is chaired by the nursing director, has the overarching role of looking at infection prevention and control and seeking to develop approaches to reduce infection.

I mentioned increased cleaning in care homes, because much of the spread of the virus is on surfaces that have become contaminated. For example, when somebody coughs on their hand, puts their hand on a desk, for instance, somebody else touches that desk in the next few hours, and then that person touches their face.

Breaking the chain of communication of a virus through cleaning is particularly important as well.

It is important that we emphasise that there is a close working relationship between the trusts, RQIA and the Public Health Agency to share information around care homes. We have to find a fine balance where we do not stigmatise homes that have an outbreak. There have been instances in the past where care homes have been stigmatised and staff have been inappropriately stigmatised where there has been an outbreak. It is important that we avoid that and, at the same time, have an intense focus, as you said, on homes that we consider are a priority.

You would, therefore, understand the sensitivity, at times, about putting all that in the public domain. We want to be there to support homes and to be rigorous in our questioning of how well they are doing but also being supportive, coming alongside them and recognising that they are facing an unprecedented challenge that they have never faced before and that their staff are doing an amazing job. I am sure that you have heard individual stories about carers in care homes of real compassion and self-sacrifice. I think that you will agree with me that we owe a debt of gratitude to the staff.

Mr McGrath: Once again, that is a fantastic answer to a question, but not to the question that was asked. I will press again: are you aware of a connection between homes that are identified as being at risk and those that have the outbreaks and the deaths?

Ms MacLeod: I will answer that for you. As we went into the pandemic, one or two homes were under enforcement and that has been lifted. In relation to a correlation between homes that have enforcement and outbreaks, there is nothing evident to us. As Hugo said, we have worked very carefully; each trust has a granular plan for supporting every home in its area to deal with the outbreak or to keep it out of the home. Hugo said that infection prevention and control is key to that. Training has been supported and increased for all homes; it is classroom-based and video-based, and there is support from infection control nurses.

We understand that investment will go into each home for extra cleaning to try to dampen down any outbreaks that are happening. When it comes to the role of the Public Health Agency and funding for homes to increase their PPE, homes would normally have the fairly basic PPE of aprons and gloves, and that has been increased to gowns, masks and fluid shield masks. There has been investment into the homes for extra cleaning and on staff from the trusts to go into the homes to provide care, particularly end-of-life care to make sure that patients are getting what they deserve.

The GPs have worked with —

The Chairperson (Mr Gildernew): OK, Olive, thank you.

Ms MacLeod: Everybody has oxygen and medication —

The Chairperson (Mr Gildernew): Olive, thank you. There may be a number of outstanding questions that we are not going to get to today. Members may want to put additional questions to you in writing on some of the issues around those linkages.

Ms MacLeod: Yes, we would be very happy [Inaudible.]

Mr Chambers: I want the panel to help me to understand whether the drive to re-establish contact tracing has come about as a result of outside pressures or whether it is a strategic response that is being driven as part of a current scientific and appropriate tactic at this stage of the crisis.

Dr Hyland: It is an absolutely normal health protection outbreak response. Once you close something down, at some point you have to reopen it. When you reopen it, you have to make sure that little pockets of infection do not arise and start the whole thing going again. It is a very standard operational process.

When we went into lockdown and saw it beginning to work, very early on, in the first three weeks of lockdown, we were starting to think ahead about what happens next. How we get out of it? How do we get people back into circulation? When they go back into circulation, the disease has not gone, we have not got treatment, and we have not got a vaccine. There is a risk to people, so we have to maintain the distancing, but we also must clamp down very quickly on any little clusters where people have not obeyed or will not obey the regulations of 2-metre distancing or are not doing so without protection. That is very important, and it was always part of the process and was always considered to be part of normal outbreak management. There was no pressure, and there was no strategic planning; it is part of the policy of what we do in health protection.

The Chairperson (Mr Gildernew): Thank you. I have a final question. The Royal College of Speech and Language Therapists has written to the Minister raising the issue of PPE for therapists conducting dysphagia assessment. Bearing in mind that the European guidance states that the disease is mainly spread from person to person through inhalation of respiratory droplets from an infected individual's cough or sneeze, can you advise on whether that will now be accepted as an aerosol generating procedure requiring PPE, which, I think, is rated as red?

Professor van Woerden: We are aware of concerns from speech and language therapy, but we will need to, I think, defer to the chair of the infection control and prevention group on that specific question, if that is OK, and come back to you on that. There needs to be a consensus around what aerosol generating procedures are and the guidance. There have been a number of situations in which different professional bodies have expressed concern, and there has been a negotiated process to reach a consensus around a position. I think that you are alluding to one of the contexts that is ongoing and needs to be negotiated to an agreed position.

The Chairperson (Mr Gildernew): Given that this is actively happening as we speak, can we be assured that that will be done at some considerable pace to protect staff?

Professor van Woerden: My understanding is that it is under active consideration. Thank you. As I said, I will defer to the chair of the infection control and prevention group, who is the nurse director here, and ask for that individual to provide a specific response to that question. Thank you.

The Chairperson (Mr Gildernew): Panel, we will leave it there. I am sure that we will be in future discussions as this rolls on. Thank you for your presentations today and for your answers. I wish you luck in the time ahead. All the best.