For the first time in this pandemic we are in the midst of a growing wave of infection and illness – the country’s fourth – that is not triggering an aggressive reaction.

The National Public Health Emergency Team (Nphet) is focusing on encouraging bottom-up precautionary actions that we can do individually rather than recommending top-down Government action to enforce behaviour on us all.

After three severe lockdowns there is limited public appetite for a return to the restrictions of the past, and, thankfully, there are alternative tools to try to avoid that option. Nonetheless, rising numbers of infections and hospitalisations are a worry, and chief medical officer Dr Tony Holohan has not ruled out more significant action if "small changes" do not work.

Hospital Report

Nphet showed this week that almost all key metrics are heading in the wrong direction. This at a time when the full impact of increased social mixing, including the effect of nightclubs reopening, has yet to be felt, and before Halloween socialising is factored in too.

Do we need to reassess our confidence in the Covid-19 vaccine?

---

Schools ‘are safe places for our children’, says Taoiseach

---

New restrictions can be avoided if numbers remain stable, says Varadkar

---

Longford town has highest rate of Covid-19 in the State

---

Then there are the risks from schools reopening after the mid-term break, with many families returning from holidays abroad, and the colder weather pushing us indoors into Covid-friendly gatherings.

It all makes for an unsettling picture with Christmas approaching.

The conflicting forces of a phenomenal vaccination take-up, waning immunity amongst those vaccinated earliest and the more transmissible Delta variant have left Nphet in an unusual situation.

Predicted peak

Dr Holohan admitted this week that even with its prediction of 700 to 800 people with Covid-19 in general hospital care and 150 to 200 in intensive care by mid-November – the predicted peak of this wave – it is not expecting to recommend any restrictions (though he is not ruling them out either).

This suggests Nphet, unusually, sees an acceptable level of pressure on the healthcare system that it can tolerate if this prediction regarding the scale of the peak proves to be accurate.

Dr Holohan noted that the models relied upon “have performed extraordinarily well” in the past.

To put that projected peak in context, there were 481 people in hospital on Friday, including 97 in intensive care units. This is well in excess of the numbers that triggered the first three lockdowns, though, admittedly, the rising curve previously was heading in a far more vertical direction.

But Ireland is in a different place now. The fact that some 90 per cent of people aged 12 and over are vaccinated means the vast majority who become infected will avoid severe illness, putting us in a better position to cope with this wave.

Still, Nphet is saying that the future trajectory is “very uncertain”. Breakthrough infections and transmission among vaccinated people make managing the situation more difficult.

‘Knife edge’

"We are on more of a knife edge now than we were before in the last couple of months with our vaccination rates as high as they are and we are still in trouble," said Dr Christine Loscher, professor of immunology at Dublin City University.

Despite the strong focus on the unvaccinated minority, she says they are not the only group disproportionately represented in hospitals and ICU: case numbers among the over-55s are also high.

Nphet said on Wednesday that one in four people hospitalised in May were aged 65 and older; this rate is now a worrying one in two. Cases in the 5-12 age group have risen 64 per cent in a fortnight, the most of any cohort. Nphet has flagged this as “concerning”.

But it is not just the children. Infections have risen across older groups too, increasing by 50 to 60 per cent across all four age categories from the age of 35 up to 74 since mid-October.

Prof Loscher says these trends should prompt a faster roll out of "booster" vaccine to the over-60s – through pharmacies, for example – and nudge the National Immunisation Advisory Committee (Niac) into approving boosters for health workers.

It should also get the HSE and Government rolling out antigen testing and reintroducing contact tracing in schools, she says.

“The messaging needs to be around people obviously being more cautious about what they do, but I feel like the HSE, the Government and Niac need to do their best because there are things they can be doing and they’re not doing them,” said Prof Loscher.

More pressure

Weathering a rising wave of cases means there will be even more pressure on a health service that Dr Holohan has said is already under “significant pressure”.

"I don't think anyone is in a position to avoid it and change it – it is what it is; there is acceptance across the board that it is not going to be easy," said Paul Harrington, an orthopaedic surgeon at Our Lady's Hospital in Navan, where the elective orthopaedic unit has been closed because of the latest Covid-19 spike.

In the absence of restrictions, what is the plan B to help the health service cope better?

Early evidence points to the benefits of booster vaccines. These third doses have been administered to people aged 80 and over since the start of October, and figures show that infections have fallen in recent days amongst the over-85s, while the increase in cases has been lower among the 75- to 84-year-olds than in other older age groups.

Israel’s experience of suppressing a Delta wave with a widespread booster programme points to a road map for Ireland for the weeks and months ahead but this may be short-lived.

“Nobody really has a plan to deal with it, other than another booster, but there is no evidence that this will have anything beyond a short-term effect,” said one source with a deep knowledge of tracking and tracing the virus.

Living with Covid remains, as ever, deeply complicated and unpredictable.