The second wave: estimating the hidden asymptomatic prevalence of COVID-19 in Ireland as we plan for imminent immunisation.

Since the first case of COVID-19 in Ireland was recorded policy makers have introduced mitigation measures to control the spread of infection. Infection is spread by both known cases and hidden, undetected asymptomatic cases.  Asymptomatic individuals are people who transmit the virus but display no clinical symptoms. Current evidence reveals that this population is a major contributing factor to the spread of the disease. There is little or no knowledge of the scale of the hidden prevalence of all infections both asymptomatic and symptomatic in Ireland. Furthermore, as governments plan for the roll out of imminent immunisation programmes, the need to know the scale of the hidden prevalence and hence knowledge of the level of immunisation required is essential. We describe and analyse the numbers of reported cases of COVID-19 in Ireland from the first case in February 2020 to mid-December 2020. Using the method of back-calculation we provide estimates of the asymptomatic prevalence of cases from June to December 2020. The descriptive analysis highlighted two epidemic waves of known cases in the time period. Wave two from June to December included twice as many cases as wave one and cases were significantly younger. The back-calculation estimates of asymptomatic prevalence during this time period revealed that for every case known there was an additional unknown case and total prevalence in wave two was estimated to be approximately 95,000 as opposed to the reported 48,390 cases. As prevalence in wave two is known to be spreading within and from younger age groups the role of mixing patterns on spread needs to be disseminated to the wider public to adequately inform them how personal modifications in behaviour can contribute to the control of the epidemic. While universally imposed lockdowns and mitigation measures may be essential, personal behavioural mixing choices are powerful protectors.