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這是中研院生醫所所長郭沛恩院士 (他也是UCSF 教授)寫給前副總統陳健仁及時中部長,関於目前COVID-19 的一些建議,希望政府能夠接納。

Dear VP Chen,

Hope that things are going well. I just completed my 9th quarantine after my 9th trip to Taipei during the pandemic and see that the Omicron variant of COVID-19 is now firmly established in Taiwan. While the CECC is moving quickly to address the widening spread of COVID-Omicron and is heading in the right direction, I find that the current policy is unsustainable and the messaging can be much improved. Since I was told that the CECC would welcome my suggestions, I have decided to do so. Please forward this message to the CECC for their consideration.

1. It is now very clear that COVID-Omicron is a very different disease than COVID-ALPHA/BETA/DELTA. Current vaccines are developed from COVID-ALPHA and cannot prevent INFECTION by COVID-Omicron even though they lower significantly the risk of SEVERE DISEASE and DEATH for those who are fully vaccinated and received booster shots recently. In addition, COVID-Omicron is highly contagious and has a very short incubation time; but it causes a milder disease, including shortened disease course and contagious period.
2. Because of the above, contact tracing does not work and avoiding infection is futile except one is in strict isolation or wears a PROPERLY FITTED N95 mask around others (see a very nice article about this in the NYT attached). This means that COVID testing in asymptomatic people is a waste of resources and is justified only in a limited set of situations (such as someone who works closely with vulnerable populations - e.g., nursing home and hospital workers - who has been in close contact with a positive case and needs to test negative to return to work).
3. Although the rate of hospitalization and death due to COVID-Omicron is low, when large populations are infected, the number of severe cases and severe disease is still significant (0.4% of 23 million people hospitalized = 92,000 in the hospital; 0.04% of 23 million people can die = 9,200 deaths) so the key is to keep the vulnerable people from developing severe disease. Medications used for COVID-ALPHA/BETA/DELTA variants such as antibody treatments and Remdesivir, etc., do not work for COVID-Omicron but the oral antivirals from Pfizer and Merck work amazingly well for preventing death (>85% reduction) and hospitalization. Paxlovid has done better in clinical trials to prevent hospitalization but it has many drug-drug interactions so many elderly people cannot use it. Molnupiravir has the theoretical risk of mutagenesis in pregnant women but for the elderly who are past reproductive age, it is a very safe and effective drug to use. I encourage the CECC to contact their counterparts in Japan, Singapore, Israel and the UK to get their experience in using these two oral anti-virals in the recent COVID-Omicron surge. [Full Disclosure: Dr. Dean Li, President of Merck Research Laboratories, is my brother-in-law so I am not pushing the Merck pill for obvious conflict of interest reasons.]

Based on the above, my suggestions on messaging are:
1. Tell the country that COVID-Omicron is an entirely different disease than the previous COVID variants so the whole country IS NOT IMMUNE to getting the infection. However, through the sacrifice and cooperation of everyone in Taiwan, the country succeeded in preventing disease and death during the previous waves of infection that caused a lot of problems around the world. This is shared success that the CECC and everyone in Taiwan should take credit, be proud of, and very relieved by.
2. Despite the fact that no one is protected from infection, but because COVID-Omicron is mild, public health policy needs to be adjusted to focus on treating the vulnerable rather than preventing infection of all.
3. Acknowledge that some segments of society have been severely affected by COVID policies so the recovery of these sectors is taken in consideration in updating the public health policy.
4. Acknowledge that some COVID policies were confusing to the public in the past so the new policies will be more consistent and logical. For example, the policy of requiring masking outdoors while people eating at restaurants indoors are not required to mask makes no sense.

My suggestions for the new policy are geared towards lowering hospitalization and death rates while avoiding unnecessary disruptions in people's lives:
1. Push vaccination for vulnerable groups (the elderly and those with pre-existing conditions that make them more prone to severe disease). Send vaccination nurses to the nursing homes and neighborhoods with elderly people to get everyone fully vaccinated (including booster shots). Getting the 30% of those 65-75 and 44% of elderly >75 who have not been fully vaccinated and boosted should be a high priority
2. Use the "test positive and treat" strategy for those in vulnerable groups. As I mentioned before, Paxlovid for all but Molnupiravir for those who cannot take Paxlovid. Treat them before their symptoms get worse because it is cheaper to give them the medicine than risk their need for hospitalization.
3. No more putting those with mild disease in special facilities or hospitals so that there are plenty of capacity for those who need hospitalization.
4. Recommend (not mandate with threat of punishment) those who have close contact with COVID-Omicron patients to mask around others for 5 days (no need to do so with household members because they are already given it to them) if they are asymptomatic.
5. No testing of asymptomatic people unless their job requires it (nursing home, hospital, etc.).
6. No more closing schools, factories, or offices because of positive COVID-Omicron cases.
7. No more mandatory masking except for those described in #4 above. People here are so used to masking that many will still do so with the threat of punishment.
8. No more mandatory quarantine, even for those who test positive. Highly recommend those who test positive to wear a mask when around people and not eat with others but not make it a punishable offense. [Treat them like people who have a bad flu, not like criminals.]
9. No more testing or quarantine requirements for visitors from abroad. As the local infection rate is now higher than that many other countries, there is no reason to require new arrivals to do anything different when they are asymptomatic. It's confusing to many that I can go anywhere in the world without quarantine but have to do quarantine plus multiple tests when arriving in Taiwan (and a handful of Asian countries).

The benefit of the policies listed above is that the resources of the country are directed toward saving lives rather than collecting lots of infection data. It will reclaim the international travel hub status of Taoyuan International Airport (and not let Singapore and Seoul dominate the air travel sector) and revive the tourism, convention, airline, hotel businesses. It will simplify everyone's life and reduce anxiety.

It may be counter intuitive but if you look at the data from the US university campuses and European countries, it is better to get as many young people infected as quickly as possible to shorten the surge while building up herd immunity for COVID-Omicron without a lot of severe cases. The old policy for flattening the curve is to prevent overwhelming the hospitals but with oral antivirals and milder disease, there is no need to flatten the curve. It is better to get the whole surge completed in 2 months like in most countries that pursue a more open policy.

I am convinced that when the messaging is clear and based on current understanding of the situation, the people will embrace it and praise the CECC's leadership.

Best,

Pui
--
Pui-Yan Kwok, MD, PhD
Director, Institute of Biomedical Sciences
Academia Sinica
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