Many friends have been reposting a blog post by Zhang Zuofeng, chair of the Department of Epidemiology at the UCLA Fielding School of Public Health, on his four-point suggestions regarding Shanghai’s Covid-19 policies. A good number have also asked for my opinions. In fact, before Zhang published his post, we have had a fair share of discussions and debates in private. In my view, Zhang’s suggestions are necessary preparatory measures in the long run but are not compatible with Shanghai’s state of affairs at the current moment.
I briefly summarize his suggestions as follows:
1. Encourage and advocate the administration of vaccination booster shots, especially for high-risk groups. It is advisable to import the BioNTech/Pfizer vaccine as an emergency measure for the elderly.
2. Practice tiered diagnosis and treatment, where patients with mild symptoms stay at home for recovery and those with severe symptoms are hospitalized.
3. Promote the use of antigen rapid self-test kits to avoid congregation and spreading of the virus at centralized Polymerase Chain Reaction (PCR) tests.
4. Import and use Pfizer’s Paxlovid antiviral pill for treating Covid-19.
Zhang’s suggestions are reasonable and necessary for the future, when coexisting with Covid-19 becomes a new normal. I also mentioned more than once in past writings that, considering the etiological features of the Covid-19 virus (contagious during incubation period, large proportion of infections asymptomatic, has animal carriers), its long-term coexistence with the human world is already inevitable. Thus, China’s Covid-19 policies will certainly have to transition from Zero-Covid to coexistence in the future. When that time comes, we do indeed need a comprehensive system to mitigate the risk of day-to-day Covid-19 infections. In this system, the effective promotion and coverage of vaccinations (especially booster shots), the establishment of tiered diagnosis and treatment for Covid-19 patients (which will undoubtedly include self-administered tests and stay-at-home recovery for patients with mild symptoms), as well as large stocks and mass distribution of oral medication, are all prerequisites.
But the problem lies in the choice of when to implement them. In the short term, there is no room to implement these suggestions in Shanghai. Instead, it may create confusion and chaos. It is clear that Shanghai’s current objective in its Covid-19-management measures is to achieve Zero-Covid quickly. Even if absolute eradication of Covid-19 is extremely difficult from a technical standpoint, the goal should still be to clear Covid-19 from public society at maximum speed to restore regular lifestyles and social order. Be it from a policymaking standpoint or a health care-readiness standpoint, Shanghai does not possess the capacity now to immediately transition to a policy of coexistence while the city is in crisis mode. Hong Kong, which just recently bore the impact of a fifth wave of the pandemic, is a prime example of what Shanghai will endure.
I will now go into detail with regards to my responses to each of Zhang’s suggestions.
First, on the subject of vaccinations: The promotion of vaccination, especially for high-risk groups to complete the regimen of two doses of inactivated-virus vaccines plus one booster shot is without a doubt the most effective and least costly measure to guard against the virus. However, we must note that vulnerable populations in Shanghai do not have a high vaccination rate — it is even lower than the national average. Only 62% of those above the age of 60 have completed two doses, compared with the national average of 80%. As a comparison, even in the U.S., where vaccination rates are well below those of other developed countries, the proportion of individuals above the age of 65 who have completed two doses of mRNA vaccines still registers at 89%. What is most worrisome is that research from Hong Kong has shown that for the elderly, three doses of the inactivated-virus vaccines are required for sufficient protection (98%) against critical conditions and death. In China, the proportion of people older than 60 who have taken a booster shot is only 40%.
Additionally, we know that it takes at least a few weeks for vaccinations to take effect, and that time increases to a few months for booster shots. This means that even if Shanghai is able to immediately dedicate a large number of health workers to vaccinate all of the elderly, the effects of the vaccine can’t kick in before the end of this wave of the pandemic. Considering that Shanghai already has a few thousand new daily cases and the figure is moving close to five digits, the city’s medical workers are already heavily strained. Diverting many of them to administer vaccinations may cause further stress on health resources.
Moving on to tiered treatment as Zhang suggests: This is also a mandatory step in facing Covid-19 as a normalized infectious disease, but similarly, Shanghai in its current state is not suited to immediately adopt this system.
Unlike what many think, home recovery programs and self-administered tests as a strategy against Covid-19 would take an entire framework of social and public health policies to make it work, even though it seems simpler on paper than large-scale PCR tests and isolation of infected individuals. If this framework is not in place, such a strategy may very likely cause mass spread of Covid-19.
For instance, the specificity of self-test kits (98%–99%) is lower than that of PCR tests (100%). That may not sound like a big difference, but in Shanghai where Covid-19 prevalence is still relatively low (only one case in 1,000 people), self-test kits would generate a huge number of false positives, perhaps more than 100,000. These individuals would have to report their results to authorities for PCR retests, and in that process they would have to be carefully treated as possible patients to avoid further spread of the virus. The amount of manpower demanded may very well be larger than that required to conduct PCR tests for the entire population. We must see that self-test kits are suitable only as a health-monitoring method for residents, or when doing an epidemiological study on a large population to better see the full picture. It is not suitable for use as a detection method for infected individuals where overall prevalence of the virus is extremely low.
Further, in a case where there is a large number of infections with mild symptoms, home recovery programs that can save health resources for high-risk groups would indeed offer a reasonable and more sustainable system. But there are three key problems with home recovery programs. First, when compared with centralized isolation and treatment, home recovery will almost definitely create higher risk for further spread of the virus. Given that emergency hospitals still have spare capacity, there is no need to turn to home recovery. Second, against the backdrop of China’s residential conditions, it is nearly impossible to have infected individuals self-isolate away from family members. The risk of the virus spreading within families will rise substantially. Considering how families often have elderly members, this risk should not be overlooked. Third, home recovery cannot simply equate to shutting infected individuals in their homes. It demands an entire system to run the program. Equipment like thermometers and oximeters must be distributed to individuals on home recovery. If their conditions worsen, there must be a working pathway for them to immediately report their condition and gain access to medical treatment. There also must be staff deployed to deliver groceries and medication. As Shanghai is in crisis mode, it is impractical for authorities to divide their attention to focus on setting up this comprehensive system from scratch.
Finally on the subject of importing vaccines and medication as Zhang proposes: The import of safe and effective Covid-19 vaccines (especially the BioNTech/Pfizer mRNA shot) and medication (especially the Paxlovid pill) is both necessary and correct. However, we should not overestimate the positive impact of these moves on Shanghai’s current situation, and neither can we start nursing the mindset that imported cures will magically drop from the sky and solve all our woes.
The mRNA vaccine has already had billions of doses administered around the world, and its safety and effectiveness have been proven. The approval of its importation is perfectly justified and should be granted. But we must take note that vaccinations cannot help us with this particular wave of Covid-19 in Shanghai because of the time it takes for them to become effective. More importantly, Hong Kong’s fresh omicron statistics have already shown that for high-risk groups three doses of inactivated-virus vaccine and three doses of the mRNA shot offer an equal level of protection. Thus, rather than placing our hopes on importation of the unapproved advanced vaccine or on an untested vaccination regimen of two doses of inactivated-virus and one dose of the mRNA shot, the more reasonable and safer option is clearly to promote booster shots of the inactivated-virus vaccines.
As for medications, the medical products administration has already approved the import and use of Paxlovid, and stocks have arrived in some parts of Shanghai. It has been proven that Paxlovid can significantly (89%) lower the risk of critical conditions or death in groups vulnerable to Covid-19, and it will provide helpful support to Shanghai’s Covid-19 situation. But we also must note that the use of Paxlovid has a very specific timeframe. It is best administered within three to five days of infection of a high-risk individual for maximum effect. Simultaneously, limited by the productive capacity of Pfizer, stocks of Paxlovid in China will not be abundant in the short term. Currently, a few tens of thousands of courses are being imported. Both of these points remind us that Shanghai needs first to better and more quickly control the spread of the virus before Paxlovid can effectively minimize rates of critical conditions and deaths. This, in fact, contradicts Zhang’s argument for promotion of home recovery and self-test kits.
To sum up my views:
1. Zhang’s suggestions — which are to promote vaccination, establish tiered recovery and import oral medication — are all pertinent advice for a future where combating Covid-19 becomes a part of regular life.
2. In Shanghai right now, the top priority is to stop the spread of the virus as soon as possible, keeping numbers of total infections and critical cases low, and to restore basic social and lifestyle order at the first opportunity. In view of this objective, a lockdown and citywide PCR testing should be the only method that fulfills the requirements. The long-term practices should be rolled out at a more leisurely pace after Shanghai has achieved Zero-Covid on this wave, or at least has the spread under relative control.
3. Coexistence with the Covid-19 virus is our endgame, but the process of transitioning from Zero-Covid to coexistence takes an entire set of policies and resources to back it up, unlike what many people may imagine. The material resources required and the level of detail needed in policymaking might even exceed that required in a lockdown. We need to be mentally prepared for this.
4. We should, indeed, approve the importation and use of foreign vaccines and medications. However, we do not need to, and should not, have unrealistic expectations of what they will do for Shanghai’s present predicament. We cannot start subscribing to the false belief that we can rely on them to overcome this wave of the pandemic. I know there is much debate surrounding Zero-Covid versus coexistence, to the point where it has become divisive. Yet at the end, I still want to speak this view which may offend both sides of the argument: Tunnel vision on Zero-Covid without keeping in mind the endgame or only focusing on future coexistence without doing preparations — both are equally problematic. I hope that after this wave of the pandemic subsides, the precious time we have fought for can be used meaningfully to prepare us for eventual reopening and coexistence.
Wang Liming is a professor at the Life Sciences Institute of Zhejiang University in Hangzhou.
Translated by intern reporter Celine Yang.
The views and opinions expressed in this opinion section are those of the authors and do not necessarily reflect the editorial positions of Caixin Media.
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