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Taiwan’s COVID-19 legacy depends on working from home and innovative testing

Taiwan’s COVID-19 legacy depends on working from home and innovative testing

Source:Ming-Tang Huang

Taiwan is now facing continuous level 3 alerts and uncertainty about how to move forward. Learning from the experience of other countries, remote work is the key to contain the epidemic.

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Taiwan’s COVID-19 legacy depends on working from home and innovative testing

By Chase W. Nelson, Wei Tai
web only

♦ Updated daily |Taiwan’s Covid-19 Outbreak

Introduction

Taiwan’s success against COVID-19 made this country the envy of the world in 2020, when its 24 million residents were able to live almost as if no COVID-19 existed. Unfortunately, that changed last month when Taiwan was finally hit with a superspreading event. The nation is now faced with a continuing Level 3 Alert and uncertainty about how to move forward.

Halting COVID-19 at the border has left this country with virtually no history of infection, and only 5% of the population has received one vaccine dose as of this writing. Taiwan therefore represents fertile ground for SARS-CoV-2, and it will take until at least October for 60% of the population to receive at least one vaccine dose. In the meantime, strict policies will be helpful only if they target the greatest risks.

Taiwan’s response to the current outbreak will determine its lasting COVID-19 legacy. We believe this must involve updated public health guidance, more workers’ rights and remote work, and increased testing.

For the present, we recommend one simple rule for the government and private sectors alike: if a person can work from home, they must.

The science of spread

It is now widely known SARS-CoV-2 can spread through the air, even when its carriers display no symptoms. Symptoms typically develop 5-6 days after exposure to the virus, with some rare cases taking 14 days or more. Infectivity peaks just before symptoms arise, but can occur up to 5 days earlier.

Additionally, 20 to 40% of carriers will never develop any symptoms at all, but can still infect others. Thus, policies that rely on detecting symptoms, such as temperature checks and self-reported illness, will miss at least 50% of SARS-CoV-2 carriers.

(Source: Chien-Ying Chiu)

The aforementioned statistics apply to the original genotype of SARS-CoV-2. Unfortunately, the situation is even more concerning for the Alpha (B.1.1.7) variant first detected in the United Kingdom, which is responsible for Taiwan’s current outbreak. Specifically, the Alpha variant is estimated to be 43-90% more transmissible than the original virus, and evidence suggests this increase is due to a longer presymptomatic stage of infection. Thus, the Alpha variant has more time to spread while carriers are still unaware of being sick.

Although Taiwan has implemented excellent policies regarding mask-wearing, hand-washing, and social distancing, other policies (or lack thereof) fail to recognize the predominance of COVID-19’s asymptomatic and airborne spread, especially indoors. Long hours spent in the same room can allow clusters to develop in workplaces, even if occupants are well over 6 feet apart and wear masks. This is because SARS-CoV-2 virus particles can remain suspended in the air and fill even large rooms as time passes. Poorly ventilated, air-conditioned environments like offices are particularly dangerous. 

Mobility remains too high

Even though Taiwan continues to experience community spread in multiple locations, we believe it is not too late to implement additional strategies to effectively suppress viral transmission. The critical question is whether the current Level 3 Alert measures — including closure of schools, non-essential retail, and entertainment venues — have been adequate to address the sustained outbreak.

(Source: Pei-Yin Hsieh)

Mobility data suggest the answer is ‘no’: Level 3 has not been sufficient. Specifically, mobility trends of “high-risk” activities — namely, visits to crowded indoor locations — have decreased to only -37% compared to pre-outbreak levels (Figure 1, middle left). Continued high-risk mobility is concentrated in grocery and pharmacy visits (-6%), and workplaces (-26%). At the same time, after reaching a peak at 2.5 cases per 100k population, daily cases are decreasing only at a slow rate (Figure 1, top left). 

ChartDescription automatically generatedFigure 1. Trends of daily cases and “high-risk” mobility in 3-month periods experiencing similar outbreaks in Taiwan, New Zealand, and Melbourne, Australia. Daily cases refer to reported values (top). The high-risk mobility trend is an average of retail, grocery, transit, and workplace data provided by Google (middle). The mobility percentage data (middle and bottom) represent the change in mobility compared to the pre-pandemic reference. Lines show 7-day moving averages. (Source: Chase W. Nelson, Wei Tai) (Click for a larger view

Taiwan’s overall drop in high-risk mobility of only -37% has thus far been insufficient to contain the current outbreak. As a comparison, New Zealand and Australia both experienced outbreaks of similar magnitude last year. In New Zealand (Figure 1, middle), a stringent Level 4 Alert was enacted at a similar stage of case surge, including a countrywide stay-at-home order that mandated non-essential workplaces to shut down. Mobility cratered to -71% within a single week, and community spread was virtually eliminated within 5 weeks. Melbourne experienced an even more serious outbreak last summer (Figure 1, right). At its start, high-risk mobility was already at -50% due to existing measures, but cases continued to surge. After daily cases peaked at 8 per 100k population, a series of escalating lockdown measures eventually reduced mobility to -67% and brought the epidemic under control. 

Comparing these three cases, a New Zealand-style “strict and early” lockdown is arguably the most effective in curbing viral transmission and minimizing the duration of the outbreak. This view is supported by a University of Sydney study in which simulations predict a far shorter time to containment when stronger social distancing measures are achieved. Although the word ‘lockdown’ may sound extreme and binary, we believe it represents a continuum of measures that can be adaptively applied in response to case trends.

One of the most important strategies is working from home.

Working from home

Unnecessary in-person work creates avoidable opportunities for infection. Specifically, contact at work is often involuntary (required by employers), brings together large numbers of people from long distances, and involves relatively long time periods. Thus, we believe additional working from home is critical to containing the current outbreak. The reality is simple: if companies wait to detect symptoms in their workers, it will already be too late to stop new transmission chains.

Indeed, Australia’s Victorian Premier Daniel Andrews reported that ~80% of all Australian COVID-19 cases were transmitted at workplaces in 2020.

Examples abound of companies that have transitioned swiftly and effectively to working from home. In the US, remote work has been widely adopted for non-essential businesses since early 2020, including companies like Twitter, CapitalOne, Microsoft, and Zillow. A PwC survey reports that 83% of US executives and 71% of office workers who have adopted remote work view the shift as a success. Furthermore, over half of employers saw improved productivity after the change. These shifting attitudes reflect the many benefits of having employees work from home, including increased time efficiency and decreased electricity consumption. In our view, the shift to remote work also accelerates progress due to the removal of time-consuming overheads such as unnecessary meetings and commuting. With a well-designed plan in which “onsite essential” workers continue in-person work while others work remotely, most business functions can still operate normally if not better, while the risk of contracting COVID-19 is greatly reduced.

(Source: Ming-Tang Huang)

A small but growing number of Taiwan businesses have shifted to remote work. The general manager of the telecommunications company Unabiz summarized the general manager’s attitude this way: “Employees are a company’s most important asset, and protecting their health is the company’s responsibility.” Such employers have recognized their duty to safeguard those they lead. Unfortunately, these role models are exceptional. Many more institutions continue to require workers to commute as normal, even from red infection zones. Employees requesting to work from home are often forced to use vacation or outright denied. 

When drafting remote work policy, it is critical for officials to consider societal inequities and power dynamics. Because a small number of bosses wield great power, it is very unlikely that workers will risk their employment by reporting any violations. Individuals and small businesses also need child care, mental health support, and financial support, and may not be able to comply with lockdown measures if they are not given the means to survive. This is especially true for mothers, who shoulder a disproportionate burden when working from home. Complementarily, those who have the means to isolate have a responsibility to do so.

Finally, Taiwan should strongly condemn the racist treatment of migrant workers, who deserve respect as a critical foundation of the economy, and prioritize them for vaccination if they are forced to live and work in crowded indoor spaces. The nation’s health depends on their health.

Increase testing

As of June, Taiwan is still trying to understand the extent of viral transmission within its borders. This uncertainty underscores the need for increased testing capacity, lack of which led to a large backlog of tests last month. It should come as no surprise that there is a clear correlation between testing and containment of viral spread. Because 20 to 40% of people infected with SARS-CoV-2 will never show any symptoms, a large fraction of cases are very unlikely to be detected without widespread testing. This ‘blind spot’ leaves ample room for superspreader events.

Numerous strategies are available for increased testing, including saliva and rapid antigen testing. However, at least two options could quickly and drastically increase testing capacity while requiring little or no additional testing equipment and reagents. They would therefore also dramatically save costs.

(Source: Pei-Yin Hsieh)

The first option for increased testing is to use a pooling strategy. With this approach, two or more samples are combined before RNA is extracted, and then analyzed together in the same polymerase chain reaction (PCR) test. The ideal size of each pool depends on viral prevalence.

For Taiwan’s current test positivity rate of ~1% for suspected cases, pools of size eight are reasonable, and would both increase capacity and save costs. For broader testing where the virus is less common, as many as 48 samples can be combined in clever ways that yield no loss of sensitivity and no delay in results. Pooling can also be strategically applied to members of the same households or workplaces.

A second method for even wider surveillance is the testing of sewage (wastewater). SARS-CoV-2 virus particles can appear in feces as soon as three days after infection, which is days or weeks before carriers may develop symptoms and seek a test. The RNA from these viruses is present in both wastewater and sewage sludge, the solid substances that settle during water treatment. Frequent sampling and testing of this water or sludge can therefore be used as an early warning system to detect community spread, and can provide an indication of viral prevalence in different locations. Indeed, there is a correlation between SARS-CoV-2 RNA concentration in wastewater and the number of confirmed cases reported in an area. Thus, testing of sewage makes it possible to detect clusters of infections while requiring no action from individuals. It has the added benefits of cost-effectiveness, non-invasiveness, and the ability to detect SARS-CoV-2 in disadvantaged communities that might be less likely to seek medical help. While not everyone has access to healthcare, everyone must use the toilet.

(Source: Pei-Yin Hsieh)

Recommendations

Taiwan has difficult months ahead. In our view, increased ventilation and the avoidance of indoor environments are currently severely underutilized strategies for preventing new clusters. We therefore urge officials to offer clear, up-to-date guidance on how SARS-CoV-2 spreads. Specifically, viruses in aerosols remain suspended in the air for seconds to hours and can be inhaled like lingering cigarette smoke, leading to superspreading events in workplaces. Indeed, one contact-tracing study in Japan suggests an 18.7-fold higher risk of transmission indoors compared to outdoors. Thus, in addition to mask-wearing, hand-washing, and social distancing, activities should be moved outdoors when possible, and indoor air should be well-ventilated and filtered. Finally, because infectiousness peaks near the time symptoms arise, it is critical that individuals are encouraged to seek healthcare at the first sign of even mild symptoms. This should be accompanied by strong condemnation of any scapegoating or shame, because anyone can become infected by any virus at no fault of their own.

Workplaces are now arguably the most dangerous indoor environment driving our continuing cases. We therefore urge policymakers to provide more than mere encouragement for companies to shift toward remote work. Policy should be flexible in recognizing the differing needs of different types of businesses. However, it must also recognize that many workers fear retaliation from their bosses and are unlikely to report any abuses.

Thus, mechanisms for anonymous reporting and workers’ rights enforcement must be put in place.

(Source: Chien-Ying Chiu)

Scaling up testing must play a central role in Taiwan’s ongoing COVID-19 strategy. This effort will have lasting rewards, because it is likely that SARS-CoV-2 will continue to circulate in humans and cause regional and seasonal outbreaks for the foreseeable future. Moreover, while vaccines are effective against known variants, they will take time to obtain and distribute, and their efficacy against future variants is unknown. Thus, investment in both increased testing and working from home infrastructure will be of long-term value.

We believe that Taiwan can continue to be a leader in COVID-19 prevention. Indeed it must, for the world is watching.

Acknowledgments

We thank Catherine Chou for conceiving and encouraging this piece; Ming-Hsueh Lin 林明學 for proofreading and assistance with visual design; Hsiang-Ling Wang 王湘苓 for translating our article into Chinese; Alexander Synaptic for providing references; James L. Reynolds for feedback; and our many friends and collaborators who are working hard for Taiwan.


About the author:

Chase W. Nelson 倪誠志, Ph.D. is a Postdoctoral Research Scholar at Academia Sinica 中央研究院 (Taipei, Taiwan), Visiting Scientist at the American Museum of Natural History 美國自然歷史博物館 (New York City), and Special Volunteer at the U.S.A. National Cancer Institute 美國國家癌症研究所 (Rockville, Maryland). His research utilizes computation and theory to study evolution in humans and viruses.

Wei Tai 戴維, Ph.D. is a San Diego based electrical engineer at Qualcomm designing smartphone RF modules. He grew up in Taipei and is a National Taiwan University alum.


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