【專文】衛福部專家諮詢小組的決定經得起檢驗嗎？

近日陳昌明醫師一篇關於Ivermectin的媒體投書，激起了一陣騷動，燃起了大家對有效治療與控制Covid19疫情的希望。衛福部很快地説要交專家諮詢小組討論，專家諮詢小組也很快的三言兩語否決了Ivermectin的使用。這樣的決定會不會太草率，經得起檢驗嗎？個人有印度第一線醫生，每天為Covid19病人奮戰的第一線醫生的親口證詞: Ivermectin在治療與預防COVID19上都非常有效。

這故事是這樣的。約兩週前，個人意外從一非主流媒體得知印度某些地區因大規模的使用Ivermectin來治療與預防Covid19，已造成每日新病例數大幅下降。如德里（Delhi）從4月中下旬的28000/day 降到6月初的大概500/day（見下面附圖）！印度整體也大慨降了60-70%。我上網查，只找到特定網站非常少的報導。然後我去美國醫學圖書資料庫查（Pubmed），的確發現一些以Ivermectin治療Covid19有正面療效的文章。這時我頃向相信Ivermectin的療效是真的，因為光靠「封城」恐怕很難有如此的效果。然後我猜想印度應有很多報導，卻意外的發現也不多。但在搜尋中出現了關於Dr. Kavery Nambisan的報導與文章。Dr. Kavery 她是印度郊區的醫生，有用Ivermectin治療Covid19的經驗。於是我從印度報紙主編那裡拿到Dr. Kavery 的電子郵件位址，寫信問Dr. Kavery關於Ivermectin的問題。從Dr. Kavery的信，我只能相信Ivermectin在治療與預防性投藥上都是非常有效的。最下面付上我與Dr. Kavery之間的信。關於Dr. Kavery 信，這裡摘要與説明如下：

1）治療上，對感染者早期給藥是非常有效的; 對接觸者、病患家屬、高風險族群預防性投藥也是非常有效的。有時在檢驗結果出來前就投藥了，這有好處，即使最後結果是陰性，也不會有什麼傷害。
2）這藥很安全。
3）這藥有抗病毒與抗發炎的效果，如果早期使用的話。它可抑制病毒繁殖，降低嚴重性。因可在感染早期有效降低病毒數目，故可減緩降低傳播。
4）治療的劑量與用法：成人每天12 mg，治療5-7天（0.2 mg/kg,體重太輕、太重可依此計算）。
5）預防性用藥的劑量與用法：12 mg 於第一天、第三天、第七天，然後每週一次，只要風險存在的話。
6）可用於4歲以上的小孩，劑量一樣是0.2 mg/kg。
7）她沒有把這藥用在懷孕與哺乳的婦女上。
Dr.Kavery的信最後提到一位在孟買（ Bombay）的Dr. Daryl DeMonte以Ivermectin跟Colchicine治療5-7天，6000個病人只有35個要住院，14個死亡，死亡率是0.233%。讓我們做一下簡單的算術。個人查到印度年紀65以上人口佔5.64%,而台灣佔16.1%。將這個死亡率用台灣的老年人口校正後是0.665%。衛福部的專家諮詢小組要不要説這不是嚴格控制的「實驗」，所以無效，我們台灣的治療在本專家諮詢小組的指導下還是比較好的！他們如果這樣説，你要信嗎？他們真的這樣說了;這群人憑什麼這麼傲慢的否決Ivermectin的使用？憑什麼？看了以上的資訊，你只要有正常的良知與常識，就知道Ivermectin有效沒效。

印度德里（Delhi）疫情從4月中下旬的確診人數28000/day 降到6月初的約500/day。圖／擷自網路，作者提供

關於印度德里每日新病例急速下降，Dr.Kavery明確回答我跟Ivermectin無關，然而這與大部分支持使用Ivermectin的人的認知不同，也與她下文所説Ivermectin可降低感染的傳播與做預防性投藥是互相矛盾的。 Dr.Kavery可能是要避免我認為Ivermectin可以像抗體一樣的方式來預防感染。我認為德里每日新病例急速下降的最合理最可能的解釋是Ivermectin的使用有效的降低感染者的病毒數目，所以就降低了傳播率;當大部分的人同時使用Ivermectin的時候，就可以急速的降低傳播。就跟抗體的群體免疫一樣的概念。不認同這個解釋的人，能提出更好的解釋嗎？不會是疫苗，印度施打率不高，這段期間也無具大變化。只是巧合或純是封城的結果？封城全世界都在封，有這麼好的效果嗎？怎麼封成都有很多人需要謀生，尤其在印度這種所得不算很高的國家。況且印度本身就有對照組;在印度有大量使用Ivermectin與沒有使用的區域，在新病例數上呈現不同、相反的走勢（詳見附圖的原始資料）。
再來簡單提一下陳昌明醫師投書中提到那篇American Journal of Therapeutics的文章，促成專家諮詢小組的討論，不是因為這篇文章嗎？他們有嚴肅對待嗎？三言兩語，不知所云就打發了。我建議全台灣看懂英文的人都應找這篇文章來看，你只要看「Exposure prophylaxis studies of ivermectin’s ability to prevent transmission of COVID-19」這段就夠了，就知道專家諮詢小組有沒有呼攏你。這裡面沒有專業醫學名詞，只有2-3個統計學術語，不了解都可看懂全段主要大意;想了解，維基百科查一下就懂了。你看完第一個感覺可能是如果藥局買得到這藥，要趕快買來備用。然後你可能會想，我們的專家小組怎麼了？這裡面列了一些大大小小的實驗，簡單介紹個人最感興趣的兩個。有一個研究在788名健康照護工作者（health care worker）做Ivermectin預防性投藥，另外407名健康照護工作者沒有投藥。劑量12 mg，每週一次，連續10週。在這近三月中，使用Ivermectin的788位沒有任何一位感染Covid19，而沒用藥的407名有58%感染。另一個描述在去年三月初法國，一個安養機構的收容者發生了疥瘡，而接著就發生了Covid19流行。他們為了治療與預防疥瘡大流行（Ivermectin可用於治療疥瘡），就在69位住戶與52位工作人員投Ivermectin,0.2 mg/kg，3/10與3/17各一次（3/17法國全國性封城）。到5/15之間七位住戶與四位工作人員被診斷Covid19，其中一位住戶PCR陽性。即有9.1%感染Covid19.這69位住戶年齡中位數為90歲。但沒人住院也沒人死亡。研究人員事後找了同時期，法國類似的安養機構，發現住戶有22.6%得到Covid19，而死亡率有4.9%.這真是有趣的自然實驗，它完美的顯示了Ivermectin的療效或保護力。在這個大標題下，還有比較有大規模用Ivermectin與沒用的地區間的病例數與死亡率，淺顯易懂，檢單明暸（Table 1 & 2）。
那篇文章還有更多的內容，但還要再寫下去嗎？我想證據已經很充分，至少就早期治療與預防性投藥而言。

再來談一下這藥的安全性。Ivermectin是個很老的藥，已經被成千上萬數不盡的人用過，重複的用來治療寄生蟲，沒有什麼嚴重的副作用。用來治療Covid19的用量雖然比傳統治療寄生蟲多，但這樣的劑量從去年下半年起就在南美洲許多國家被大量的使用，也沒傳出有嚴重的副作用。今年4月下旬至今，在印度更是被大量大量的使用，一樣沒聽説有副作用。如果有嚴重副作用，American Journal of Therapeutics那篇文章內羅列的許多實驗都不用做了，也不可能發表。所以是很安全的。
最後，個人具體做如下建議:

1) 全台有良心的藥商或進口商，應盡快自有合格製造Ivermectin的國家，如印度，大量進口非常便宜、台灣已經核准的Ivermectin，分銷全台各藥局。目前這個藥在台灣只有原廠默沙東藥廠的Stromectol, 3mg/table. 藥局報價很貴（200-220/table）而且缺貨。
2) 確診病人、親密接觸者、病人家屬應儘早給藥。
3) 全台灣的基層診所，對有上呼吸道症狀的病人，應開立Ivermectin預防性投藥的處方籤，讓病人做預防性治療。就我所知，已核准的藥的非建議用法（off-label use）並不需食藥署的再同意，醫師只要取得病患的同意就可。相反的，如果你有症狀，你的醫師卻不願開這藥給你，你可切結後果自負，請他開藥。保命要緊。
4) 對高風險族群與職業，衛福部應對其做預防性投藥。
5) 雙北與一些高風險區域（如之前的萬華），可考慮大規模投藥以快速控制疫情。
6) 現有衛福部專家諮詢小組應解散重組。台灣人不需要這麼草率、這麼不尊重人命、這麼不尊重科學的專家小組。只會把WHO的聲明再對台灣人念一遍的專家算什麼專家？WHO、FDA…為什麼到現在依然對Ivermectin的療效視而不見？為什麼你在主流媒體上幾乎看不到Ivermectin的消息？這背後可能有很黑暗的國際政商勢力。但台灣跟人家湊什麼熱鬧？將來分錢不會有我們的份，只有現在一條條人命失去的代價。講白了就是如果這麼便宜的Ivermectin真的那麼有效，那現在還在研發抗Covid19新藥的藥廠就要倒大楣了！幾乎可以斷定藥做得成也不會有市場。疫苗廠也擔心，Ivermectin會取代疫苗。其實幾乎沒有人主張要用Ivermectin取代疫苗，大家只是希望用它來挽救生命，來爭取一些時間，等待有合格、安全、有效、和足夠的疫苗。我們的衛福部、專家諮詢小組想的是人命還是藥廠？
最後最後，我簡單對Dr.Kavery給我的與我自己加的幾個網路連結做介紹，有興趣的人可找到更多的資訊。但很抱歉，這些都只能是英文的：
https://covid19criticalcare.com/ from FLCCC Alliance
FLCCC官網。FLCCC是美國提倡早期治療與Ivermectin使用的團體

https://bird-group.org/ from UK
BIRD 官網。英國提倡使用Ivermectin的團體。

https://covid19criticalcare.com/videos-and-press/flccc-releases/joint-statement-may-03-2021-joint-statement-on-widespread-use-of-ivermectin-in-india-for-prevention-and-early-treatment
5/3/2021 FLCCC與BIRD 的聯合聲明

https://health.economictimes.indiatimes.com/news/industry/immediate-global-ivermectin-use-can-end-pandemic-scientists/82479538
5/8/2021 印度媒體關於Ivermectin的報導

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8088823/
就是陳昌明醫師投書中提到American Journal of Therapeutics那篇文章

https://covid.aiims.edu/clinical-guidance-for-management-of-adult-covid-19-patients/
印度機構AllMS對Covid19治療的準則

https://www.researchgate.net/publication/345321623_Title_Role_of_ivermectin_in_the_prevention_of_COVID-19_infection_among_healthcare_workers_in_India_A_matched_case-control_study一篇關於Ivermectin預防感染的專業論文

https://timesofindia.indiatimes.com/city/bhubaneswar/odisha-to-buy-7-2-lakh-ivermectin-tablets-to-cater-to-needs-of-covid-19-patients-in-home-isolation/articleshow/82570387.cms另一篇印度媒體關於Ivermectin的報導

https://www.thedesertreview.com/news/national/ivermectin-obliterates-97-percent-of-delhi-cases/article_6a3be6b2-c31f-11eb-836d-2722d2325a08.html
（附圖的原始資料來源）

https://www.thedesertreview.com/opinion/columnists/indian-bar-association-sues-who-scientist-over-ivermectin/article_f90599f8-c7be-11eb-a8dc-0b3cbb3b4dfa.html
一篇關於印度律師協會控告WHO在Ivermectin的資訊上誤導的新聞

https://youtu.be/QciiFYJJiJk
一個許多醫生發言支持Ivermectin的影片

https://youtu.be/D2ju5v4TAaQ
BIRD的Dr. Tess Lawrie討論他們關於Ivermectin實驗的統計數字。最後面質疑WHO的統計方法與結論。只適合非常懂統計的人。

https://www.newindianexpress.com/states/karnataka/2021/jun/01/kodagu-doctor-writes-to-health-minister-suggesting-use-of-ivermectin-to-treat-covid-patients-2310375.html
印度媒體關於Dr.Kavery的報導

參考資料

On Sat, 5 Jun 2021 at 13:28, XXX wrote:
Dear Dr. Kavery,
My name is XXX, a retired professor in Taiwan. I accidentally noticed the usage of Ivermectin in India for treatment or prophylaxis of Covid 19. In search of more information, I encountered your name and article in The New India Express and Deccan Herald. I read your article on Deccan Herald with interest and respect, and think you might be the right person to answer my questions about Ivermectin since you had experiences at the first hand. So I get your e-mail address from editor of Deccan Herald. Hope this mail is not too disturbing to you. Following is my questions:
1） Is the dramatic drop of fresh Covid19 cases in whole India and some cities, for example Delhi, in recent 3-4 weeks due to the wild-spread use of prophylaxis Ivermectin? Or it is the effect of others public health measurement? It is hard for me to imagine what kind of public health measurement could have such striking effect. On the other hand, how can Ivermectin prevent infection? Might it act through actually "curing" the very early and mild initial infection so that those cases will never show up in report? Would you suggest wild-spread use of Ivermectin for prophylaxis?
2） If prophylaxis use did work, do you have the protocol and dosage to share with me?
3） I assume PCR-confirmed case will be treated and administrated Ivermectin immediately. How about close-contact individuals who are still awaiting PCR result? Should they be given Ivermectin as soon as possible just like confirmed patients? In Taiwan, they said near 30% of infected individuals age over 60 will develop into severe disease （though I do not know the definition of severe disease）; if Ivermectin can be applied to those population as soon as possible, can you estimate what percentage might develop into severe disease? Again, Can I get the protocol and dosage of Ivermectin for treatment from you?
4） How safe is Ivermectin? If side effects do happen, what would that be? What should we pay special attention to when using Ivermectin?
5） In my search for information about Ivermectin, I found there were not much out there. A lot of media, worldly or even in India （that is my impressive）, seem to ignore its effectiveness. It is especially hard for me to understand if the dramatic drop of new case in India does relate to Ivermectin. As you mentioned in report of New India Express, there are some published researches indicating the at least potential effectiveness of Ivermectin, but why did FDA, WHO, EU... still discourage the use of Ivermectin? If the Ivermectin is safe and cheap, why not? As a past scientific researcher, I really felt confused. What are your comments on behavior of media and health organization?
Finally, I apologize my rash action of writing you this mail. Your kind responses will be a great help and appreciated.
Sincerely yours,
XXX

Kavery Nambisan 於 2021年6月6日 週日 下午6:06寫道：
Dear Dr XXX,
I have tried to answer your questions.
The decrease in cases in Delhi is not due to Ivermectin use. But because of strict lockdown. It is a temporary solution and we are worried about a new mutant that might set off a third wav.e.
The suffering in India due to Covid has been terrible to say the least. I learnt about Ivermectin from drs in other countries and started to use it. I will send you important links soon
It is a v safe drug and can be used in children too, if infected. It is an old drug used for ohter purposes and foudn to be safe. In Covid it is antiviral and anti ininflammatory if started early. It will kill the virus, prrevent multiplication and severity of disease. I use 12 mg once daily for 5 to 7 days for adults and 6 mg for children. I start as soon as person develops symptoms -- even before test results. It can do no harm and will prevent spread. It works well as a prophylactic drug. I give 12 mg on 1st, 3rd and 7th day and then once weekly for as long as risk exists. It is given to all family members of a covid patient. Also useful in frontline workers, police, traffic inspectors, taxi and bus drivers. It can be taken a day before a flight also.
It is cheap and that is why big pharmacueticals do not like it being used. Vacccination is diffeicut to get for all so this is important in a country like India where the population is so big. I am sure you can use it too.
I have not tried it on pregnant and lactating women.
Rest for 2 weeks is essetila to prevent covid complications mainly cardiac and neurological.
I will write again.
best wishes,
Kavery

On Sun, 6 Jun 2021 at 16:55, XXX wrote:
Dear Dr. Kavery,
Thank you for the reply and kindly answering my questions. I am more clearer now.
Look forward to your further information.
best wishes,
XXX

From: Kavery Nambisan
Subject: Re: Some questions about Ivermectin
Date: June 8, 2021 at 11:18:07 AM GMT+8
To: XXX
In many cases we start Ivermectin before test results show positivity. Because early start gives an advantage and if negative, no harm done. It is prophylactic.
Kavery

On Tue, 8 Jun 2021 at 07:58, Kavery Nambisan wrote:
Dear Dr XXX,
I am sending several links regarding the use of Ivermectin. A doctor in Bombay has treated 6000 cases with Ivermectin and Colchicine for five to seven days and only 35 needed admission. 14 deaths. His name is Dr Daryl DeMonte.
We feel that if started as early as symptoms start, it is v effective. Can be given to children over four years at .2mg /kg weight.
I do feel it is v effective as prophylaxis for all family members and front line workers.
I hope you will find the links useful. For some reason, the effectiveness of Ivermectin is being suppressed. Perhaps because it is cheap!
best wishes,
Kavery

專文屬作者個人意見，文責歸屬作者，本報提供意見交流平臺，不代表本報立場。