CORONAVIRUS/How Taiwan has been able to keep COVID-19 at bay

03/16/2020 07:14 PM
Engineers tasked with assembling mask production units at a factory in New Taipei.
Engineers tasked with assembling mask production units at a factory in New Taipei.

By Chiang Yi-ching, Wen Kuei-hsiang and Wang Cheng-chung, CNA staff writers

In January, when the world started taking notice of COVID-19, a new coronavirus disease that was rapidly spreading from the Chinese city of Wuhan, researchers at John Hopkins University predicted that Taiwan would be one of the hardest-hit countries.

Taiwan sits just 130 kilometers from China; 404,000 of its 23 million citizens were working in China in 2019, and more than 2.7 million Chinese nationals traveled to Taiwan that same year. A massive outbreak in the country seemed all but inevitable.

Yet despite the odds, Taiwan had recorded only 67 cases of the disease as of Monday, with one patient dying. That's significantly lower compared to its East Asian neighbors. China, where the disease was first detected, has 81,020 cases and 3,217 deaths to date. South Korea has seen 8,162 people infected and 75 dead, while Japan has reported 839 cases and 22 deaths.

As COVID-19 continues to spread at an unprecedented pace in countries like the United States, Italy and Iran, public health scholars have pointed to Taiwan as a society that has responded quickly to the crisis and has effectively protected its citizens.

Here's how Taiwan has been able to keep COVID-19 at bay:

Fast Response

We were the earliest country to activate epidemic prevention measures against this disease, said Vice Premier Chen Chi-mai.

Taiwan enacted its first prevention measures early -- on Dec. 31, the day that the Wuhan authorities first announced publicly that there were several patients in the city who had an unidentified type of pneumonia.

At 8 a.m. that day, during an Executive Yuan briefing, Vice Premier Chen Chi-mai (陳其邁) told Premier Su Tseng-chang (蘇貞昌) of the issue. An inter-ministerial meeting about the disease was held an hour later, Chen told CNA in a recent interview, with two conclusions emerging from the discussion.

Vice Premier Chen Chi-mai
Vice Premier Chen Chi-mai

The first was that Taiwan would immediately activate stricter border control measures, Chen said. These included stepping up testing of incoming travelers who had a fever, as well as questioning suspected cases about their travel and contact history.

Passengers arriving on direct flights from Wuhan would also be subjected to health screenings before they could deplane, starting that day.

These measures were enacted when Wuhan had reported only 27 cases, and Japan and South Korea had yet to become alert to what was happening, Chen said.

"We were the earliest country to activate epidemic prevention measures against this disease," said Chen, who has a master's degree in public health from National Taiwan University.

A sign at Taoyuan International Airport reminding travelers from Wuhan to be mindful of their health, and to call the 1992 Disease Prevention Hotline if they feel unwell.
A sign at Taoyuan International Airport reminding travelers from Wuhan to be mindful of their health, and to call the 1992 Disease Prevention Hotline if they feel unwell.

In the lead-up to Taiwan's presidential and legislative elections on Jan. 11, Taiwan's government remained vigilant toward the outbreak, asking doctors to report suspected cases of the disease and requesting that Beijing allow it to send medical experts to Wuhan so they could gain a better understanding.

Four days after the election, Taiwan listed the virus, which had received an initial title of 2019-nCoV, as a category 5 communicable disease, granting the government the legal basis to quarantine individuals with symptoms, as well as fining doctors who fail to report suspected cases within 24 hours.

All of this took place before the number of cases had reached even 50 in Wuhan.

Central Command Center

This trend of fast response continued after Taiwan activated its Central Epidemic Command Center (CECC), which serves as a coordinator of all epidemic responses and updates the public about COVID-19.

Activated on Jan. 20, the day when the total number of global cases surpassed 200, the CECC decided on Jan. 24 to ban all exports of surgical masks, more than a month before South Korea adopted the same policy.

Taiwan was also the first to ban entry of Chinese nationals from Hubei Province, where Wuhan is located, on Jan. 26, six days before Japan decided to do the same.

According to a March 3 article published in the Journal of the American Medical Association (JAMA), titled "Response to COVID-19 in Taiwan: Big Data Analytics, New Technology, and Proactive Testing," the CECC has rolled out more than 124 measures since its activation.

These include measures on border control, case identification, resource allocation, implementing quarantine for all travelers who have visited regions hit hard by the disease, and postponing the reopening of schools following the winter break.

The center has also served as a crucial source of information for the public, and has held daily press conferences since its activation to update Taiwanese residents about the outbreak.

Every day, Health and Welfare Minister Chen Shih-chung (陳時中), who heads the CECC, announces new confirmed cases, how the patients were infected, as well as the issuance of new travel alerts and entry restrictions.

Health and Welfare Minister Chen Shih-chung (second from right) at a press conference.
Health and Welfare Minister Chen Shih-chung (second from right) at a press conference.

These press conferences, on top of additional announcements made by Vice President Chen Chien-jen (陳建仁), an epidemiologist by profession, has reassured the public "by delivering timely, accurate and transparent information regarding the evolving epidemic," according to the JAMA article.

The article, co-authored by Stanford University Professor Jason Wang (王智弘), University of California, Los Angeles Professor Robert Brook and MBA, MPH of the The New School for Leadership in Health Care Chun Y. Ng, also points out that the CECC is proof that Taiwan has learned from previous disease outbreaks.

In 2003, the SARS epidemic infected over 8,000 people and killed more than 770 across the world. Taiwan, with 346 cases and 73 deaths, was one of the countries hit hardest by the disease.

Learning from this experience, Taiwan's government established a "public health response mechanism" -- the National Health Command Center, of which the CECC is a part -- in 2004, and as the article writes, this has allowed the country to implement rapid action when a health crisis strikes.

Using Technology to Fight the Virus

According to Vice Premier Chen Chi-mai, identifying cases of COVID-19 early and being able to track the movements of these cases has been crucial in Taiwan's disease prevention measures, and a significant part of these efforts is only possible through technology.

A pharmacist (right) hands a woman two masks after swiping her National Health Insurance (NHI) card, one of the many ways the NHI card has been used in COVID-19 measures.
A pharmacist (right) hands a woman two masks after swiping her National Health Insurance (NHI) card, one of the many ways the NHI card has been used in COVID-19 measures.

For instance, Taiwan integrated travel records from its National Immigration Agency with the National Health Insurance Administration (NHIA)'s existing database to alert doctors of their patients' travel history.

This was accomplished in one day, Chen said.

Now, whenever a doctor digitally scans a patient's National Health Insurance (NHI) card, an alert will pop up if the patient has traveled to or transited through countries listed in the CECC's warning list in the past 30 days.

Using patients' medical records stored in the NHIA database, Taiwan can also find those with severe respiratory symptoms but who have tested negative for influenza and retest them for COVID-19, to ensure that no possible case of the disease is missed.

Taiwan tested 113 patients who fit this profile, and one tested positive for the disease: a 61-year-old man living in central Taiwan who worked as a private driver for hire.

As the man, who passed away shortly after being diagnosed, had not traveled overseas before becoming infected, there was concern that his case meant that community-level transmission of the disease was occurring in Taiwan, and it became crucial to find out who had infected him.

"This was a race against time," Chen said, as every minute spent toward finding the source of the infection could mean that another person would come into contact with the virus and become infected.

Chen said they analyzed the driver's correspondence records to find passengers he had transported, cross-checked that list with the immigration agency's database to see who had traveled to Taiwan from high-risk regions, and then used the NHIA system to see if anyone on the list had sought treatment for upper respiratory tract infections.

This narrowed the suspects down to three people, Chen said, who the CECC then contacted and tested. One, a Taiwanese businessman based in the Chinese province of Zhejiang, was found to have antibodies of the virus in his blood, meaning that he had contracted the disease but had recovered. He was confirmed as the source of infection.

This was done through "the use of modern technology, big data, and cross-ministerial cooperation," Chen said, adding that with the support of the people, these methods have allowed Taiwan to overcome challenges posed by the disease.

Nation-wide Epidemic Prevention Team

"Because of everyone's understanding and cooperation, Taiwan has been able to hold the line of defense in the battle against COVID-19," Chen said.

In recent updates about the disease posted by the government on social media, the term "national epidemic prevention team" is often mentioned.

The term has been used to describe medical personnel in charge of treating confirmed patients, pharmacists who distribute masks to buyers under Taiwan's surgical mask rationing system, and researchers that are working to develop medication, rapid-screening kits and vaccines for COVID-19.

It has also been used to describe government officials leading Taiwan through the crisis, engineers who have set up the systems necessary to implement measures by the CECC, and factory workers operating mask-production units.

Medical personnel in protective gear prepare to conduct health checks on Taiwanese evacuated from the Chinese city of Wuhan, where COVID-19 was first detected.
Medical personnel in protective gear prepare to conduct health checks on Taiwanese evacuated from the Chinese city of Wuhan, where COVID-19 was first detected.

As Chen pointed out in a Facebook post, however, the work of epidemic prevention also relies on every citizen cooperating with the government to prevent further spread of the disease.

"Because of everyone's understanding and cooperation, Taiwan has been able to hold the line of defense in the battle against COVID-19," Chen said.

"As long as we work together, we will be able to win this war," he said.

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