By taking early measures to combat the spread, the country had a medical laboratory test for COVID-19 available as early as Jan. 24, and was able to focus medical laboratory testing on the most at-risk individuals
With the Coronavirus disease 2019 (COVID-19) outbreak dominating headlines and medical laboratories under growing pressure to increase testing capacity, Taiwan’s rapid response to the pandemic could provide a critical model for other countries to follow.
Given its proximity to mainland China—just 81 miles—and the large number of individuals who frequently travel back and forth between the countries, Taiwan was at risk of having the second-highest number of imported COVID-19 cases, according to a model developed by researchers at Johns Hopkins University and the University of New South Wales Sydney. News reports indicate that, each year, about 60,000 flights carry 10 million passengers between Taiwan and China.
But after the first reports emerged of the infection in Wuhan, China, “Taiwan quickly mobilized and instituted specific approaches for case identification, containment, and resource allocation to protect the public health,” wrote C. Jason Wang, MD, PhD; Chun Y. Ng, MBA, MPH; and Robert H. Brook, MD, ScD, in an article for the Journal of the American Medical Association (JAMA), titled, “Response to COVID-19 in Taiwan Big Data Analytics, New Technology, and Proactive Testing.”
Data from Taiwan’s Centers for Disease Control (CDC) and Central Epidemic Command Center (CECC) indicate that the country has managed to contain the outbreak thanks to these aggressive actions.
As of March 19, Taiwan’s CECC reported a total of 108 laboratory-confirmed COVID-19 infections. That compares with 81,155 in China, 41,035 in Italy, and 10,755 in the US, according to data compiled by the Center for Systems Science and Engineering at Johns Hopkins University. When the World Health Organization (WHO) reports on the number of COVID-19 cases by country, it includes the number of COVID-19 cases from Taiwan under the totals for the People’s Republic of China. WHO made this decision several years ago, under pressure by China to not recognize Taiwan as an independent nation.
The World Population Review website says Taiwan’s population is about 23.8 million. But its infection rate is low even on a per capita basis: Approximately 45 infections per million population, compared with 6,784 in Italy, 564 in China, and 326 per million in the US.
The JAMA authors noted that Taiwan was prepared for an outbreak after its experience with the severe acute respiratory syndrome (SARS) pandemic in 2003, which also originated in China.
Timeline of COVID-19 Outbreak at the Earliest Stages
Taiwan apparently learned a lesson about preparedness from the SARS outbreak the rest of the world did not and that enabled the tiny nation to respond immediately to the novel Coronavirus threat.
The country’s efforts began on Dec. 31 with inspections of flight arrivals from Wuhan. “When there were only a very few cases [of COVID-19] reported in China, [Taiwanese health authorities] already went onto every airplane that came from Wuhan,” C. Jason Wang, MD, PhD, an Associate Professor of Pediatrics and Director of the Center for Policy, Outcomes, and Prevention at Stanford University and lead author of the JAMA report, told Vox. “Health officials came on the airplane and checked people for symptoms,” he added.
Travelers who had recently visited Wuhan and displayed symptoms of pneumonia were quarantined at home for 14 days. Taiwan’s CDC reported that quarantined individuals were being tested for the 2019-nCoV coronavirus (later renamed to SARS-CoV-2) soon after it was identified. The CECC, activated in January to coordinate the government’s response, reported the first confirmed imported case on Jan. 21.
On Jan. 24, their CDC announced that testing for the virus was being performed at the CDC and eight designated hospitals. Testing included samples from physicians around the country. As of Feb. 17, daily testing capacity was about 1,300 samples, the JAMA authors reported.
Wang told Vox that aggressive measures to identify and isolate at-risk individuals at the earliest stages reduced the volume of clinical laboratory tests that had to be performed. “Here in the US and elsewhere, we’re now seeing community spread,” he said. “It’s probably been here for a while. And so now we’re trying to see, ‘Oh, how many people should we test?’ Then, you really need to have a very large capacity in the beginning.”
More Actions by Authorities
The JAMA report supplementary materials notes a total of 124 actions taken by Taiwanese authorities between Jan. 20 and Feb. 24 to contain the outbreak. In addition to the border inspections, quarantines and testing, they included integration of data between the country’s National Health Insurance Administration and National Immigration Agency, so authorities, and later hospitals, could identify any patient who had recently traveled to China, Hong Kong, or Macau.
The steps also included:
- An escalating series of travel restrictions, eventually including suspension of most passenger flights from Taiwan to China, as well as a suspension of tours to Hong Kong or Macau.
- Use of government-issued cell phones to monitor quarantined individuals.
- Fines for individuals breaking the 14-day home quarantine.
- Fines for incoming travelers who failed to provide accurate health information.
- Fines for disseminating false information or rumors about the epidemic.
- Fines and jail sentences for profiteering on disease-prevention products.
- Designation of military camps and other government facilities for quarantine.
- Nationwide disinfection of universities, colleges, and public spaces around schools.
The government also took aggressive action to ensure adequate supplies of surgical masks, including stepped-up manufacturing, export bans, price limits, and a limit of one to three masks per purchase.
The JAMA authors noted that government officials issued daily press briefings to educate the public about the outbreak. Communication efforts also included public service announcements by Taiwan Vice President Chen Chien-jen, a trained epidemiologist.
A poll taken in Taiwan on Feb. 17 and 18 indicated high approval ratings for officials’ response to the crisis.
The JAMA authors also noted some “challenges” in the government’s response. For example, most real-time public communication was in Mandarin Chinese and sign language, leaving out non-Taiwanese citizens in the country. And the cruise ship Diamond Princess, later found to have infections on board, was allowed to dock near Taipei and disembark passengers. There are also questions about whether similar policies can be sustained through the end of a pandemic.
Still, “well-trained and experienced teams of officials were quick to recognize the crisis and activated emergency management structures to address the emerging outbreak,” the JAMA authors wrote. “Taiwan is an example of how a society can respond quickly to a crisis and protect the interests of its citizens.”
One noteworthy difference in the speedy response to recognition of a novel coronavirus in Taiwan, compared to recognition of the same novel coronavirus in the United States, was the fast availability of clinical laboratory tests for COVID-19 in Taiwan.
Pathologists and clinical laboratory professionals here in the US are frustrated that their skills and talents at developing and validating new assays on an accelerated timeline were not acknowledged and leveraged by government officials as they decided how to respond to the emergence of the novel coronavirus now called SARS-CoV-2.