From time to time, until the crisis has passed, the HEPL blog series authors will be given the opportunity to provide short updates on their country/region’s continuing response to this worldwide catastrophe and their further reflections on those responses. Each update will be labelled accordingly with the original response at the bottom of each post.

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HEPL blog series: Country Responses to the Covid19 Pandemic

Taiwan’s Response to the Coronavirus Pandemic – the August update (2020)

Chunhuei Chi, Director, Center for Global Health, Professor of Global Health Program and Health Management and Policy Program, Oregon State University

On June 7^th, after 56 consecutive days with no new domestic cases, Taiwan lifted its final pandemic restrictions on the cap of crowd gathering size (200/2,000 for indoor/outdoor) and declared that people could resume all activities without restrictions. Before that, Taiwan was one of the few nations in the world in which people were able to maintain relative normalcy without shutting down businesses, public offices, or schools. As of August 7^th, with a total of 477 confirmed cases and 7 deaths, Taiwan has one of the world’s lowest COVID-19 cases per million (20.1), deaths per million (0.30), and case fatality rates (1.47%), while also never having had any community outbreaks. This second update will focus on Taiwan’s “challenges from success” and its responses, new insights on factors in its success, and preparation for the future.

Numerous articles have been published detailing Taiwan’s effective pandemic control policies, including the use of information technology and government trustworthiness.  On July 30^th and 31^st, three leading national universities and several academic associations in Taiwan held the largest COVID-19 physical conference since the onset of the pandemic. Taiwan’s leading researchers and policymakers gave presentations on pandemic responses and challenges, and economic impacts and mitigations. Former Vice President and renowned epidemiologist Dr. Chen Chien-Jen, who has been instrumental in guiding Taiwan’s pandemic control policies, gave the keynote speech. He shared new insights on how Taiwan’s 2003 SARS and 2009 H1N1 experiences contributed to the present success. In addition to the previous Response series, several new insights will be helpful for all nations managing the coming challenges. One major concern during the H1N1 pandemic was that in the fall, it would be difficult for healthcare providers to differentiate between H1N1 and seasonal flu infections because of their similar symptoms. Foreseeing this challenge, Taiwan’s CDC accelerated its advanced planning by deploying point-of-care testing kits and viral medicine for seasonal flu in the spring of 2009, developed guidelines, and trained numerous clinical health professionals for differential diagnosis and treatment. It worked successfully in the fall to prevent flu patients from confusing providers and overwhelming hospitals. This proven strategy will be very critical for the current combat against COVID-19 as we will be facing the same challenge.

Another important lesson that benefited Taiwan from previous combats with SARS and H1N1 is the attitude toward novel contagious diseases. In addition to having a large group of veteran professionals who are operational experts, equally important are the attitudes of both these experts (many are key policymakers) and the general public in facing a novel disease. Instead of questioning the validity of such a threat, they take every trivial sign of new disease extremely seriously and would rather err on overreaction than under-preparedness. This was why Taiwan was the first nation to warn WHO on December 31, 2019 and the first nation to mobilize experts against COVID-19 on January 5, 2020. Such an attitude will be important for all nations and WHO in the future, as COVID-19 is unlikely to be our last pandemic. This “pandemic veteran’s attitude” also made Taiwan’s public a critical partner to the success of Taiwan’s pandemic control. Instead of relying on the uncertain effect of herd immunity, this herd attitude was essential to controlling the pandemic.

By July 31, Taiwan had seen 115 consecutive days with no new domestic cases. One vital reason why Taiwan is obsessively guarding its border and maintaining strict isolation/quarantine is that Taiwan’s healthcare system was already operating at near capacity prior to the pandemic, which could be easily overrun by community outbreaks. Consequently, both the government and the public have been obsessed with “zero new domestic cases” since mid-April. Between late June and late July, there were three suspected domestic infections; the government ruled out the first two and is still investigating the third. These events generated new debates on how to safely open the national border and the level of strictness required in preventing domestic cases.

One chief factor of Taiwan’s success is strict isolation and quarantine. By July 30^th, Taiwan quarantined 153,040 people at home and prevented community transmission by 288 of them who became confirmed cases. Taiwan quarantined over 150,000 people so that 23.7 million wouldn’t have to be quarantined.

Looking ahead, Taiwan is preparing to face the challenges of safely opening up its border for international commerce and other activities, balancing maintaining regular activities while still vigilant on pandemic control, and collaborating with other nations in developing effective vaccines and treatments. Taiwan recognized that it cannot be safe if the world is not safe. This will require a new framing of the problem. So far, Taiwan’s response has been framed as pandemic control. To effectively respond to the new challenges, Taiwan is reframing it to post-pandemic development that includes maintaining pandemic control, while expanding into social and economic development.

Taiwan’s Response to the Coronavirus Pandemic – Update (May 2020)

Chunhuei Chi, Director, Center for Global Health, Professor of Global Health Program and Health Management and Policy Program, Oregon State University

Taiwan continues to keep up its highly effective epidemic control and maintain its outstanding record of being one of the very few nations that do not have any community outbreaks of COVID-19. At the time of writing (May 8^th), Taiwan has a total of 440 COVID-19 cases with 6 deaths, and 26 consecutive days without a domestic case. In this follow-up, I will highlight some measures that played a critical role in epidemic control and how they were effective in containing one specific crisis mid-April.

Taiwan developed the innovative Intelligent Electronic Fence System (IEFS) in early February, to complement its quarantine and monitoring system that was established at the end of the 2003 SARS epidemic. IEFS is a GPS-based information system that is a collaboration between the Central Epidemic Command Center (CECC) and major cellphone carriers. It is based on an individual’s cellphone signals and nearby cell towers to triangulate the location of quarantined individuals. It is capable of monitoring the nation’s entire population under quarantine, and tracks locations every 10 minutes. If it cannot identify the location of a quarantined person for 2 consecutive times (20 minutes), or if an individual infringes on the quarantine perimeter, it automatically sends a warning message to that person, the CECC, local government, and the police department. If a person violated the mandatory quarantine and went to public places, the IEFS can identify these locations and inform the public.

The IEFS was a vital tool to complement Taiwan’s highly efficient contact-tracing system in containing a crisis from a major community outbreak. On April 15, 744 navy sailors disembarked three naval ships after over one month of an overseas mission and visited their family/friends around the nation. They were recalled to a quarantine center on April 18 after two of them had symptoms. CECC immediately tracked places these sailors visited during those 3 days and sent warning messages to people who had visited these public places. Apart from 35 sailors who became confirmed cases, there was no community outbreak from this incident.

The critical reason that most Taiwanese accept this breach of privacy was a very high level of trust between the public and the government. The CECC is a model of communitas that has both the highest level of power to coordinate national epidemic control, while also being immensely transparent and responsive in its decision making. At the same time, it always goes the extra mile to protect and respect individuals. It has exemplary leadership that enjoys high support and trust from the public.

As a mature full democracy, despite a high approval rating, the Taiwanese Government has its share of opposition. From mid-April to May, the opposition party and some academics have been advocating mass testing and criticizing the CECC for not implementing it. In its daily briefing on April 27 the CECC Commander educated the public on why mass testing is both unnecessary and an inefficient use of resources. Given Taiwan never had a community outbreak, a mass testing of PCR would generate very few extra cases. Further, it is highly contested how frequent mass testing has to be performed. As for mass testing of antibodies, there are still problems with current methods in terms of sensitivity and specificity. This is another example of CECC’s openness in responding to policy adversaries.

Taiwan’s highly effective control measures resulted in a surplus of epidemic control capacity. This afforded Taiwan to isolate even asymptomatic patients in negative pressure hospital rooms, while treating them with anti-viral drugs to reduce their viral loads and contagiousness. With so few active cases and between 0 to 3 daily new cases, moreover, Taiwan can afford to take a very conservative criteria in testing: for a suspected case, one has to pass two consecutive negative test results to leave quarantine; for a confirmed case, one has to pass three consecutive negative test results to be declared cured.

Recently, there has been some debate on whether a democracy can be as effective as an authoritarian government at controlling epidemics. Taiwan’s success in COVID-19 control proves that a mature democracy can outperform authoritarian governments in protecting public safety and freedom, while also protecting the economy. Further, Taiwan’s achievements have allowed for assistance to other nations. At the same time, it continues to practice advance planning and is preparing for controlling this pandemic in case it resurges in the late fall. Aside from accelerating vaccine and drug research, Taiwan is also expanding medical resources and capacity for controlling the COVID-19 in case of resurgence, while improving its border inspection and quarantine measures. Its spirit is highlighted in the recent CECC motto: “New life with epidemic prevention”, which encourages the public to relax, enjoy life, while continuing to be vigilant in all hygiene practices.

Taiwan’s Response to the Coronavirus Pandemic – Original post (April 2020)

Chunhuei Chi, Center for Global Health, Oregon State University

Despite Johns Hopkins’ team predicting that Taiwan will have the second most COVID-19 infected cases in the World after China, a little more than two months later, a nation of 23 million people, Taiwan is still at a low number of 380 total cases with 5 total deaths, as of April 9th. Over 100 international media around the world have reported Taiwan’s apparent success at controlling the pandemic. “Taiwan sets gold standard in epidemic response to keep infection rates low” was the title of The Telegraph’s report. In this essay I will review Taiwan’s approach by first describing what Taiwan had been preparing since the SARS epidemic of 2003, followed by a summary of the critical system, policies and key players that synergistically contributed to Taiwan’s effective epidemic response.

Few nations were as well prepared for this pandemic as was Taiwan. After the bitter experience from 2003 SARS, Taiwan decided never again to be caught unprepared against a new epidemic. When there were early signs of a new virus infection emerging in Wuhan in December 2019, Taiwan was the first nation to sound an alarm to WHO’s International Health Regulation on December 31^st 2019, suggesting that this coronavirus could be transmitted between humans. However, WHO ignored it. That same day Taiwan began on-board inspection of all passengers’ temperature for all flights from Wuhan to Taiwan. When the first confirmed case of COVID-19 appeared on January 21, Taiwan activated the Central Epidemic Command Center (CECC) that was established during the latter part of SARS epidemic. Below are the key measures Taiwan implemented since the end of SARS in 2003 to strengthen its epidemic control infrastructure.

(1) Trained all hospital-based nurses on communicable diseases.

(2) Developed hospital standard operating procedures for contagious diseases.

(3) Expanded the number of negative pressure isolation hospital rooms to 970 units.

(4) Heavily invested in cutting-edge biomedical research capacity.

(5) Developed standards and measures for quarantine, isolation, and community control of highly contagious epidemics.

In the next section, I will summarize the key policies that Taiwan implemented from the beginning of COVID-19 pandemic in January. Some of them could be implemented by other nations, and indeed a few countries already done so.

Effective leadership with solid national coordination

The CECC was activated on January 20^th and was upgraded to the highest level of government agency on February 27^th, which gives it the authority of commanding all sectors. This single-line of command is highly efficient in coordinating and mobilizing all sectors in a concerted effort to control the pandemic. Its success has been demonstrated from both the outcome and the unusually high 91% public approval rating for the Commander Dr. Chen Shih-chung. Further, Taiwan happened to have a “dream team” of leaders during this pandemic. They include Taiwan’s President Dr. Tsai Ying-wen, who is gifted in appointing exceptional national leaders with a high level of delegation. In addition, several other prominent leaders also contributed to Taiwan’s effective response. They include the Vice President Dr. Chen Chien-jen, who was the Minister of Health that led a successful campaign in controlling 2003 SARS epidemic – he is an accomplished epidemiologist and regularly provides advice to CECC; and the Vice Premier Dr. Chen Chi-Mai (a physician with an MPH degree), who together with IT Minister Audrey Tang, are instrumental in developing a digital fence for monitoring quarantine and potential contacts.

Strong infrastructure and information technology

Taiwan implemented a universal health care system, the National Health Insurance (NHI) Program, in 1995, administered by the National Health Insurance Administration (NHIA). Its role in coordinating all health care facilities was vital in combating the SARS epidemic. In 2018, the NHIA implemented the MediCloud, which stores all citizens’ and visitors’ health data in a cloud server. The MediCloud became an extremely helpful informational tool for combating this pandemic. In late January, NHIA Director General Dr. Lee Bo-chang linked MediCloud with Taiwan’s immigration data. It allows CECC to both screen and track imported cases, while also providing every health care facility with vital information regarding a patient’s travel history. Furthermore, MediCloud became an essential platform for distributing government rationed medical masks. One innovation Taiwan developed for controlling this pandemic is a digital fence monitoring system that tracks and monitors people under quarantine and identifes locations where a confirmed case had visited.

Advanced planning and advanced deployment

Taiwan instantly mobilized the nation into an “epidemic combat mode” against this pandemic after only a few confirmed cases in January, and its CECC immediately rolled out its plan against the COVID-19 pandemic. Its advanced planning included setting up quarantine and isolation venues while prioritizing healthcare facilities. One example best illustrates how Taiwan’s advanced planning works: Taiwan’s “mask miracle.” Taiwan’s government banned export of all medical masks on January 24^th. This was followed by government monopolization of all medical masks on January 30^th, which allowed CECC to prioritize all masks for health professionals and facilities, and ration the rest to the public. Moreover, the government

allocated USD 6.8 million on January 31^st to build 60 new medical mask production lines. These new lines began producing by the beginning of March. They dramatically expanded Taiwan’s daily production of surgical/N95 masks from 1.88 million per day to 12 million per day by early April. It allows Taiwan to gradually increase the rationing to the public from an initial 2 masks per person per week to 9 per person per 14 days on April 9. It not only made Taiwan the first nation to have universal access to medical masks, but also gave Taiwan the capability to offer mask aid to other nations.

Transparency in policy making with clear guidelines for the public

Taiwan’s CECC serves as the single stop go-to place for all relevant information. The public can access its daily updates on new cases, source of infection, new regulations/restrictions, changing quantity of rationed masks, travel advisories, and self-quarantine guidelines etc., from its website or free App on mobile phones. Furthermore, the government also provides clear guidelines on when to wear masks, how to keep oneself safe from coronavirus in public places, how to safely organize indoor and outdoor gatherings, and when to suspend a class or an entire school, etc. Additionally, the CECC has been very transparent and responsive to public inputs in its decision making. This level of transparent, clear and timely communication plays a critical role in public confidence and calmness, while leaving little room for misinformation. 

Smart testing with meticulous tracking and strict isolation and quarantine

Taiwan implemented “smart testing”, coupled with meticulous tracking of potential patients by employing its high-tech information technology. For every confirmed case, the CECC obsessively tracks the source of infection and all possible places and persons whom the case contacted, and tests most of them. The smart testing works only with a strict isolation and quarantine regulation, coupled with digital monitoring fence, and daily phone calls by local government officials. It is a combination of smart testing, extensive tracking, strict quarantine, and mandatory mask wearing in public transportation and many indoor places including schools, that contributed to Taiwan’s effective control of the pandemic.

One more factor that is critical to Taiwan’s effective response is strong social solidarity. Taiwan’s relative international political and public health isolation and bitter experience from SARS made the vast majority of Taiwanese very supportive of the government’s measures in fighting the pandemic. Without such spirit, those policies and measures may not have been as effective.

Thanks to Taiwan’s very effective control measures, Taiwan is one of only a few nations where (as of April 9^th) the vast majority of businesses, government offices, schools, shops, and restaurants and bars are still open. This effective response also minimizes the pandemic’s negative impact on Taiwan’s economy. Further, this achievement puts Taiwan in the position to assist other nations in this pandemic. In early April, President Tsai announced Taiwan will donate 10 million medical masks to health professionals in Europe and North America. Moreover, Taiwan is also providing technical assistance to many nations that have requested help, as well as collaborating with the US and several European nations in developing vaccines and drugs for COVID-19.

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