Response to COVID-19 in Taiwan
Big Data Analytics, New Technology, and Proactive Testing
C. Jason Wang, MD, PhD1,2; Chun Y. Ng, MBA, MPH2; Robert H. Brook, MD, ScD3,4
Author AffiliationsArticle Information
JAMA. Published online March 3, 2020. doi:10.1001/jama.2020.3151
Taiwan is 81 miles off the
coast of mainland China and was expected to have the second highest
number of cases of coronavirus disease 2019 (COVID-19) due to its
proximity to and number of flights between China.1 The country has 23 million citizens of which 850 000 reside in and 404 000 work in China.2,3 In 2019, 2.71 million visitors from the mainland traveled to Taiwan.4
As such, Taiwan has been on constant alert and ready to act on
epidemics arising from China ever since the severe acute respiratory
syndrome (SARS) epidemic in 2003. Given the continual spread of COVID-19
around the world, understanding the action items that were implemented
quickly in Taiwan and assessing the effectiveness of these actions in
preventing a large-scale epidemic may be instructive for other
countries.
COVID-19 occurred just before the Lunar New Year during
which time millions of Chinese and Taiwanese were expected to travel for
the holidays. Taiwan quickly mobilized and instituted specific
approaches for case identification, containment, and resource allocation
to protect the public health. Taiwan leveraged its national health
insurance database and integrated it with its immigration and customs
database to begin the creation of big data for analytics; it generated
real-time alerts during a clinical visit based on travel history and
clinical symptoms to aid case identification. It also used new
technology, including QR code scanning and online reporting of travel
history and health symptoms to classify travelers’ infectious risks
based on flight origin and travel history in the past 14 days. Persons
with low risk (no travel to level 3 alert areas) were sent a health
declaration border pass via SMS (short message service) messaging to
their phones for faster immigration clearance; those with higher risk
(recent travel to level 3 alert areas) were quarantined at home and
tracked through their mobile phone to ensure that they remained at home
during the incubation period.
Moreover, Taiwan enhanced COVID-19 case finding by
proactively seeking out patients with severe respiratory symptoms (based
on information from the National Health Insurance [NHI] database) who
had tested negative for influenza and retested them for COVID-19; 1 was
found of 113 cases. The toll-free number 1922 served as a hotline for
citizens to report suspicious symptoms or cases in themselves or others;
as the disease progressed, this hotline has reached full capacity, so
each major city was asked to create its own hotline as an alternative.
It is not known how often this hotline has been used. The government
addressed the issue of disease stigma and compassion for those affected
by providing food, frequent health checks, and encouragement for those
under quarantine. This rapid response included hundreds of action items
(eTable in the Supplement).
Recognizing the Crisis
In 2004, the year after the SARS outbreak, the Taiwan
government established the National Health Command Center (NHCC). The
NHCC is part of a disaster management center that focuses on
large-outbreak response and acts as the operational command point for
direct communications among central, regional, and local authorities.
The NHCC unified a central command system that includes the Central
Epidemic Command Center (CECC), the Biological Pathogen Disaster Command
Center, the Counter-Bioterrorism Command Center, and the Central
Medical Emergency Operations Center.
5
On December 31, 2019, when the World Health Organization
was notified of pneumonia of unknown cause in Wuhan, China, Taiwanese
officials began to board planes and assess passengers on direct flights
from Wuhan for fever and pneumonia symptoms before passengers could
deplane. As early as January 5, 2020, notification was expanded to
include any individual who had traveled to Wuhan in the past 14 days and
had a fever or symptoms of upper respiratory tract infection at the
point of entry; suspected cases were screened for 26 viruses including
SARS and Middle East respiratory syndrome (MERS). Passengers displaying
symptoms of fever and coughing were quarantined at home and assessed
whether medical attention at a hospital was necessary. On January 20,
while sporadic cases were reported from China, the Taiwan Centers for
Disease Control (CDC) officially activated the CECC for severe special
infectious pneumonia under NHCC, with the minister of health and welfare
as the designated commander. The CECC coordinated efforts by various
ministries, including the ministries of transportation, economics,
labor, and education and the Environmental Protection Administration,
among others, in a comprehensive effort to counteract the emerging
public health crisis.
Managing the Crisis
For the past 5 weeks (January 20-February 24), the CECC
has rapidly produced and implemented a list of at least 124 action items
(eTable in the Supplement)
including border control from the air and sea, case identification
(using new data and technology), quarantine of suspicious cases,
proactive case finding, resource allocation (assessing and managing
capacity), reassurance and education of the public while fighting
misinformation, negotiation with other countries and regions,
formulation of policies toward schools and childcare, and relief to
businesses.
Border Control, Case Identification, and Containment
On January 27, the National Health Insurance
Administration (NHIA) and the National Immigration Agency integrated
patients’ past 14-day travel history with their NHI identification card
data from the NHIA; this was accomplished in 1 day. Taiwan citizens’
household registration system and the foreigners’ entry card allowed the
government to track individuals at high risk because of recent travel
history in affected areas. Those identified as high risk (under home
quarantine) were monitored electronically through their mobile phones.
On January 30, the NHIA database was expanded to cover the past 14-day
travel history for patients from China, Hong Kong, and Macau. On
February 14, the Entry Quarantine System was launched, so travelers can
complete the health declaration form by scanning a QR code that leads to
an online form, either prior to departure from or upon arrival at a
Taiwan airport. A mobile health declaration pass was then sent via SMS
to phones using a local telecom operator, which allowed for faster
immigration clearance for those with minimal risk. This system was
created within a 72-hour period. On February 18, the government
announced that all hospitals, clinics, and pharmacies in Taiwan would
have access to patients’ travel histories.
Resource Allocation: Logistics and Operations
The CECC took an active role in resource allocation,
including setting the price of masks and using government funds and
military personnel to increase mask production. On January 20, the
Taiwan CDC announced that the government had under its control a
stockpile of 44 million surgical masks, 1.9 million N95 masks, and 1100
negative-pressure isolation rooms.
Communications and Politics
Reassure and Educate the Public, While Fighting Misinformation
In addition to daily press briefings by the minister of
health and welfare the CECC, the vice president of Taiwan, a prominent
epidemiologist, gave regular public service announcements broadcast from
the office of the president and made available via the internet. These
announcements included when and where to wear a mask, the importance of
handwashing, and the danger of hoarding masks to prevent them from
becoming unavailable to frontline health workers. The CECC also made
plans to assist schools, businesses, and furloughed workers (eTable in
the Supplement).
Taiwan’s Outcomes so Far (as of February 24)
Interim Outcomes
The CECC has communicated to the public in a clear and
compassionate manner. Based on a poll of 1079 randomly selected people
conducted by the Taiwan Public Opinion Foundation on February 17 and 18,
the minister of health and welfare received approval ratings of more
than 80% for his handling of the crisis, and the president and the
premier received an overall approval rating of close to 70%. As of
February 24, Taiwan has 30 cases of COVID-19. These cases represent the
10th-highest case number among countries affected thus far, but far
fewer than the initial models predicting that Taiwan would have the
second-highest importation risk.
Challenges
First, real-time public communications were mostly in
Mandarin Chinese and sign language. Other than the Taiwan CDC website,
there was not enough communication in different languages to
non-Taiwanese citizens traveling or residing in Taiwan. Second, while
its attention was focused on air travel, Taiwan permitted the docking of
the Diamond Princess cruise ship and allowed passengers to
disembark in Keelung, near New Taipei City, on January 31, before the
ship left for Japan. The ship was subsequently found to have numerous
confirmed infections onboard. This created a temporary public panic with
concern about community spread. The government published the 50
locations where the cruise ship travelers may have visited and asked
citizens who may have been in contact with the tour group to conduct
symptom monitoring and self-quarantine if necessary. None were confirmed
to have COVID-19 after 14 days had passed. Third, whether the intensive
nature of these policies can be maintained until the end of the
epidemic and continue to be well received by the public is unclear.
Conclusions
Taiwan’s government learned from its 2003 SARS
experience and established a public health response mechanism for
enabling rapid actions for the next crisis. Well-trained and experienced
teams of officials were quick to recognize the crisis and activated
emergency management structures to address the emerging outbreak.
In a crisis, governments often make difficult decisions
under uncertainty and time constraints. These decisions must be both
culturally appropriate and sensitive to the population. Through early
recognition of the crisis, daily briefings to the public, and simple
health messaging, the government was able to reassure the public by
delivering timely, accurate, and transparent information regarding the
evolving epidemic. Taiwan is an example of how a society can respond
quickly to a crisis and protect the interests of its citizens.
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Article Information
Corresponding Author: C. Jason Wang, MD, PhD, Stanford University, 117 Encina Commons, CHP/PCOR, Stanford, CA 94305 ([email protected]).
Published Online: March 3, 2020. doi:10.1001/jama.2020.3151
Conflict of Interest Disclosures: None reported.
References
1.
Gardner
L. Update January 31: modeling the spreading risk of 2019-nCoV.
Johns Hopkins University Center for Systems Science and Engineering.
Published 2020. Accessed February 20, 2020. https://systems.jhu.edu/research/public-health/ncov-model-2
2.
Pan
T, Yeh
J. Number of Taiwanese working in China hits 10-year low. Focus Taiwan. Published December 17, 2019. Accessed February 21, 2020. https://focustaiwan.tw/business/201912170022
3.
Statistics
on the number of Chinese people working overseas in 2018 [in Chinese].
News release. Directorate General of the Budget and Accounting; December
17, 2019. Accessed February 21, 2020. https://www.dgbas.gov.tw/public/Attachment/91217104242H1AK10HM.pdf
4.
Wang
S, Lin
K. Foreign visitors to Taiwan up 7% in 2019. Focus Taiwan. Published January 6, 2020. Accessed February 20, 2020. https://focustaiwan.tw/society/202001060014.
5.
NHCC
[National Health Command Center]. Taiwan Centers for Disease Control.
Updated February 1, 2018. Accessed February 22, 2020. https://www.cdc.gov.tw/En/Category/MPage/gL7-bARtHyNdrDq882pJ9Q
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