The Case for Eliminating COVID-19 Transmission

Taiwan

COVID-19 isn’t the first coronavirus epidemic Taiwan has faced; in 2003 Asia dealt with outbreaks of a then-new coronavirus strain called Severe Acute Respiratory Syndrome (SARS-CoV). Home to nearly 24 million people with economic ties to mainland China, Taiwan was (and still is) at higher risk of imported cases. Guangdong and Hong Kong were epicenters linked to travel. In those five months, the uncertainty of SARS threatened Taiwan’s economy and healthcare system. The first SARS cases were reported on March 14 of 2003. That same day, Taiwan’s government formed a response system with the Department of Health to focus on surveillance. A Task Force Committee maintained a rapid-assessment quarantine system by assigning medical aid teams to review cases within three days of a report. By 28 March, Taiwan’s government established procedures for handling the spread: healthcare workers at SARS treatment hospitals were also guaranteed personal protective equipment (PPE) and N-95 masks.

As a further measure of surveillance, suspected SARS cases were reported to Taiwan’s Department of Health so public health workers could trace contacts and place them under home quarantine. Cases were assessed for a history of exposure to individuals with SARS or areas affected by it; symptoms and signs were also reviewed with WHO criteria for confirming SARS. Another important step Taiwan took was isolating both probable and suspected cases early on. Standard procedure was to prepare isolation rooms with HEPA air filters, negative pressure, and separate bathrooms so that SARS patients were kept away from the general hospital population. This was the main way of handling probable cases until the hospital system exceeded its capacity for negative pressure rooms between April 23 and May 8. Individuals identified for quarantine were split into two classes: Class A were healthcare workers exposed outside of isolation facilities, close contacts of confirmed patients, and those who boarded a flight within three rows of a SARS patient. People who weren’t exposed to a SARS patient or an infected healthcare worker had to home quarantine for the incubation period. Class B individuals were travelers from a SARS-affected area between April 28 to July 4. Quarantine for 10 days was required at home, an airport transit hotel, or an employer-assigned quarantine site. Government quarantine centers were also available.

On June 9, 2003 quarantine measures were eased so employees from China-based Taiwanese businesses could travel with masks. Quarantined individuals were required to self-monitor their body temperature and report by phone three times a day. Local public health nurses would deliver meals. Masks had to be worn at home if any area was shared with others in the household. If the person became sick while in quarantine, an ambulance would be arranged to transport them to the hospital. The driver would wear a Tyvek suit, gloves, and an N-95 mask. Taiwan’s CDC established 17 mobile containment teams early on, made up of frontline healthcare workers from Taiwan’s CDC and County Department of Health and United States CDC staff between March and May 2003. The teams had doctors and nurses assigned to evaluate hospital infection control practices. Checklists were used and isolation rooms were tested for sustained negative pressure. Standard equipment for evaluations included PPE and a specimen cooler to hold nasal swabs, culture media, and blood samples.

As the SARS epidemic petered out, Taiwanese officials found that early containment allowed for better outcomes without straining resources. However, improvements were still needed for infection control. In late April an outbreak of SARS occurred in Hospital ‘H’ that caused case clusters in eight other Taipei hospitals. A worker with a fever on April 12 interacted with staff, visitors, and patients in the emergency department. He was admitted on the 16th due to worsening symptoms but wasn’t suspected of SARS or moved to isolation until the 18th. Since the employee slept in the hospital’s basement quarters and socialized off-duty, it was estimated that up to 10,000 patients and visitors were potentially exposed in the six days he was symptomatic. Hospital H quarantined staff, patients, and visitors on April 24. One less center was available to prepare for the wave of new cases. As a result, the virus spread to other cities in Taiwan before exposed people tested positive. If future epidemics like SARS were to strike again, infection control practices needed improvement.

When COVID-19 emerged, Taiwan long had the infrastructure needed to withstand outbreaks of diseases like SARS. In 2004, Taiwan founded the National Health Command Center to work closely with the CDC and monitor emerging health threats. Surveillance systems again played a crucial role in guiding the pandemic response, coordinated by Taiwan’s CDC and the Central Epidemic Command Center. When a woman returning from Wuhan on January 21st 2020 was Taiwan’s first confirmed case of COVID-19, event-based surveillance systems led to screening airline passengers returning from Wuhan. All were placed under a 14-day mandatory quarantine. This first measure served Taiwan well in case control; between January and February, almost half of the 46 confirmed cases were imported from China. At first, Taiwan only considered travel to Wuhan and a fever/upper respiratory infection as COVID-19 criteria. When cases peaked in March 2020, COVID criteria expanded to include general travel and pneumonia with suspected symptoms. These changes coincided with border control escalations of travel alert levels (level 3 being a global travel alert).

As of this writing, Taiwan’s cumulative COVID cases are just over 1,100 with a mortality rate of only 1% (12 deaths). For comparison, 181 of the 668 SARS cases from 2003 were fatal (27%). The 2003 SARS epidemic allowed Taiwan to understand the nature of how coronaviruses can spread. Newer infrastructure was set up to support rapid assessment and isolation of new cases. Proximity in geography and economy to the Wuhan epicenter was also a factor for using surveillance, assessment, and restriction to contain transmission.