Taiwan’s nationwide epidemic response is outstanding. But China prevents the WHO from sharing information about it. Here’s a fairly thorough description below.
Taiwan has so far prevented community infections, despite its extensive family and business ties with China. The US CDC has now removed it from the list of countries with travel warnings. So how did they do that?
One reason is because they took action early in the epidemic. Despite having only a handful of cases, Taiwan’s government ordered schools to delay restarting classes for one month after the winter holiday. Some schools prepared to hold virtual classes online.
This delay gave government agencies and the medical community time to assess the situation and coordinate a nationwide response. Prior experience with SARS in 2003 has helped.
Below I describe Taiwan’s society-wide response, including (in no particular order):
- Screening for fever at entrances to schools, hospitals, and businesses & monitoring employees & visitors
- Connecting travel data with national health insurance data
- Large scale public gatherings and public transportation
- Distributing surgical masks and preventing price gouging
- Voluntary self-monitoring, at-home isolation, and quarantine
- How hospitals have reorganized work to prevent transmission and shut downs
- Strategic use of Covid-19 test kits
- Taiwan’s Central Epidemic Command Center and National Health Insurance system as a model
- Is the U.S. ready?
SCREENING FOR FEVER AT ENTRANCES
Many institutions, including schools, hospitals and companies, take the temperature of everyone who enters the facility.
At the nursing school where I work, campus is surrounded by a wall that has multiple entrances. Now only the main gate remains open for entering and exiting campus. At the gate, someone takes every person’s temperature, checks their ID, and gives them a colored sticker to wear. There is a different color for every day. So theoretically, no one on campus has a fever.
Some institutions can afford machines with a heat-sensing camera that automatically screens the temperature of every person who enters. The machine has to be adjusted for ambient temperature every day. On cold days, it will be adjusted downward. This is done by having five employees who don’t have a fever pass through it every morning. The machine records their average temperature and adds 2 degrees (celcius)
to it to set a cutoff.
Companies have assigned someone (usually from HR) to take the temperature of employees as they enter the building. If you have cold symptoms or a fever you are referred to medical care and sent home for two weeks WITH PAY. The government has ordered that people asked to isolate themselves continue receiving pay, so there’s less incentive to hide symptoms or break quarantine. This is an expense imposed on businesses. Large employers can afford. Not sure what happens with small businesses.
Someone from HR must not only find out which employees have been in China or another place with community infection, they have to find out if that person has had visitors from such places. This makes a lot of work for HR. It’s not an airtight system; a dishonest person can lie to HR about having a visitor. A combination of measures that work most of the time can still be used to stop community transmission before it goes too far.
Schools and companies are asked to sterilize door knobs, elevators, bathrooms, phones and keyboards twice a day.
During the 2003 SARS epidemic, outside contract workers turned out to be a blind spot. So companies and schools also need to keep track of electricians, cleaners, and other service providers who enter and exit like employees.
Hospitals go one step further–they not only check the temperature of all people who enter, they also register every visitor who enters by scanning their National Health Insurance card with a card reader. That way if they can trace contacts inside and outside the hospital, if they need to.
CONNECTING TRAVEL DATA WITH MEDICAL RECORDS
Travel data of people entering and exiting the country has now been linked to the National Health Insurance card: When you see a medical care provider, they can see if you recently entered the country and where you came from. (However, I’m not sure it can see where you changed planes, so this is imperfect. Also, people who have more than one passport can evade the system. The system does not have to be perfect to be effective most of the time.)
PUBLIC GATHERINGS & TRANSPORT
After intensive public debate on talk-shows and in newspapers, large scale events, including a massive outdoor religious festival, have been canceled or postponed. Probably because of that debate, the public seems to have accepted the government order.
On public transportation, nearly everyone wears a surgical mask, whether or not they have cold symptoms. On the. subway, I’d say 1 in 20 people isn’t wearing a mask. On the High Speed Rail it looked like 1 in 50. Subway cars, trains, and buses are cleaned with disinfectant at the end of each run.
DISTRIBUTING MASKS & PREVENTING PRICE GOUGING
Initially people started buying up surgical masks leaving too few for health workers. First the country stopped exporting masks. Then they worked out a system to ration them, limiting people to two masks per week, to ensure that health care workers have enough, while they step up production. People use their NHI card to buy masks, so they don’t cheat. Profiteering by raising the price on masks and cleaning supplies is forbidden.
VOLUNTARY ISOLATION, MONITORING, AND QUARANTINE
If a health care provider determines you should be under at-home isolation or at-home quarantine, the hospital takes your address and informs an elected neighborhood-level official called a lizhang. The lizhangs are pretty busy now: they have to telephone every person in their district who is under isolation once a day. They also have to spray sterilizing chemicals at certain places in the neighborhood where transmission is more likely once daily (like public bathrooms).
Reporting Temperature Online
If you are under at home quarantine or isolation, you have to take your temperature twice a day and report it online. If you forget, you will get a phone call from someone (I’m not sure who does this. My employer appointed one nurse to the task of tracking students and employees who are under observation and reporting to other agencies.)
There are three levels of “quarantine”:
The least strict is voluntary at home self-monitoring. For two weeks, you’re not supposed to go to work but you can go outside if necessary. You are asked to not take public transportation or go to supermarkets and to stay away from crowded spaces.You are given contact information for a health care provider who has been informed of your case. If you develop symptoms you are to contact them in advance so they can take precautions for your arrival.
At-home mandatory monitoring for people who had contact with an active case or came from a country with community infection. You’re really not supposed to leave home. Someone else should get food for you. If you are under at-home quarantine, you should try to maintain some separation from family members in the apartment, like sleeping in separate rooms and not using the same utensils.
If you are in mandatory monitoring or quarantine for two weeks, building supervisors are informed and your cell phone movements may be tracked. There’s a widespread view that violating quarantine is an act of selfishness. If you break quarantine, you may be fined. I’ve seen fines as low as $300, $2000-3000 and up to $30,000USD. This does not apply to people requested to do voluntary self-monitoring. Their phones won’t be tracked.
HOW HOSPITALS HAVE REORGANIZED WORK TO PREVENT TRANSMISSION & SHUTDOWNS
During the 2003 SARS epidemic, one entire hospital had to be quarantined. The outbreak was traced to a cleaner who handled laundry and continued coming to work despite being sick.
Hospitals have prepared to avoid being shut down by changing the organization of work. As much as possible, teams of doctors and nurses stay on a single ward instead of rotating through the whole building. That way, if infection starts spreading on that ward, they can shut one ward down without closing the hospital. Patients with the illness will be moved to medical observation or medical quarantine. The doctors and nurses working on that ward will stay home for two weeks to see if they develop symptoms.Scheduling nursing shifts is a lot of work in ordinary times, so reorganizing work according to these criteria is probably more complicated still.
The number of both inpatients and outpatients at hospitals have dropped. There are about 30% fewer inpatients at one hospital and outpatients have dropped by 20%. Because risk of infection is higher in a hospital than at home, patients who can avoid being hospitalized are managed at home.
At most hospitals, any outpatient with cold symptoms will be directed to the emergency department, which is where screening for Covid-19 cases is done. So while most of the hospital has a lighter workload, emergency departments are busier. That means doctors who usually don’t work there can help in the emergency departments .Hospitals are also contributing doctors for shifts at airports, where they wear full protective gear when in contact with possible cases.
Nursing Attendants for In-Patients
At hospitals in Taiwan, inpatients are expected to provide their own personal attendants to do the work done by certified nursing assistants in the U.S. (A CNA is the person who routinely helps feed and wash patients and help them to the bathroom). In Taiwan (and many countries), family members usually take turns to provide this care. They may alternate day and night shifts or contribute financially to one family member who takes time off to attend to the patient. Families may also pool resources to hire a private caregiver. Hospitals refer patients & families to outside agencies that provide caregivers.A hospital may work with more than one outside agency. Usually a family hires one person to attend to the patient–it’s not a rotating position, the caregiver develops an extended relationship with the family and patient.
At one hospital where a number of medical personnel got infected they have restricted visitors. For now, each patient can have only one caregiver attend to them, whether that person is a family member or hired by the family.
STRATEGIC USE OF TEST KITS FOR COVID-19
No country has enough test kits to test its entire population. To check community spread of infection, there must be criteria for using the kits that are available.
In Taiwan, previously only people with fever and a history of travel were tested. Now it is anyone with cold symptoms and a travel history. First they take a throat and nose culture to see if symptoms are caused by a bacteria or the flu virus. If symptoms cannot be explained that way, then blood is drawn for a covid-19 test that looks for antibodies. A person with Covid-19 is released from hospital only after they have three tests that show they are free of antibodies (the global standard is two times).
TAIWAN’S EPIDEMIC RESPONSE & NATIONAL HEALTH INSURANCE MODEL
Taiwan’s health care providers are rightly proud of the system they created.
Knowing they will always be faced with the challenge of diseases from other places, they didn’t dismantle their Central Epidemic Command Center after the 2003 SARS epidemic–so they have an experienced chain of command able to mount a swift response. Despite its proximity to China and extensive ties, Taiwan has so far been able to restrict COVID-19 to minor community outbreaks, mostly contagion within families.
Having a permanent Central Epidemic Command Center means no need to recreate one for every disease that appears.
Taiwan has a national health insurance system where everyone is covered, access to medical care is easy, and there are no wait times for routine care–even without an appointment. You can register for an appointment online for the same day, or walk into a hospital, take a number and see a doctor within an hour. There is no system of gatekeepers to prevent you from going to a specialist. Traditional Chinese medicine is covered by NHI. To prevent people from hoarding or reselling prescription medications, prescription data linked to your NHI card is shared across medical institutions.
Even though Taiwan is excluded from membership in the WHO (due to China’s insistence that it is not a country), its health care system has been rated number one or two in the world for several years running. So the U.S. should not be ashamed to follow Taiwan’s example for coordinating epidemic response planning.
Taiwan is a democracy with a high degree of personal liberty and low levels of surveillance. In China, by contrast, people are expected to download a government app to their phones that gives them a green, yellow, or red QR code based on where they have been and who they have been in contact with. People generally don’t know why their rating changed. If you have a red code, you will find it impossible to go anywhere.You have to scan these QR codes to take public transportation, enter buildings, or even to exit a highway. The government is capable of tracking all people’s movements by their phones all the time and a system of facial recognition surveillance cameras blankets the country (all reported by the NY Times). Taiwan demonstrates that effective epidemic measures don’t have to be draconian.
TAIWAN’S RESEARCH ESTABLISHMENT
…is formidable and is testing drug combinations, participating in international clinical trials, discovering novel ways to synthesize ingredients in drugs and test kits, and developing vaccines. I don’t know much about this–so just a brief mention here.
Taiwan’s premier Su gave the responsibility to coordinate a nationwide response to someone of lower rank who had medical training–the Minister of Health, Chen Shih-chung (陳時中)–and raised the Central Epidemic Command Center to a top tier government agency to facilitate communication within the government.
Providing reliable information to the public and debunking fake news is part of the epidemic response. Chen Shih-chung, Minister of Health and head of the Central Epidemic Command Center, is on the news daily and is widely trusted. They actively fight particularly egregious disinformation from China–such as news claiming that Taiwan’s president Tsai is in the hospital with Covid-19–online.
This is a sensitive issue for China. Taiwan is an example to the world–that China is constantly trying to censor. And here’s a situation where Taiwan is especially outstanding, in contrast to China’s failure to stop the virus’ spread.
- Stefani Pfeiffer