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March 3, 2020

Response to COVID-19 in Taiwan: Big Data Analytics, New Technology, and Proactive Testing

Author Affiliations
  • 1Departments of Pediatrics, Medicine, and Health Research and Policy, Stanford University School of Medicine, Stanford, California
  • 2The New School for Leadership in Health Care, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan
  • 3David Geffen School of Medicine, Department of Medicine, University of California, Los Angeles
  • 4The Pardee RAND Graduate School, RAND Corporation, Santa Monica, California
JAMA. 2020;323(14):1341-1342. 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 (cjwang1@stanford.edu).

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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    12 Comments for this article
    EXPAND ALL
    Taiwan Experience Worth Spreading to The International Community
    Sha SA, MD, PhD | Taipei Medical University
    I as an expat who has been living in Taiwan for the last 9 years. Taiwan is an example of how a society can respond quickly to a crisis and protect the interests of its citizens. It is very unfortunate that WHO doesn't recognize and learn from the experiences of Taiwan to deal with outbreaks.
    CONFLICT OF INTEREST: None Reported
    Someone Please Send this Info to the Washington State governor
    MR Johns |
    Very impressive and I wish the US Federal and Washington State local government acted in such systematic and proactive manner! Probably too late. We already missed the time window at several crucial junctures
    CONFLICT OF INTEREST: None Reported
    Taiwan's Coronavirus response gives confidence
    Lloyd Lalande, ClinPsych, PhD | Tzu Chi University
    I'm another expat living in Taiwan. There has definitely been a sense here that the COVID-19 threat has and continues to be managed competently by the government with community members also responsibly and cooperatively playing their part. That response is visible everywhere, whether coming through immigration control, having my temperature checked each time I enter my campus, using the alcohol hand spray at my favorite coffee shop, or buying masks with my residential card. Watching Taiwan's response, as detailed in this excellent article, and then the WHO response (or lack of) makes one question the relevancy of that organization.
    CONFLICT OF INTEREST: None Reported
    Taiwan
    Ernest Ciambarella, MD, Pediatrics | Retired
    This article shows what can be accomplished when you have a health care system where profit is not the motive and a government whose primary concern are its citizens and not the stock market. Noteworthy too that their VP is an epidemiologist.
    CONFLICT OF INTEREST: None Reported
    Health IT
    Wei-yi Chung, RN, MS in CS | NYU Langone Health
    Thank you for the great example of how real-time analytics works in epidemics.
    CONFLICT OF INTEREST: None Reported
    Fast and Furious Response to COVID-19 in Taiwan
    Michael McAleer, PhD (Econometrics), Queen's | Asia University, Taiwan
    Geographic proximity, history, culture, finance and economics intertwine Taiwan and the People's Republic of China.

    A similar connection might have been expected in the respective responses to COVID-19.

    The informative article presents an instructive and workable model to the WHO and the world community of how to deal with and contain epidemics.

    The arsenal of information includes the use of advanced analytics, technology, proactive screening, testing and retesting, communication strategies, accountability, and the presentation of informative and credible daily updates.

    An emphasis on risk and disaster management for quarantine during incubation, as well as health care
    concern for citizens and residents, is reassuring.

    Taiwan's universal health and medical system might be expensive, but seems to be working efficiently when needed in times of crisis.

    The alternative to effective universal health care is evident in a number of developed countries, where the response to COVID-19 has been disappointing, and anything but fast and furious.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Drug Inhibitor Testing
    Ethan Tu, MS | Taiwan AI Labs
    The outbreak of novel coronavirus (COVID-19) infections occurring in 2019 is in dire need of finding potential therapeutic agents. In a recent study -- not yet peer reviewed (1) -- we used molecular docking strategies to repurpose HIV protease inhibitors and nucleotide analogues for COVID-19. The evaluation was made on docking scores calculated by AutoDock Vina and RosettaCommons. Preliminary results suggested that Indinavir and Remdesivir have the best docking scores and the comparison of the docking sites of these two drugs shows a near perfect dock in the overlap region of the protein pocket. However, the active sites inferred from the proteins of SARS coronavirus are not compatible with the docking site of COVID-19, which may give rise to concern in the efficacy of drugs. Our data are shared publicly (2).

    References

    1. https://www.preprints.org/manuscript/202002.0242/v1?fbclid=IwAR1tVOdtxqI1vQyJcgH8D_XsXQ1pSTWaHIa5QPbfQWB13sCQkhIAHUZLarM

    2. COVID19 Taiwan NHI Drug Data Repository by Taiwan AI Labs Intelligent Medical Genomics Team. https://github.com/ailabstw/COVID19-taiwan?fbclid=IwAR0j_p4-Z7zoUuzoUXtSiKi4b3srW_YC-Gmdnq_dTBLJ5iGEyuXBZvD_IdQ
    CONFLICT OF INTEREST: Taiwan AI Labs
    READ MORE
    Using Technology to Fight The Epidemic
    Faye Kleeman, Ph.D. |
    This is an excellent article. Just want to add one more thing that the article did not mention. The Taiwan government not only rations face masks to prevent hoarding, it also created a virtual map guided by GPS that tells you where the nearest pharmacies are and which pharmacy still have face masks in stock. On March 11th, it started on-line ordering of face masks so those who have to work or attend classes can pre-order the mask and just stop by a convenient store to pick them up after work. Citizens are cooperative in this crisis as you hardly see anyone in public space, buses and subways, markets, campuses without a mask.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Taiwan learned to protect herself when abandoned by WHO in 2003
    Risa Tei |
    With the medical and infectious professionals in full command in NHCC (Taiwan's CDC), the government administration gives full support and follow up in all related areas, as mentioned in your report: setting up border control, providing medical supplies, securing masks for people in need, arranging hospital duties, giving out guidance for school kids and more. This helped to expedite all processes in a timely and effective manner.

    Maybe we heard that masks are not really essential in epidemic, but there were some cases proving that wearing masks really helped. There was one caregiver diagnosed positive after taking
    care of an elderly patient, and didn't spread the virus even though she had taken all subways, trains and buses around for several days. After NHCC checked the videos, they found out she and the people around her were wearing masks the whole time.

    There is a saying for the Taiwan situation: the kids without umbrellas must run faster than others in a heavy rain. With no protection and help from World Health Organization, Taiwan has no other choice but to be strong and proactive against any virus or epidemic.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Confirmation of Airport and Local Screening
    Andrew Ku, MD | Allegheny General Hospital
    Having visited Taiwan in January and February I can confirm the measures at the airport upon deplaning. I couldn't board a taxi to my hotel without a face mask. I was given one at a taxi stand. At the hotel and airport I had a noninvasive temperature taken. I provided a local address to immigration prior to leaving the airport.

    All highly efficient without being too obtrusive.

    I strongly commend the support given by their health authorities to those who self quarantine.

    Similar US Public health support would increase community acceptance of self quarantine measures.
    CONFLICT OF INTEREST: None Reported
    SARS and Climate Change
    Rey Tiquia, PhD | University of Melbourne
    A significant fact that Taiwanese researchers discovered from their experience in dealing with the SARS epidemic in 2003 was the correlation between the rise of epidemics and climate change.

    In a paper published in the Journal of Chinese Medicine 15(4): 231-239, 2004, Taiwanese researchers Jun-Ran Jiang, Ye Fang, Chin Lieh Hung, Hen-Hoing Chang, Sie Hung Yang, Jong-Jen Kuo and Yu-sheng Chen observed that since the 1980’s climate change has been playing a major role in the outbreak of epidemic diseases such as:

    1. The outbreak of hanta virus epidemic in May 1993
    in the southwestern region of the United States.
    2. Prevalence of meningitis in Nigeria in 1997-1979.
    3. Prevalence of malaria in Rwanda in 1987.
    4. The phenomena of El nino and La nina which brought about climate changes and in turn influenced the occurrence and spread of infectious diseases.
    5. The outbreak of the Murray River encephalitis and Ross River virus in Australia.
    6. The outbreak of ‘eastern equine encephalitis in the easter region of the United States.
    7. The outbreak of malaria in Sri Lanka.
    8. The SARS outbreak in Mainland China

    Looking at the ocurences of epidemics in China from 1371 up till 1911, Taiwanese researchers discovered that epidemics transpired in 98 ‘disharmonious years’ when there were fierce and extreme weather and climactic changes.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Joel Zonszein MD
    Joel Zonszein, MD, Prof of Medicine | Albert Einstein College of Medicine
    In reviewing the literature JAMA has published regarding susceptibility to COVID-19 infection in China, Singapore, Taiwan, Italy and early US (Seattle Washington), I was unable to determine obesity and diabetes are real risk factors. There are many opinion articles without data and minimal information regarding the “true” incidence or prevalence of COVID-19. The prevalence of COVID-19 in Vò, a hot spot of Northern Italy, showed that mass screening testing all 3,300 of inhabitants showed that approximately 3% of residents were  infected and ½ asymptomatic. The data differ from projections of 50-70% being infected, and approximately 80% asymptomatic. There are not many other studies with mass screening using reliable 2019-nCov Real-Time Reverse Transcriptase (RT)-PCR diagnostic tests.

    Obesity and diabetes are often mentioned as risk factor sfor mortality – I tried finding such evidence in the literature, but was unable as there is no “real data.” In fact, the incidence of diabetes in the elderly population who died from COVID-19–caused ARDS, had a below average incidence of diabetes and I was unable to find any data with weight and or obesity in either the affected population or in those with unfortunate outcomes. I am trying to gather “real data” of obesity and diabetes, often mentioned as risk factors for COVID-19 or mortality.

    It is important to separate facts from opinions; opinions cause more confusion to our susceptible population and after more than three months of this epidemic data needs to be available.
    CONFLICT OF INTEREST: None Reported
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