Covid-19: how Japan squandered its early jump on the pandemic

Dear Editor,

We read with great interest the article “Covid-19: how Japan squandered its early jump on the pandemic” by Professor Erika Hayasaki [1] that described in detail the quagmire in which Japan got stuck in its battle against the COVID-19 pandemic. In contrast, the number of cases in Taiwan with COVID-19 is relatively small for a population of 23.8 million according to the latest update (i.e., 429 patients with confirmed diagnosis and six mortalities to date, mortality rate 1.4%) compared with that in the United States, European (e.g., Italy) and Middle Eastern (e.g., Iran) countries, taking into account the earlier onset of the disease in Taiwan, its geographic proximity to China (i.e., Kinmen County, one of the Taiwanese islands, is merely 2.31 km away from Mainland China), and the high frequency and volume of travelers between Taiwan and Mainland China. Besides, of the 429 confirmed cases, 374 (87.2%) were imported and there is no large-scale community-acquired infection.
The relatively well-contained pandemic in Taiwan may be attributable to some important changes in governmental healthcare policies following the Severe Acute Respiratory Syndrome (SARS) attack in 2003. In addition to some of the reported key Taiwanese measures in response to the threat of COVID-19 [2], a review of all incidences of COVID-19 in Taiwan and the corresponding responses of the Ministry of Health and Welfare (MHW), Taiwan, revealed some essential strategies that the Taiwan adopts at national and institutional levels.

Strategies at national level

1. Portable record of citizens’ travel history
The National Health Insurance Card, which all Taiwanese citizens possess for presenting to medical institutes on seeking medical help, contains not only records of medications and the sources of prescription but also detailed travel histories. It proved to be an effective screening tool for healthcare workers.

2. Assigning responsible medical institutes for management of possible endemic and quarantine of patients
Following the previous assault of SARS, MHW assigned the responsibilities of endemic control to 134 medical institutes nationwide with facilities considered adequate for this purpose. The list is renewed every three years based on the results of assessment. Despite variations in their strategies adopted, these medical institutes form the basis of responses at the institutional level following changes in government policies as disease progresses.

3. Establishment of a central command post governing all epidemic-related measures
The Taiwan Centres for Disease Control (TCDC) (https://www.cdc.gov.tw/En) is a branch of MHW overseeing the prevention, surveillance, and screening of infectious diseases in the country. It also governs the establishment of legislation regarding the standard operating procedures to be adopted by governmental bodies and medical institutions on encountering potential infection threats. After 2003, the Taiwanese government realized the need for organising a central command post in response to a nationwide threat of infection for monitoring and controlling disease spread through effective communications between the central government and different regions in the country. The Central Epidemic Command Centre (CECC) has a fixed location fully equipped with personnel as well as communicating software and hardware to allow round-the-clock information updating and timely decision making.

4. Ensuring accuracy of information to the public
Not only does CECC act as a central commanding post and a bridge between the central government and local governmental units but it also ensures the accuracy and transparency of health-related information when confronted with severe health threat; there are three separate webpages for public access titled “Public newsletters”, “Information clarification”, and “Letters to medical professionals” that are kept updated to eradicate possible misinformation. Besides, updated information on the pandemic is constantly being sent to the general public whose smart phones have established links to MHW.

5. Making rolling plans
Instant reviewing and updating of existing plans at governmental level are mandatory to keep pace with the latest development regarding the extent and pattern of infection spread, both locally and internationally. There have been five steps taken starting from Jan 15, 2020 in response to major trigger events, including: Step 1: Strict surveillance, import control, and immediate reporting (Trigger event: WHO disease outbreak new on Jan 12, 2020); Step 2: Containment of infection and identification of infection source (Trigger event: The first patient with confirmed diagnosis on Jan 21, 2020.); Step 3: Minimising risks of community-acquired infection (Trigger event: The first mortality with confirmed diagnosis but without travel history); Step 4: Prevention of nosocomial infection (Trigger event: First confirmed nosocomial cluster infection in Taiwan); and Step 5: Eliminating risks of disease importation through lockdown and close monitoring of those subject to mandatory self-quarantine through contact tracing with cellphones (Trigger event: Dramatic increase in the number of confirmed cases mainly from Europe).

6. Ensuring constant communication between health administrative departments and healthcare institutes
Daily and unscheduled communications between infection control departments of the government at regional level and the personnel in the frontline (e.g., infection control physicians) of the assigned medical institutes are important for the central government to close the gap between policy and the ever-changing clinical situation as well as to re-allocate medical resources in the country.

Strategies at institutional level

Basically, the assigned medical institutes reacted to the evolving crisis in pace with the changes in government policies. There are variations in strategy at different medical institutes according to the number of confirmed cases being treated and the resources available. The common strategies are listed in Table 1 and summarised as follows:

1. Strict surveillance and immediate reporting
Setting up checkpoints at hospital entrances for screening patients and visitors (i.e., body temperature, travel history, respiratory symptoms) has been found effective for diversion of patients to receive management at different levels of precautions to avoid nosocomial infection. History taking for patients at the emergency department or outpatient clinics should emphasise on travel, occupation, contact, and cluster for early screening of imported cases. Immediate reporting of suspected cases to TCDC is also critical for preventing disease spread and limiting the number of contacted individuals who could be timely traced and isolated.

2. Early organisation of “Infection Control Response Unit”
A sustained coordinated effort involving all levels of a medical institute (e.g., governance, physicians, engineers, and maintenance staff) is essential to reaching consensus regarding the allocation of resources (e.g., personnel) and taking effective measures against the spread of infection (e.g., planning spaces for quarantine).

3. Rolling plans in pace with government policy
Stricter policies than those announced by the government are adopted by the medical institutes which are the last line of defense (e.g., prohibition of out-of-country travel for all hospital personnel). Rolling planning is also crucial to the decision of re-allocating hospital resources (i.e., humans and materials) to cater for the increasing number of infected patients.

4. Compliance with government policy and timely reflection of difficulty
All the medical institutes in the country adopt a synchronised approach with unobstructed communications with the government for early identification of possible pitfalls of a policy and arriving at a practical solution.

Despite differences in culture, healthcare policies and resources, the Taiwanese strategies against the COVID-19 pandemic may be of reference value for other countries. Provided that not a single country can stay isolated from the rest of the world, fortifying one’s own defense against a spreading global infection is merely building a crumbling fortress. Strictly disciplined and coordinated international efforts may be necessary for achieving positive outcomes.

References

1. Hayasaki E. Covid-19: how Japan squandered its early jump on the pandemic. BMJ 2020;369:m:1625 doi: 10.1136/bmj.m1625

2. Wang CJ, Ng CY, Brook RH. Response to COVID-19 in Taiwan: Big Data Analytics, New Technology, and Proactive Testing. JAMA 2020 doi: 10.1001/jama.2020.3151