The Taiwan Model of COVID-19 Control and Its Global Implication 1 The Taiwan Model of COVID-19 Control and Its Global Implication Chang-chuan Chan Dean, Professor, College of Public Health, National Taiwan University Chi-hsin Sally Chen Assistant Professor, College of Public Health, National Taiwan University Abstract In this on-going global pandemic of COVID-19, Taiwan stands out as a leading country in preventing any outbreak. We delineate four non-pharmaceutical interventions —border control, contact tracing, resource allocation (face masks), and social distancing —of the acclaimed Taiwan model of controlling COVID-19. We explain the social- political background of what makes Taiwan’s model possible and successful, stressing the most effective measure of the model is the travel ban on visitors from China at the very early stage, due to hard lessons learned from 2003 SARS outbreak. We also demonstrate collaboration among all layers and all ministries of the government in a democratic country that can effectively bring a disease outbreak under control. We also point out political and technological challenges Taiwan is facing to continue its success in the next wave of the pandemic. We conclude that Taiwan’s model has a positive implications for COVID-19 control in the world, and Taiwan has an opportunity to play a meaningful role in global health in the future world order where public health is an important global security issue. Keywords: COVID-19, Pandemic, Global Health, Taiwan, World Health Organization Coronavirus 2019 (COVID-19) is an infectious disease caused by a newly discovered coronavirus, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The COVID-19 outbreak occurred in Wuhan City, China, in December 2019, and quickly became the most devastating pandemic the world has seen in a century. As of June 11, 2 Taiwan Strategists No. 6 confirmed COVID-19 cases has exceeded 7.3 million, with 416 thousand deaths in 188 countries (Figure 1).1 The World Health Organization (WHO) declared it a Public Health Emergency of International Concern (PHEIC) on January 30, 2020 and characterized it as a “pandemic” on March 11.2 Currently there are no medical treatment or vaccines for COVID-19, therefore governments can only take defensive actions and rely on non-pharmaceutical interventions (NPIs) to control the outbreak.3 Figure 1. Global COVID-19 Confirmed Cases and Fatalities until June 11, 2020 Source: Johns Hopkins University Center for Systems Science and Engineering, “COVID-19 Dashboard.” I. Taiwan Model As countries around the world thought over how NPIs could be implemented and when, many looked to Taiwan as the model to follow. Taiwan’s performance during this pandemic has been exemplary. As of June 11, Taiwan recorded relatively low number of confirmed cases (443), deaths (7), and limited locally transmitted cases Johns Hopkins University Center for Systems Science and Engineering, “COVID-19 Dashboard,” May 18, 2020, accessed, Johns Hopkins University, <https://coronavirus.jhu.edu/map.html>. World Health Organization, “Rolling updates on coronavirus disease (COVID-19),” May 14, 2020, accessed, WHO, <https://www.who.int/emergencies/diseases/novel-coronavirus-2019/ events-as-they-happen>. World Health Organization, “Non-pharmaceutical public health measures for mitigating the risk and impact of epidemic and pandemic influenza: annex: report of systematic literature reviews,” 2019, WHO, <https://apps.who.int/iris/handle/10665/329439>. The Taiwan Model of COVID-19 Control and Its Global Implication 3 of COVID-19 over the first few months of the pandemic (Figure 2).4 Border control, contact tracing, resource allocation (surgical face masks), and social distancing were four major NPIs that have been successfully implemented to contain the COVID-19 epidemic in Taiwan, and the four cornerstones of what we name the Taiwan Model of COVID-19 control.5 Taiwan was one of the first countries to begin border control to contain the COVID-19 outbreak, starting as early as December 31, 2019, with onboard quarantine for direct flights from Wuhan, banning visitors from Wuhan (January 23), then all of China (February 6), and eventually other affected areas in the rest of the world.6 Comprehensive and diligent contact tracing was conducted from the beginning to suppress the COVID-19 outbreak, beginning with integrating travel history into the National Health Insurance (NHI) database to identify persons under investigation (PUI), applying information technology to perform digital tracing for those who were in quarantine and isolation, and identifying people who had been in close proximity with confirmed patients.7 The government suspended N95 and Taiwan Centers for Disease Control, “COVID-19 (2019-nCoV),” May 18, 2020, accessed, Taiwan CDC, <https://sites.google.com/cdc.gov.tw/2019-ncov/taiwan>. C. Jason Wang, Chun Y. Ng, & Robert H. Brook, “Response to COVID-19 in Taiwan: Big Data Analytics, New Technology, and Proactive Testing,” JAMA, Vol. 323, No. 14, March 2020, pp. 1341-1342. Taiwan Centers for Disease Control, “Two experts from Taiwan visit Wuhan to understand and obtain information on severe special infectious pneumonia outbreak; Taiwan CDC raises travel notice level for Wuhan to Level 2,” January 20, 2020, Taiwan CDC, <https://www.cdc.gov.tw/ En/Bulletin/Detail/jFGUVrlLkIuHmzZeyAihHQ?typeid=158>; Taiwan Centers for Disease Control, “In light of outbreak of 2019-nCoV in China, Central Epidemic Control Center (CECC) stipulates restrictions on entry of Chinese citizens,” January 26, 2020, Taiwan CDC, <https:// www.cdc.gov.tw/En/Bulletin/Detail/AbXx37glDFCRtGihlDGOmA?typeid=158>; Taiwan Centers for Disease Control, “Starting from February 6, 2020, China (including Hong Kong, Macau) to be listed as Level 2 Area or above; Chinese residents to be prohibited from entering Taiwan,” February 5, 2020, Taiwan CDC, <https://www.cdc.gov.tw/En/Bulletin/Detail/KMAEC24Yf_ 5cm94oNL4Jxg?typeid=158>. Chi-Mai Chen, et al., “Containing COVID-19 Among 627,386 Persons in Contact With the Diamond Princess Cruise Ship Passengers Who Disembarked in Taiwan: Big Data Analytics,” J Med Internet Res., Vol. 22, No. 5, May 2020, JMIR, <https://www.jmir.org/2020/5/e19540/>; Hao-Yuan Cheng, et al., “Contact Tracing Assessment of COVID-19 Transmission Dynamics in Taiwan and Risk at Different Exposure Periods Before and After Symptom Onset,” JAMA Internal Medicine, May 1, 2020, pp. 1-8; National Health Insurance Administration, 〈防疫再 4 Taiwan Strategists No. 6 surgical mask exports on January 24, and announced nationwide requisition of domestically produced surgical masks on January 30.8 On February 6, a name-based mask rationing system began, and the number of masks each person could purchase increased as more production lines were installed (Figure 3).9 Taiwan was delayed the start of its spring semester in all schools (February 2-3) and implemented social distancing policies, which allowed governments and schools to have sufficient time to adopt necessary precautionary measures and allocate resources to mitigate potential COVID-19 outbreak in communities.10 升級健保雲端系統提供高風險地區旅遊史〉, January 27, 2020, National Health Insurance Administration, <https://reurl.cc/QdaxRo>; National Health Insurance Administration, 〈高風 險地區出境轉機資訊納入旅遊提示名單，縮小防疫破口〉, February 16, 2020, National Health Insurance Administration, <https://www.nhi.gov.tw/News_Content.aspx?n=FC05EB85BD 57C709&s=CD99CFE1CA7DEE26&sms=587F1A3D9A03E2AD>. Bureau of Foreign Trade, 〈公告自 109 年 1 月 24 日起至 109 年 2 月 23 日止CCC6307.90.50.10-6 「紡織材料製口罩，過濾效果 94%及以上者」及 CCC6307.90.50.20-4「其他紡織材料製 口罩」2 項貨品增列輸出規定代號「111」，並列入「限制輸出貨品表」〉, January 23, 2020, MOEA, R.O.C., <https://www.moea.gov.tw/Mns/populace/news/News.aspx? kind=2& menu_id=41&news_id=88547>; Ministry of Economic Affairs,〈努力讓大家都買得到，限 量購買（3 片）政策將持續〉, January 30, 2020, MOEA, R.O.C., <https://www.moea.gov.tw/ Mns/populace/news/News.aspx?kind=1&menu_id=40&news_id=88565>. Taiwan Centers for Disease Control, “Name-based rationing system for purchases of masks to be launched on February 6; public to buy masks with their (NHI) cards,” February 4, 2020, Taiwan CDC, <https://www.cdc.gov.tw/En/Bulletin/Detail/ZlJrIunqRjM49LIBn8p6eA?typeid=158>. Ministry of Education,〈高級中等以下學校因應武漢肺炎疫情延至 2 月 25 日開學〉, February 2, 2020, Ministry of Education, <https://www.edu.tw/News_Content.aspx?n=9E7AC85F1954DDA8& s=F430DC0E892811A6&sms=169B8E91BB75571F>; Ministry of Education, 〈大專校院因 應武漢肺炎疫情延至 2 月 25 日以後開學，暫緩陸生來台，並啟動安心就學措施〉, February 3, 2020, Ministry of Education, <https://www.edu.tw/News_Content.aspx? n=9E7AC85F1954DDA8& s=8CFC4B7DD566A8F4&sms=169B8E91BB75571F>. The Taiwan Model of COVID-19 Control and Its Global Implication 5 Figure 2. Number of Confirmed Cases of COVID-19 by the Onset Dates During January-May, 2020 in Taiwan Source: Taiwan Centers for Disease Control, “COVID-19 (2019-nCoV),” June 11, 2020, accessed, Taiwan CDC, <https://sites.google.com/cdc.gov.tw/2019ncov/taiwan>. Figure 3. The Process of the Name-Based Mask Distribution System Using a Smart Phone Source: Screenshot by Chang-chuan Chan. Taiwan was able to react quickly to COVID-19 because its society as a whole learned lessons from the 2003 severe acute respiratory syndrome (SARS) epidemic. We knew that we should be ready for newly emerging infectious diseases, and that we cannot expect timely and accurate data from China. This is why in the early stages of COVID-19, the Taiwanese government decided to err on the side of caution and take serious actions based on a small number of initial reports. The border control 6 Taiwan Strategists No. 6 policy turned out to be the most important and successful containment measure. John Hopkins University (JHU) later predicted a grim outcome for Taiwan because of the high risk of voluminous imported cases, based the trade and travel with China, if border controls had not been implemented early.11 For nearly two decades, we have been preparing for the next epidemic as a vulnerable country, by creating new agencies and scientific institutions at national and local levels, and training medical and scientific personnel for the purpose of guarding against new emerging diseases.