Response to the COVID-19 Pandemic in Taiwan

Abstract

In the midst of the COVID-19 pandemic, the world witnessed a large number of infections and deaths. Due to its proximity to China, it was initially feared that Taiwan would become the country worst affected by the pandemic. However, COVID-19 has been widely controlled in the region; a few local outbreaks occurred with limited cases since the pandemic began. Taiwan leveraged its experience in containing the SARS outbreak in 2003 to respond to the COVID-19 crisis with proactive measures, early deployment, prudent actions, and transparency. Most political debate in Taiwan has centered around vaccines. However, from challenges like vaccine availability to increasing the willingness to take vaccines by the population, the Taiwan government has succeeded well. Taiwan’s National Health Insurance system is a vital component of its strategy to improve the efficiency of healthcare delivery throughout the country. And the database integrated with the Centers of Disease Control provides real-time alerts to healthcare providers about patients whenever they are identified. In response to delta variant spread after a community outbreak, health monitoring measures were tightened, leading the country to successfully control the spread of the infection. Other countries can learn lessons from Taiwan's response to COVID-19.

Background

Taiwan's success with the COVID-19 pandemic was no coincidence. An essential component of the Taiwan model was transparency. The Taiwan model, one of the most effective globally, was the product of a democratic system. Measures that Taiwan undertook to control the spread of COVID included epidemiological surveys, border control, effective monitoring, testing and tracing, investigations, and triage. The Taiwan government was willing to listen to critics and make needed changes in its policies. Taiwan's media also played an understated role in fighting the pandemic. There was some degree of vaccine hesitancy, but most of the media channels promoted appropriate behavior during the pandemic. The people demonstrated that they were responsible citizens by actively cooperating with the government. Most religious groups were willing to support the government’s disease prevention policies; they postponed several religious celebrations. Everyone treated the fight against the virus as a personal matter.

Taiwan donated 50 million surgical masks to countries worldwide [1]. Taiwan collaborated with the United States and some countries of Europe to develop rapid diagnostics, anti-viral drugs, and vaccines [1]. The Central Epidemic Command Center (CECC) held regular press conferences to provide risk management and health education information. People were encouraged to keep an appropriate distance and to avoid large-scale gatherings. Financial relief and economic stimulus packages were vital measures for containing the COVID-19 pandemic in Taiwan.

Combating COVID-19

Early Response to the COVID-19 Pandemic

Taiwan's Center for Disease Control learned from some online sources that a few unusual pneumonia cases had been reported in Wuhan on December 31, 2019. Taiwan immediately sent reports to the World Health Organization (WHO) and to China's CDC [2]. Taiwan believed that the clustering of atypical pneumonia in Wuhan was a sudden severe, unusual, and incidental event that required quick attention and action from the WHO and from China's CDC.

Taiwan operationalized prudent action, rapid response, and early deployment into its epidemic prevention system. All passengers arriving from Wuhan were checked. Taiwan strengthened its case reporting and hospital infection control of the health care system in January 2020. In January 2020, China convened an advisory committee on atypical pneumonia followed by establishing a Level 1 travel notice in early January in Wuhan, where the outbreak was attributed to a new disease labeled 2019-nCoV by the WHO. Subsequently, Taiwan’s CDC classified COVID-19 as an emerging infectious disease on January 15. Taiwan had previously contained an outbreak of SARS (severe acute respiratory syndrome) in 2003 and had experienced the H1N1 pandemic flu in 2009.

Taiwan was the first country in the world to conduct onboard screening of passengers arriving on direct flights from Wuhan to get all arriving travelers to complete a health declaration [3]. The CDC played a vital role in disease prevention in the early days. It implemented a disease prevention plan that consisted of two phases. The first phase, Preparedness Planning, was activated when suspected cases of COVID-19 were reported in neighboring countries but there was no community transmission. The second phase, Contingency Planning, was activated after the first phase during the pandemic. On January 20, 2020, while sporadic cases were reported from China, the CDC in Taiwan set the CECC in motion to handle severe infectious pneumonia under the auspices of the National Health Command Center, with the Minister of Health and Welfare as its designated commander [4]. The CECC facilitated the efforts of several ministries, including the ministries of transportation, economics, education, labor, and the environmental protection administration, in a comprehensive effort to check this emerging public health crisis.

Containment

The first outbreak in Taiwan occurred shortly before February 16 and ended by April 11, 2020. The second outbreak started a little before January 12 and ended on February 9, 2021. The third outbreak started shortly before April 20, 2021; the highest peak of reported cases occurred on May 28, 2021. Between the first and second outbreak, Taiwan had a period of 273 days when there were no reported local infections other than an isolated case with an unknown source reported on August 2, 2020 and a local case reported on December 22, 2020. The latter was a woman in her 30 s who came in close contact with Case No 765, the New Zealand pilot who had been associated with a cluster of infections among pilots. Further, during a period of 69 days, there were no reported cases between the second and third outbreaks. However, this situation did not last long. Starting in April 2021, multiple clusters of cases occurred that were related to the flight crew from the airlines at Taoyuan International Airport (the Taiwan’s largest airport situated near the capital city of Taipei). These outbreaks resulted in a sharp increase in cases far exceeding the levels observed in 2020. The reasons for the sharp increase of cases were possibly non-compliance with quarantine rules and an abbreviated period of mandated quarantine for pilots. In addition, the highly contagious and virulent Delta variant breached Taiwan's borders. On June 5, 2021, Taiwan reported its first domestically transmitted case of the Delta variant of the coronavirus.

Taiwan has a four-tier epidemic alert system like that of New Zealand but with more stringent criteria to reach level four. It uses a level 3 alert system which includes several restrictions and closures. A level 4 alert system is typically activated after a maximum of 100 cases are reported per day. On May 20, 2021, the alert level was extended to level 3 in Taiwan which included guidelines requiring that individuals wear masks, stay outdoors, and limit social gatherings to 10 persons. A semi-level four lockdown was implemented in June 2021 in several villages in Pingtung County. Unlike New Zealand and Australia, where strict but relatively short lockdowns were used successfully to control the spread of infection, Taiwan avoided a national lockdown since it did not reach the threshold to implement these measures. Figure 1 illustrates daily confirmed COVID-19 cases per million population, comparing Taiwan, Australia, New Zealand, and global data. The Bureau of Consular Affairs pulled up all foreign nationals not holding a valid ROC (the Republic of China, i.e., Taiwan) Resident Certificate on arrival. Taiwan was gradually able to control the outbreak. After the Central Epidemic Command Center assessed the situation, it announced in late November 2021 that a Level 2 epidemic alert would continue to be in place until December 13, 2021 [5].

Fig. 1

Source Johns Hopkins University CSSE COVID-19 data

Daily confirmed COVID-19 cases per million population, comparing Taiwan, Australia, New Zealand, and global data (7-day rolling average).

Taiwan's COVID-19 vaccination program started in March 2021. Its vaccination rates were lower during the third outbreak than in many high-income countries. This was due to the lack of willingness of healthcare workers and the general population to get vaccinated [6]. On top of this, the Delta variant B.1.617.2 showed up in the community. While some feared the worst with only 0.1% of the population fully vaccinated, the outbreak was contained. Fourteen days after it was identified, the increase in cases due to the Delta variant appeared to slow down. And, there was a rapid expansion of the vaccination program.

Initially, Taiwan relied on vaccines imported through COVAX. Countries like the USA helped Taiwan get Moderna and BioNTech and Japan helped Taiwan get the AstraZeneca vaccine. Taiwan also began domestic production of vaccines. Taiwan’s law prohibits the import of Chinese vaccines for use in humans. Currently, 76.6% of Taiwan's population is vaccinated with one doze and 57% of the population is fully vaccinated [7]. Figure 2 illustrates the cumulative COVID-19 vaccination status in Taiwan. Recently, in response to the emergence of the Omicron variant, the CECC announced that COVID-19 vaccine booster shots will be given to people who have completed their COVID-19 vaccine doses five months earlier [5]. Taiwan’s government withstood criticism from the opposition party and shared its local vaccine in partnership with the U.S. National Institutes of Health, which clearly established Taiwan as playing a contributing role in the global health community.

Fig. 2

Source Official data collated by our world in data

Cumulative COVID-19 vaccination status of Taiwan’s population.

Preparedness of Healthcare System

Taiwan's healthcare system is fully covered by National Health Insurance (NHI) which was introduced in 1995. Taiwan currently allocates 6.5% of its GDP (gross domestic product) on a progressive, low-cost healthcare system characterized by excellent accessibility, comprehensive coverage, and short waiting times. It has also established a national data collection system to support research and future planning. Funding is covered by payroll-based premiums. The government provides generous premium subsidies for low-income households, civil servants, and others as a single-payer system. Private providers provide preventive, primary, specialist, hospital, and mental health services. Long-term care was recently added to this list. Out-of-pocket costs include co-payments for outpatient care, prescription drugs, and coinsurance for hospital stay. Private health insurance consists primarily of disease-specific cash indemnity policies [9]. The financial structure of Taiwan’s NHI system is shown in Fig. 3.

Fig. 3

Source Financial structure of Taiwan’s NHI system [8]

The financial structure of the Taiwanese National Health Insurance system.

Pandemic preparedness of Taiwan's healthcare system was impressive. Because of the application of an early containment policy, Taiwan successfully lowered the impact of SARS-CoV-2 [10]. Taiwan began to increase its case finding by proactively seeking outpatients with severe respiratory problems who tested negative for influenza and re-tested them for COVID-19. A free hotline number (1922) was set up to report COVID-19 patients and cases with suspicious symptoms. During the peak of the pandemic, the hotline reached its total capacity. Consequently, the government decided that each major city should have its own hotline.

Persons under quarantine were provided with food and frequent health checks. The government had had the same experience during the SARS outbreak in 2003. Taiwan’s health care planner had developed a public health response mechanism to facilitate speedy action for the next emergency. Taiwan’s well-trained and experienced healthcare workforce could quickly responded to the crisis, activated emergency management structures, and addressed them during an emerging outbreak [4, 10]. The government made every effort to inform and reassure the public through daily simple health messaging that was timely, accurate, and transparent.

Healthcare resources were important for controlling the pandemic. Shared contributions and efforts of all interdependent stakeholders ensured the availability of pharmaceutical supplies. There were drug shortages because of disruptions in overseas manufacturing and stock-outs in pharmacies. Taiwan's health system met this challenge through active management, transparency, and well-timed communications, which are all-important to ensure a stable supply of essential medications during a pandemic. An example of such activities was organizing meetings between commercial associations and pharmaceutical manufacturers, to respond to future critical shortages created by COVID-19, and careful inventory control to predict such shortages. Sources of and applications for critical active pharmaceutical ingredients and medications were actively investigated and reviewed. The government developed a financial stimulus package and reimbursement plans for the costs associated with these critical supplies. The supply–demand balance ruling was reinforced to ensure rational distribution, allocation, and stockpiling of medications [11].

Similarly, in hospital settings, high levels of vigilance and an immediate response to changes in the outbreak situation took place within specific timelines. The safety of hospital team members was essential for delivering health services to save patients’ lives. Therefore, infection control measures were undertaken in hospital settings. There was emergency preparedness of the hospital administration. Activities conducted included education, surveillance, patient flow, partitioning of hospital zones, and prevention of a systemic shutdown by using the ‘divided cabin, divided flow’ strategy [12]. Also, some routine services like elective surgery and minor procedures were cancelled to increase service capacity to respond to the increasing number of COVID-19 cases. This was key to a quick transformation from regular services to COVID-19 care [13]. Strategies were put in place to reduce the use of personal protective equipment by building sample collection stations for COVID-19 testing outside hospitals which also reduced the time required for sample collection.

One hospital in Taiwan introduced a strategy in its emergency department that included a double triage and a telemedicine protocol. This strategy helped in reducing the exposure time and the risk of frontline healthcare workers contracting the infection while managing patients suspected of having COVID-19 [14]. If any cases or contacts were identified, they were moved to a nearby hospital or the Long-term Care Facility (LTCF) or other quarantine locations. Testing was repeated one week later on persons who had encountered the virus.

Border control and travel restrictions were key in preventing COVID-19 [15]. Because of Taiwan’s unique culture and economy, the government used a unique approach to combat the COVID-19 pandemic. The NHI has a big data system and has added to it digital contact tracing, mobile geo-positioning, automated self-restriction monitoring, and the ability to follow up on COVID-19 cases. Thus, actions taken to control the pandemic also contributed to addressing future problems.

Community Response

According to media reports, the Taiwanese population did an excellent job of preventing COVID-19. They contacted confirmed cases who were isolated at home for 14 days. Local health agencies contacted people in home isolation to check up on them twice a day. If individuals developed symptoms, they were admitted to the hospital.

Most importantly, people collaborated with telecom companies. The government introduced an electronic self-assurance monitoring system to identify the location of people in home quarantine by detecting mobile phone signals connected to the exchange tower. If quarantined individuals moved away from the nearest cell tower, an assigned worker received a notification via SMS, after which immediate follow-up was carried out that could result in fines or forcible quarantine. Figure 4 provides the flow of community screening of COVID-19 cases based on information from the CECC. Quarantined individuals were required to remain at home for the entire 14-day period. Both central and local government agencies partnered to provide services such and daily follow-up calls. They made transportation arrangements and provided household services such as settlement planning for people without a residence. They also organized food delivery and garbage collection services. The Tourism Bureau organized a subsidy plan for hotels. Homeless patients were provided government-funded shelter by cooperating hotels. From April 1 to July 31, 2021, the hotels were reimbursed USD 37 per room.

Fig. 4

Source International Journal of Infectious Disease [16]

The flow of community screening for COVID-19 cases according to the CECC.

In the early stages of the COVID-19 pandemic in January 2020, schools delayed opening for two weeks. Schools were not closed for longer durations. The Ministry of Education (MOE) framed rules for the suspension of classes and organized and earmarked medical supplies for schools to protect students from COVID-19 infection. Schools cooperated by monitoring students, disinfecting classrooms, and organizing activities to ensure that both teachers and students were safe and followed safety guidelines. Social distancing measures were announced on April 1, 2020 and the public was urged to maintain social etiquette and follow social distancing.

In Taiwan, disease prevention measures require a legal basis before they can be implemented. And these measures must be supervised by citizens. To gain people's trust and support, the Central Epidemic Command Center (CECC) was activated. The CECC held routine press conferences releasing the latest information on COVID-19 and clarifying disinformation through various channels. The citizens applauded CECC's efforts. As of April 2020, Taiwan had put in place public mask mandates. It was an island-wide mandate to wear masks outside the home. The people not only complied but also required accountability from their politicians. Historically, Taiwan has always led the fight against contagious diseases. Even during the colonial period when the country was occupied by the Japanese, medical officials attempted to eradicate infectious diseases. Other related regulations and recommendations for mass transportation, businesses, public gatherings (large or medium scale), community management, large commercial sites, and administration of quarantine in hotels were also implemented. The public followed self-care safety measures intended to stop the spread of COVID-19. Unlike in many other countries, the people in Taiwan demonstrated excellent behavior.

The Economic Effects of the Pandemic

Taiwan experienced a negligible impact on its economy thus disproving the widely held belief that controlling infection must always come at the cost of economic growth. Several factors contributed to Taiwan’s early success by controlling the COVID-19 outbreak. These included border control, a strict quarantine policy, efforts to ensure a sufficient supply of critical medicines, transparent public education, advanced medical facilities, and a well-established national health insurance program with access to technology and big data [17]. As a result, Taiwan began to assume a leading role in a new global health initiative in sharp contrast to its sole efforts to control the SARS outbreak 17 years ago. As a result, businesses remained operational even during the Level 3 alert from May 19 to July 23, 2021.The work-from-home policy was not adopted in Taiwan. The CECC imposed strict border control measures to temporarily stop all foreigners without a permanent residence permit from entering Taiwan.

From August 2021, the pandemic continued to subside with sporadic domestic cases with unknown sources of the infection. Taiwan maintained a nationwide Level 2 epidemic alert but has relaxed the rules on domestic social events, gatherings, travel, and catering. However, its export-dependent economy is highly vulnerable to a global recession. Taiwan did not experience the extreme economic effects felt elsewhere when extreme lockdown measures were put in place. The country was able to carry on business and manufacturing as usual although retail revenue decreased. Taiwan’s population had freedom of movement. Schools, offices, and restaurants remained open. During February 2021, retail and restaurant sales increased by 0.5% compared to the same period the previous year. This was important since private consumption accounts for over half of Taiwan's GDP [18].

The island is vulnerable to reduced global trade flows because it has an export-oriented economy. Taiwan’s exports and its overall economy were affected by weaker external demand and supply chain disruptions. The NDC (the National Development Council) announced the five industries most heavily affected by the pandemic. The airlines and travel industries were the hardest hit when border controls were reinforced and the demand for air travel suddenly dropped. Consequently, local EVA and China Airlines carriers with their subsidiaries were ordered to cancel or limit flights to many destinations. The number of passengers on domestic airlines declined by 50% in February 2020 and are expected to decline further as COVID-19 continued to spread around the globe. The hotel industry and non-essential retail businesses were significantly impacted because of the collapse of consumer and business expenditures caused by travel restrictions, long quarantines, and social distancing measures. Eighty-seven percent of exports from Taiwan to China are intermediate products. The biggest export area is electric components. Manufacturing and supply chains were predicted to be deeply affected by the pandemic since the factories for electronic parts are in China. In 2021, drops of as much as 50% in annual profits for electronics companies and machine tools exported to China were predicted. In addition, 45% of Taiwan’s total production of petrochemicals was exported to China. So, the oil production and distribution sector experienced significant losses due to the pandemic. On the other hand, there was an increase in sales of some products such as semiconductors industry communications technology (ICT).

International demand for the Taiwan's signature hi-tech products grew sharply because of the expansion around the world of online activities and videoconferencing to support work from home and social distancing guidelines. The Ministry of Economic Affairs (MOEA) indicated a 40.4% growth in Taiwan-based companies during the pandemic period which demonstrated an increase in export purchases of USD 11.58 billion since February of 2021 and an annual growth of 4.3%. This reflected a 24% increase in the demand for manufactured electronic goods in a single year. Taiwan's world-leading semiconductor industries also did well. The Semiconductor Manufacturing Company (TSMC), a contract chipmaker, stated that the company's first-quarter profits had increased by 42% compared to the previous year [17]. Figure 5 illustrates the increased global demand for the chips from Taiwan Semiconductor Manufacturing Company Limited (TSMC).

Fig. 5

Source Taiwan Semiconductor Manufacturing Co Ltd. (TSMC)

Increase in global demand of Taiwan Semiconductor Manufacturing Corporation Limited (TSMC) chips.

In 2019, the government endorsed a wide-range relief package of USD 35 billion equivalent to 5.5% of its GDP. Several government agencies provided funding for the package. One example is the renovation and strengthening of Taiwan’s tourism industry supported by USD one billion toward the tourism infrastructure and efforts to make Taiwan a major tourist destination. The MOEA provided USD 3.25 billion for a financial bailout aimed toward regenerating local consumption and supporting businesses undergoing difficulties—a rescue measure for airlines, hotels, and travel agencies. The MOEA also focused on the country's large number of small businesses, service sectors, and family businesses such as night market vendors and hairdressers. They were qualified to get upto 30% of their power and water bills. Upto 40% of their salaries were subsidized. The MOEA provided stimulus coupons to its local consumers as part of its efforts to promote consumption and boost the local economy. The Ministry of Labor provided special funding together with additional funds of USD 2.07 billion to alleviate unemployment among young people, support those who were unemployed, subsidize those with unpaid leave. Subsidies were also provided for self-employed individuals. Exports are the major contributor to Taiwan's GDP and account for more than 65% of its GDP. In spite of Taiwan’s vulnerability to decreases in global trade, it was able to reduce its dependence on Chinese travelers and improved its industrial blueprint [11]. Based on data from 2019 and 2020, Taiwan’s public debt was 33.6% of the GDP in 2019 [19]. It was projected to decrease to 32.3% and 30.7% of the GDP in 2020 and 2021, respectively [20]. The central part of Taiwan’s public debt was domestic and was owed in New Taiwan Dollars (NTD). The unemployment rate in 2019 remained stable at 3.8%. It was projected to rise a little to 4.4% in 2020 due to the COVID-19 pandemic. Figure 6 shows an increasing trend of the industrial production index in October 2021 compared with the same month in 2020. An ageing population, low birth rates, and a still tense relationship with China are Taiwan’s immediate challenges.

Fig. 6

Source Department of Statistics, Ministry of economic affairs, Taiwan

Increase in the industrial production index in October 2021 compared with the same month in 2020, which included the manufacturing sector.

In early 2020 (first quarter), Taiwan’s economy remained stable. However, the pandemic caused a reduction in growth in the second and third quarters due to global recession, unemployment, and drops in income [20]. At the start of 2021, Taiwan’s investments in China began to take place due to insecurity and decreased revenues caused by U.S.-Chinese trade relations. As of March 2021, export orders of Taiwan-based companies grew more than 40.4% compared to USD 40.26 billion in February 2021 [19].

Education

Taiwan was among the few countries where schools functioned normally during the pandemic. To secure the safety of students and staff, the Ministry of Education (MOE) established general guidelines for college campuses. These included task forces at universities and risk screening based on data on travel history, contacts, and disease clusters. Education on general hygiene, indoor use of masks, self-quarantining and care, ventilation and sanitization of indoor spaces, and group activities was provided. Guidelines were put in place for reporting suspected cases and on how to deal with school closures and make-up classes. Adjustments were made to school schedules and preparation was made for online education. At that time, schools were partially closed, and few students were allowed to go to school. Most of them were learning from home. It was announced that classes should be suspended if even one student or staff member tested positive. The school was expected to be closed for 14 days if it had two or more confirmed cases of COVID-19. As of June 18, 2020, there were seven confirmed cases at six Taiwanese universities. Only one university had to close and offer online education; it was only closed during standard 14-day period. In addition, distance learning options were put in place for international students and quarantined students.

Distance and online learning are, as of now, part of the norm and this will continue. Institutions of higher education provide resources and training for their teachers and students. This provides a general platform on which all aspects of distance learning can be obtained by both teachers and students and includes instruction on the use of various software programs. The Internet is offered at a discount for low-income students as well as for students who are unable to obtain face-to-face instruction. Several open-source platforms for online courses, such as Taiwan Massive Open Online Course (MOOC), Open Edu, and Taiwan LIFE Insurance Company Limited are made available.

The experiences in Taiwan suggest that with appropriate measures in place including both containment and mitigation procedures, it is possible to safely reopen colleges and universities. Strategies should include access to information, contact tracing, quarantining, proper hygiene and sanitation measures, social distancing, and wearing masks.

Concluding Comments

Taiwan's response to COVID-19 shows how a country can quickly address an emergency and protect its citizens. Taiwan proved its potential as a global leader in the area of public health response and preparedness. Its success was due to the joint efforts of the government, health workers, and the citizens of Taiwan. A combination of small gestures and big data gave Taiwan an unprecedented edge over other countries for controlling the pandemic. Future endeavors will include population-based preventive behavior, especially in regions with fast spreading SARS-CoV-2 variants.