Translation Section Editors
Prof. Ya-Wen Cheng, PhD (Q. 1-6)
Prof. Wang-Huei Sheng, M.D. PhD (Q. 7-9, 13-18)
Prof. Chi-Tai Fang, PhD (Q. 10-18)
For people notified before Feb. 25th, 2020: according to Clause 67 and Clause 69 of the Communicable Disease Control Act, those under home isolation will be fined between 60,000 and 300,000 NTD for leaving the household (or the designated area) without permission, and will be placed at a designated facility for centralized quarantine; and those under home quarantine will be fined between 10,000 and 150,000 NTD for leaving the household (or the designated area) without permission the first time, and the noncompliance at the second time will be subject to enforced quarantine at a designated facility. The names of those who fail to stay in contact will be released immediately and their whereabouts will be sought.
For people notified after Feb. 25th, 2020: according to Clause 8 and Clause 15 of the Special Act of Prevention and Bailout Revitalization to COVID-19 Epidemic, a breach of home isolation regulations is subject to a fine between 200,000~1,000,000 NTD, and a breach of home quarantine regulations is subject to a fine between 100,000 and 1,000,000 NTD. Necessary disease prevention and control measures could be imposed by the CECC, including video-taping, photo- taking, and release of personal information, on those who violate regulations for isolation or quarantine.
In response to the emergence of pandemic, Premier Su scaled up the level of CECC to the highest, and assigned the Minister Chen Shih-Chung of the Ministry of Health and Welfare as the chief commander, and the Deputy Minister Chen Chung-Yan of the Ministry of Interior as the deputy commander for the supervision and coordination of decision making. The commanding system consists of 3 domains, namely information, combat, and logistic. A total of 9 working units are formed–epidemic surveillance, border control, control of community transmission, mobilization of medical care facilities, supplies, research and development, informatics, administration, and public communication. As an inter-ministry body consisting of top officers from different ministries and the Executive Yuan, the CECC is able to facilitate the mobilization and coordination of resources of different ministries and to strengthen prevention measures.
On top of the 9 working units which are in charge of the planning of prevention policies and measures, the CECC also sets up an advisory panel for consultation purpose, with Prof. Chang Shan-Chwen, the executive vice president of National Taiwan University, as the chair. The panel consists of specialists in multiple disciplines including clinical medicine, epidemiology, laboratory sciences and nursing, and has been active in providing professional suggestions to the CECC.
Through the above mentioned mechanisms, the CECC is able to make swift and meticulously planned decisions with a “deploy-in-advance” approach for broader control and reduction of community transmission to safeguard safety and health of people in Taiwan.
Given the severity of the COVID-19 pandemic, community spread is likely to occur following local transmission in Taiwan. Because school campuses tend to be crowded and the risk of respiratory infectious disease clustering could be high, it would be difficult to contain the spread of virus once there are imported cases. To safeguard students’ health and to minimize the risk of virus spread in campus, on Feb 3rd, 2020, the CECC demanded all elementary, junior and high schools to extent the winter break for two weeks, based on the Disaster Prevention and Protection Act (Clause 31, sub-clause 1, sub-sub-clause 11). Starting from Feb, 27th, 2020, to prevent the spread of COVID-19in campus, parents of children whose schools or organizations meets the COVID-19 epidemic suspension criteria are eligible for family care leave. Regulations concerning the eligibility of applicants, level of pay during the leave and other related rights benefits also apply to parents of children in short-term after-class schools, kindergartens, after-class child care facilities and related educational institutions.
Family care leave due to COVID-19 is a specific measure designed for the COVID-19 epidemic. According to the Children and Youth Welfare Act, children under 12 years old are not allowed to stay home alone, therefore, family care leave due to COVID-19 allow parents, guardians, or other actual caregivers of children to stay home to accompany children. Eligibilities of applicants for family care leave due to COVID-19 include the following:
Taiwan has learned a lot from the SARS epidemic in 2003 and has made many improvements, which include amending regulations concerning notifiable infectious disease to ensure the legal basis for intervention, establishing the Central Epidemics Command Center in order to have a centralized leadership, setting up mechanisms for body temperature check-up, strengthening border quarantine, strengthening nosocomial infection control measures, establishing medical and prevention network for infectious disease, checking the stockpiles of materials for epidemic prevention and the capacity of screening as to ensure the preparedness of medical provisions, and enhancing international cooperation to receive timely information.
Taiwan also learned from the lockdown of the Taipei Municipal Hoping Hospital during the SARS epidemic. The lockdown triggered public panic. At that time, the decision of hospital lockdown was based on the concern that there might be infected cased not yet detected inside the hospital, who might spread the virus if being allowed to return back to community. It was the right direction, however the measures taken by the implementers could be reconsidered, since the indiscriminate lockdown policy would intensify fear and confrontation. This experience had taught us that to protect people in the hospital and the community, we should reroute people in the hospital including the staff, patients, families and visitors according to the level of infection risk after a primary medical assessment. Confirmed infected cases and cases with related symptoms should be placed in negative pressure isolation room for medical treatment, while asymptomatic cases should be isolated at a centralized facility for follow-up to prevent cross-infection. Hospital should be thoroughly disinfected throughout the process.
Since the outbreak of COVID-19 epidemic, people in Taiwan have learned from other countries that concealing information and failing to communicate with people could lead to unawareness of infection risk and worsen the epidemic, and lack of transparency in decision making could lead to public panic. Therefore, since the outbreak of Wuhan occurred at the end of last year, the government of Taiwan has provided one to two press releases daily to inform the public what the government has done, and what cooperative measures people are expected to adopt. Moreover, the government also expropriate the prime time slot of the television channel for public education purpose.
To ensure transparency in information and to affirm to the public that information concealing will not happen in Taiwan, we conduct retrospective investigation on patients who had pneumonia with unknown cause and had tested negative for influenza. Such practices allowed us to identify the first death of COVID-19 in Taiwan and to take an initiative to inform the public. All these activities undertaken were meant to ensure information transparency and public communication, aiming to increase social trust and social support toward the government. We hope to bring together government and public to fight against the epidemic, safeguarding all people in Taiwan.
First version of the Name-Based Mask Distribution System:
Allocating face masks through local pharmacies and public health centers.
The work of preventing an epidemic can change rapidly. In response to the dispatch of epidemic prevention materials, the Executive Yuan announced the mask rationing plan on February 3, 2020. Using the National Health Insurance card as a certificate, face masks were available in contracted pharmacies and local public health centers nationwide. The National Health Insurance Administration, once again making good use of the National Health Insurance Pharma Cloud System, built the “Epidemic face mask control system” as a selling platform under National Health Insurance Pharma Cloud System. This system allowed pharmacies and public health centers to register their purchase and selling information of face masks. The system was put online in time, three days after the policy was announced.
The government also put open-up cooperation into practice. The National Health Insurance Administration collaborates with non-governmental communities led by Audrey Tang, the Digital Minister, to build a mask supply and demand information platform. Non-governmental communities have developed a variety of applications on this platform, including APPs, map applications, LINE applications, Chatbot, voice assistants, etc. As of March 11, 2020, there are over 120 types of applications, e.g. APP, map, LINE applications, and Chatbot, etc. The variety and quantity of applications are still increasing, providing people a wide variety of choices to check for the remaining amount of face masks in each pharmacy.
Second version of the Name-Based Mask Distribution System:
To improve the allocation of face masks and to reduce queuing time for purchasing masks, and to make it more convenient for office workers and students to make their purchases,the government set up the“Name-Based Mask Distribution System 2.0” was officially established on March 12, 2020. Aside from physical sale channels such as pharmacies and public health centers, the Name-Based Mask Distribution System 2.0 adds online pre-ordering as a new sale channel. Citizens can log in the platform with their National Health Insurance Card, Citizen Digital Certificate, or through an application called “NHI Express - My Health Bank” after binding by phone verification, and can log in to My Health Bank and pre-order face masks. Citizens can verify their identities through confirming phone numbers, and after reading cards via personal cellphones or laptops, it is ready to pre-order face masks through binding cellphone or over-the-counter services.
The“Central Epidemic Command Center (CECC)” was established on January, 20, 2020 to develop specific measures against the epidemic and to facilitate rapid mobilization against the epidemic. These measures include identifying cases, containing the spread of virus, allocating resources, and safeguarding public health. The CECC also adjusts its response level according to the domestic and international development of epidemic to facilitate the coordination of resources and manpower from multiple sectors of the government. Combining with the power from private sectors, we can fight more effectively against the epidemic on a national security level.
In order to reinforce disease surveillance and border quarantine practices, and to increase the completeness rate of registration data from incoming passengers with the community tracing system, we combine data from non-government community and multiple ministries to establish the “Health Declaration and Home Quarantine Notice (Quarantine System for Entry)”system, aiming to increase accuracy and completeness of registration data of health declaration and home quarantine notice for passengers from China, Hong Kong, and Macau. Besides, by cooperating with National Immigration Agency and National Communications Commissions to get the contact information of incoming passengers, this system allows the health authorities to conduct community tracing in a more efficient way.
As the epidemic goes on, the whole society has been severely affected in all aspects, including public health, economic life and social psychological conditions, Daily life and interpersonal interaction have also changed to a certain degree. To take care of socially vulnerable groups and rebuild the society after the epidemic, the Central Epidemic Command Center has united all central government departments, e.g. Health Promotion Administration, Social and Family Affairs Administration, Department of Social Assistance and Social Work, Department of Mental and Oral Health, Environmental Protection Administration, Department of Nursing and Health care, together with local governments and non-government force to build a support network in community. In this way, we hope to provide mental care, medical assistance, transportation services, daily life assistance, and hotline consultation to socially vulnerable groups and people who are under home isolation and quarantine . Through these corresponding measures, we aim to eliminate discrimination and to increase social resilience against the threat of the epidemic. Besides, to strengthen the tracing system of the high-risk population, we make different rules and surveillance regulations based on their risk of infection. Also, with the help from Department of Health Affair, Department Civil Affair, Department Police Affair, together with National Communications Commission, National Immigration Agency, National Office of Information & Communication Security, National Health Insurance Administration and five major telecom operators in Taiwan, e.g., Chunghwa Telecom Co., we are able to keep track of activities and contact histories of people who are potentially infected. We also use the GPS system on cellphones to facilitate relevant actions on infection control, such as the reinforcement of the trace and management of people who are under home isolation and home quarantine.
As for improving and maintaining medical supplies and equipment, in order to stabilize the supply of disease control resources, the Ministry of Economic Affairs has cooperated with lots of private sectors and formed a face mask national team. The government has requisitioned all domestic face masks, and helped the local face mask manufacturing companies to purchase equipment and machineries in order to increase the production capacity.
Furthermore, the government has implemented several measures on mask control, such as the mask rationing plan, limiting the export, and imposing restrictions on bringing along and sending face masks overseas. Such measures aim to ensure fair and transparent allocation of resources and prioritize sufficient supplies of protective equipment to front-line healthcare workers and infection control personnel. Besides policies and actions on face masks , we also supply alcohol for disinfection use through NIH-contracted pharmacies, convenience stores, supermarkets, and wholesale stores. In order to ensure fair allocation of face masks, the government introduced the second version of the mask rationing plan on March, 12, 2020. In addition to the existing distribution channels, online pre-order channel was introduced. People can log in to the platform and pre-order face masks with their National Health Insurance Card, Citizen Digital Certificate, or through the APP by National Health Insurance Administration.
To prevent the epidemic from becoming a full scaled pandemic, the government of Taiwan has adapted many measures along the course of epidemic. Meanwhile, we plan ahead of time and adopt long term strategies. The health administration has allied with the Academia Sinica, National Health Research Institutes, and private companies to form a national team. Obstacles in the fields of laboratory diagnosis, rapid diagnostic testing methods, medications and vaccine development will be tackled, including issues such as the capacity of laboratory tests, the effectiveness of pharmaceuticals, and the pace of research and development, and long term plans are needed to combat the threat of this epidemic.
Given the geographical proximity as well as the massive air traffic between Taiwan and China, we have been on constant
alert and ready to respond to any epidemic on the other side of the Strait since the severe acute respiratory syndrome (SARS) outbreak
in 2003. Key early measures we’ve taken to control the COVID-19 epidemic include:
(Supplementary information：In mid-December, Taiwan CDC learned from the Internet that at least seven cases of atypical pneumonia were reported in Wuhan, China. In view of the lessons learned from SARS, Taiwan was highly cautious of this information. On December 31st, 2019, Taiwan promptly reported to the WHO International Health Regulations (IHR) by email, asking for further information. Rumors were spreading due to the unclear epidemic information then. All parties were expected to put on high alert, since the epidemic outburst was closely followed by the Chinese New Year, when a large stream of people would be moving. To be more meticulous, Taiwan specifically mentioned “atypical pneumonia” and that “cases have been isolated for treatment”, and public health professionals can then suggest that such cases have the possibility of “human-to-human transmission.” However, Taiwan had not had cases yet, and wasn’t able to clearly indicate that this disease had already transmitted human-to-human. Taiwan CDC also contacted the China CDC at the same time, in the hopes of acquiring more information about the epidemic. The WHO IHR point of contact, however, only responded that they had already handed Taiwan’s information to relevant authorities, and China only provided Taiwan with a press release. Strongly suspecting that human-to-human transmission existed and not being able to clarify through available channels, the Taiwanese government took immediate measures on the same day we reported to the WHO. According to procedures for possible human-to-human transmission, Taiwan has activated fortified border quarantine measures and dispatched personnel to carry out onboard quarantine for inbound flights from Wuhan.)
The details of these strategies are as illustrated below:
We give all patients the best supportive care, including intensive care ventilatory support and extracorporeal membrane oxygenation (ECMO) in life-threatening severe cases. Patients can get compassion use of remdesivir if clinically indicated. To inform all physicians treating COVID-19 patients on the evolving evidence on other potentially beneficial treatments, such as hydroxychloroquine, Taiwan CDC published and kept updating an “Interim Guidelines for Clinical Management of COVID-19 Patients”.
In short, “information sharing”. Taiwan need to get timely epidemiological information from other countries. On the other hand, Taiwan is willing to share information we obtained and experience we learned with other countries. However, such health information sharing is not possible when Taiwan is not allowed to join WHO.
We would like to further elaborate this key point below
We counter misinformation through the continuous release and update of accurate, real-time information. We actively gather opinions voiced by the news media and internet community on a daily basis, including those of 16 domestic television news channels, 10 print media, as well as foreign news media and social media (eg. PTT (a bulletin board system-based forum highly popular in Taiwan), web forums, Facebook, etc.). Strategies to combat fake news include holding press conferences, cooperating with third parties, releasing statements, and proactively delivering accurate information through social media channels including LINE and Facebook, as well as publicizing those information on the Taiwan CDC official website for further clarification, so as to minimize the effect of misinformation.
Given its nature as an emerging infectious disease, much about COVID-19 is still uncertain at the moment. This makes the general public more susceptible to misinformation during a pandemic like we now face Unnecessary panic and fear over the crisis may lead to distrust of the CDC command system, breakdown of social order, or even reduced compliance with anti-epidemic measures that hinders the effort of overall epidemic prevention. Therefore, fighting misinformation is crucial during the COVID-19 pandemic.
Vice President Chen used to hold an important position in the Academia Sinica, expertizing in research on epidemiology and public health. Besides academic activities, he also participated in public services as the former Director General of the Department of Health in 2003 (the former Minister of Health and Welfare). With his expertise in epidemiology, he fought the battle against SARS and led Taiwan through the crisis alongside many experts. Bearing the 2003 SARS experience in mind, Vice President Chen served his people once again during the COVID-19 epidemic. Not only has he publicly shared the correct knowledge of disease prevention on the media, but he has also led the government, the first-line health care personnel, and the public to become part of Taiwan’s disease prevention. Therefore, Taiwan has gained international reputation and kept the domestic epidemic under control. Just as what President Tsai Ing-wen has said, “the combined effort of medical professionals, the government, private sectors, and the public has strengthened Taiwan’s national defense”.
The Central Epidemics Command Center (CECC), which was quickly established at the beginning of this epidemic, holds daily press conferences to provide updated information on the epidemic. This has effectively raised public awareness and strengthened risk communication. Such transparency builds trust between the government and the general public, and further enables our government to introduce strict control measures, such as centralized “out-of-home” quarantine or suspension of classes when necessary.
Under the Taiwanese democratic system, the Executive Yuan is supervised by the Legislative Yuan, and this check-and-balance system ensures that every policy implemented by the government is in the best interest of the Taiwanese people.
Circumstances vary from country to country. The formulation of pandemic-control policies should adapt to both time and local conditions. However, through past experiences in fighting epidemics, we identified five essential strategies critical in all conditions: swift mobilization, decisive strategy-making, practical implementation, fair resource distribution, and last but not least, open and transparent information.
After receiving reports of the earliest COVID-19 cases in Wuhan, Hubei Province, China on December 31, 2019, we immediately initiated aircraft onboard quarantine for all direct inbound flights from Wuhan on the same day. In addition, we have notified all hospitals to report cases of pneumonia of unknown etiology since January 5, 2020, when most of the world were not yet aware of the severity of the disease.
Establishment of a commanding system responsible of overall planning and leading all anti-epidemic efforts:
A Level 3 Central Epidemic Commanding Center in response to COVID-19 (hereinafter referred to as CECC) was established on January 20, 2020. Its missions include timely escalation of the level of command unit activation in response to both local and international situations, coordinating and facilitating inter-departmental collaboration and communication, as well as swift mobilization based on joint efforts involving local governments and the civil society. For further details on command unit activation and contingency planning, please refer to Taiwan CDC “Preparedness and Contingency Planning in Response to COVID-19 Epidemic”.
Measures taken against COVID-19 include tightening border quarantine, designating COVID-19 as a notifiable communicable disease, establishing the CECC, tracing and managing high risk cases under smart technology assistance, expanding community-based testing and surveillance, strengthening the reserve capacity of the healthcare system, initiating preparations for COVID-19 admission and treatment among designated responding hospitals of the Communicable Disease Control Medical Network (CDCMN), as well as raising production and perfecting allocation of medical supplies and equipment. Timely implementation and comprehensive planning of the aforementioned policies have ensured their effectiveness. Further strategies based on these policies include strengthening epidemiological surveillance, optimizing border quarantine workflows, utilizing smart technology in community-based prevention, increasing responding capacity in healthcare systems, ensuring sufficient reserve of medical supplies and equipment, while encouraging accelerated development of related products.
Distribution of accurate information:
The CECC delivers information promoting personal hygiene and disease awareness continuously through mass media including TV and radio channels, in the form of public service announcements (PSA) broadcasted on an hourly basis. Details include routes of virus transmission, how to wash hands correctly and its importance, as well as the appropriate timing of wearing masks, so as to educate the public on correct measures of epidemic prevention, to combat against fears and rumors brought by misinformation, to build trust between the general public and the government, and to increase compliance with relevant measures.
The battle against COVID-19 is long-lasting. Before a successful vaccine development, the epidemic can still spread periodically through global population movement. Humans must learn to coexist with the virus, since the latest progress of the epidemic has told us that we will have to wait for successful development and production of vaccines to truly tackle this virus, which generally takes up 12 to 18 months or even longer. Before that, only by the implementation of all government disease control measures in the public’s daily lives, can we prevent the epidemic from reaching the stage of community spread. Such measures include obeying social distancing regulations, reducing unnecessary entertainment, etc. By doing so, we can lower the domestic death toll and number of people infected, keep the healthcare system under normal operation, and wait for antiviral drugs and vaccines to hit the market.
Based on contact tracing of confirmed cases and travel records in National Immigration Agency (NIA) database, public health officials notify individuals at high risk to stay at home for quarantine. Public health officials use mobile phone location tracking to ensure that they stay at home. If the geolocating signal falls outside a certain range beyond the designated quarantine site, alert SMS messages will be automatically sent to public health officials, civil affairs officials, and police. They will then contact the quarantined individual to clarify whether quarantine breach occurred or not.
Taiwan is a free and democratic country ruled by law. The Personal Data Protection Act mandates that collection of personal data should be limited to the minimum extent for the authorized purpose only. If the government illegally abuses the system, people can simply report their bad experience to the media. The wide publicization of such scandals will almost certainly let the ruling party lose the next election.
When the quarantine ends, the geolocation tracking stops immediately. All collected data are deleted, as mandated by law.
No additional mobile apps are required. Individuals under home quarantine simply have to bring their mobile phone with them (with the same phone number as reported to the authorities) wherever they go and stay reachable at all times.
According to Article 15 of the Special Act on COVID-19 Prevention, Relief and Restoration, those who violate home quarantine measures are liable to a fine between TWD 200,000 to 1,000,000 (USD 6,667 to 33,333 at exchange rate of 30TWD/1USD).
Translation Associate Editors
Ruen-Yi Chen, Li-Tien Hsu, Ju-Hsin Ou-Yang, Feng-Yun Fan
Li-Ling Hsu, Shin-Yi Tai, Nan-Su Huang, Ssu-Chi Cheng, Yi-Hsuan Yen, Yi-Hsuan Tsai, Shi-Tin Liang, Hsien-Wei Hsiao
Yi-Yun Cheng, Yao-Chung Chang