Medicosnext
Countries around the world have used different strategies to beat the COVID-19 pandemic since its emergence in Wuhan, China, last December.
Nine months into the pandemic, the world is still struggling to contain the virus with little success. Cases are rising at relentless pace across the globe, and new outbreaks are being reported even in countries that had previously contained the infection.
The virus is still spreading rapidly in United States, India, Brazil, and Russia, accounting for the majority of recorded cases worldwide. As of September 23, 2020, COVID-19 has affected 213 countries and territories and two international conveyances around the world, with a total of 31,787, 455 confirmed cases and a death toll of 975,535 (wordometers.info)
.Amid the global struggle to control the infection, a few countries like Taiwan, New Zealand, Cambodia, Rwanda, Germany, China, and Canada have managed to slow down the spread of the virus.
Among the Asian countries, Taiwan and South Korea have been particularly hailed as the countries that were best prepared for the COVID-19 outbreak. Though South Korea saw a resurgence of virus in mid-August, both countries have been looked on as role models for their effective actions to contain the initial wave of infection.
Below, we will look at the strategies employed by the two countries in response to tackling the current pandemic.
TAIWAN
Taiwan has thus far successfully contained the pandemic, with one of the lowest infection rates around the world. Despite being only 100
miles away from the virus epicenter, Taiwan has felt only a moderate effect of the pandemic, compared to many other Asian countries. As of September 23, 2020, eight months after identifying its first coronavirus case, Taiwan, with 23.8 million population, has only 509 confirmed cases (of which 414 are imported) and 7 deaths, according to the Taiwan Centers for Disease Control. And, the country has been able to achieve all this without any lockdown measures.
How did Taiwan do it?
- Fast action, border shut down, early containment policy
Taiwan acted at the earliest warning signs. As soon as the news came out about the novel virus from Wuhan, China on December 31, 2019, Taiwan started inspecting all fight passengers from Wuhan and imposed home quarantine on all those who had transited through China, Hong Kong, and Macau. The world was still unaware if the virus could pass between humans at this time.
It was also one of the first countries to ban visitors from Wuhan and to shut down its borders. Two days after confirming its first COVID-19 case on January 21 it banned visitors from Wuhan. From March 19, it banned the entry of foreign nationals and imposed a 14-day home quarantine on all returning residents, and anyone defying the order faced a hefty fine of $33,000. It started these procedures almost two months prior to other countries initiated such measures.
2. Preparedness
Taiwan had remained vigilant against a possible wave of new infection since the 2003 SARS outbreak. It had been continually enhancing its preparedness and response measures since and made several reforms to the health system to better handle future epidemics.
In 2016, the country even undertook a voluntary evaluation on its epidemic preparedness using the IHR Joint External Evaluation tool developed by the WHO, according to the British Medical Journal. The tool, used by 97 countries since 2016, provides a standard metric to assess public health emergencies capability. Taiwan updated and revised its legal framework to support the implementation of IHR, which enabled the country to act responsively during the first 100 days of the pandemic, the BMJ stated.
Since the SARS epidemic, Taiwan had made long-term investment in additional capacity at the Centers for Disease Control (CDC), hospitals, and infectious disease laboratories, The Lancet’s EClinicalMedicine reported. “Once China released the genetic sequence of COVID-19, Taiwan CDC’s laboratory rapidly developed a test kit and expanded capacity via the national laboratory diagnostic network, engaging 37 laboratories that could perform 3900 tests per day.”
After the 2003 health crisis, Taiwan further established infection control practices by installing fever-screening stations and triage systems, along with 1100 negative pressure wards in most of the hospitals and health care facilities to minimize cross-infection. It also installed fever-screening checkpoints and implemented border quarantine measures at airports and seaports. On top of that, many hospitals performed annual drills to cope with the potential re-emergence of SARS.
Taiwan had also recognized early on the role of a centralized decision-making body in times of public health emergencies from SARS. And, a year later the government created a Central Epidemic Command Center (CECC) to enable coordination across different ministries and stakeholders. The government could activate the command center in times of health emergencies and it was given broad legal powers including authority to close schools, restrict events and gatherings, and controlling public transportation and the production and sale of facemasks, the Nikkei Asian Review reported.
All this preparedness came in handy during the COVID-19 crisis. On January 20, 2020, the Taiwan government activated the CECC and it started producing and implementing a total of 124 measures, including border control from the air and sea, case identification (using new data and technology), quarantine of suspicious cases, proactive case finding, resource allocation, and fever screenings, according to the Journal of American Medical Association. This happened even before Taiwan saw it’s first COVID-19 case and by January end it had already activated infection-control mechanisms and negative pressure isolation wards in hospitals.
- Use of AI and big data analytics
Taiwan used artificial intelligence and big data techniques to proactively find high-risk cases and these methods were very effective in 
containing the early transmission of virus.
Taiwan gathered a large set of information by merging its national health insurance (NHI) database and immigration and customs database to track travel histories and clinical symptoms of possible COVID-19 victims.
The government collected data from individual’s national health insurance card—health insurance that covers 99% of Taiwan’s total population—that had their medical history embedded in a computer chip. Meanwhile, the immigration database provided the records of passengers’ flight origin and their 14-day travel histories.
This joint-database was shared among all hospitals, clinics, and pharmacies to help classify a patient’s risk level based on their 14-day travel histories and clinical symptoms. “The availability of almost immediate data on patient visits allowed the country to efficiently identify, test, trace, and isolate cases. This has dramatically reduced COVID-19 spread without the need for extensive lockdowns,” the JAMA stated.
Individuals identified as high- risk were then subjected to 14-day home quarantine and they were monitored via GPS on their mobile phones. The officials also called them twice a day to ensure they were at home during the confinement period and anyone found breaching the quarantine order was slapped with $32,955 fine.
Taiwan is believed to be the first country to leverage cell phone location data to monitor the location and movements of people in quarantine. If people in home quarantine ventured out of their houses or if their mobile phones were switched off, the system alerted the individual, civil affairs departments, health departments, and the local police with a message. If they were still unreachable, the officials came knocking at their door within 15 minutes.
- Mask-rationing plan
In Taiwan, people had been wearing facemasks to prevent from infection before the pandemic. But the fear of coronavirus sparked panic buying among the citizens and soon there were long queues in front of pharmacies and other outlets as the outbreak emerged.
To meet the demands, the Taiwanese government produced a stockpile of 44 million surgical and 1.93 million N95 masks before the first
case was reported, according to Cambridge University Press. Then, it requested the local mask-manufacturing companies to ramp up their production. On January 24, 2020, the country banned the export of surgical masks and personal protective equipment to ensure adequate local reserve for healthcare workers and the general population.
The government also introduced a mask rationing system and fixed the price of masks to prevent bidding wars and drain the local supply. The rationing mainly prioritized health workers and allowed every citizen to buy two surgical masks per week for $0.17, then three masks per week, and nine masks every two weeks as the production surged in the following months. The purchase was tracked using the individual’s national health insurance card. By February 20, 66 factories were producing nearly 6 million masks per day in Taiwan and that quickly scaled up to 10 million per day, according to the American Journal of Public Health (AJPH). By the end of April, Taiwan was producing 17 million masks per day. The country has, now, stockpiled sufficient facemasks for the safety of public and health workers in case of new outbreak.
- Regular and transparent communication with public
A day after the first case was identified Taiwan established an open transparent epidemic information platform in accordance with the ‘Communicable Disease Control Act’, according to The Atlantic Council. The government held press briefings daily for months to reassure and explain the pandemic situation to the public.
“Taiwan’s Health and Welfare Minister hosted a daily 90-minute televised press conference and gave a case- by-case update on the current status of the outbreak in order to maximize transparency and awareness, and minimize public anxiety,” the AJPH reported.
According to ABC News, apart from daily press briefings, top government health officials, including the minister of health, the vice president and a prominent epidemiologist, regularly gave public service announcements about travel, personal hygiene recommendations and dangers of stockpiling masks. The Ministry of Foreign Affairs also actively sought out and fought misinformation from both the news media and Chinese cyber attacks.
The government focused on disseminating correct guidance on pan
demic prevention and control among the public. As a result, both public and private sectors trusted and followed the government’s guidelines that helped in the nation’s containment efforts.
South Korea
South Korea reported its first COVID-19 case on January 20, 2020. The case numbers rose slowly, with only 30 cases until February 17. But, things changed quickly when a 61-year-old woman tested positive
in Daegu, South Korea’s third largest city, according to Center for Strategic and International Studies. Dubbed as ‘Patient 31’, and labeled as a ‘super spreader’, she had traveled around Daegu and Seoul before being diagnosed. This led to rapid transmission of the virus, with more than 2,000 confirmed cases in the next 10 days. By February end, Korea had the second largest outbreak of COVID-19 cases outside China, reaching a peak of 909 cases on February 29, 2020.
The country, however, effectively contained the outbreak in a month, with the daily cases falling from 851 on March 3, to 22 infections by April 17, The Conversation reported. The country took several measures to curb its first largest outbreak. Of them, extensive testing and effective tracing and isolation were at the heart of its strategy.
But, this pandemic has taught us not to let our guard down even when the infection rate goes down. South Korea had almost contained the virus for the past several months, until on August 14 it reported 103 new cases, one of the biggest daily jumps since early March.
The country raised its social distancing guidelines to Level 2 after the daily caseload of new infections crossed the 400 threshold on August 27. Many of the new and small infection clusters throughout the country were tied to churches and the anti-government protest rally. The daily transmission number fell below 100s in the recent week after staying in triple digits for almost a month.
Below, we will look at how the country flattened its early major outbreaks, and how it handled the staff and bed shortages from overwhelming the hospitals.
- Mass Testing
After the dramatic escalation of cases in February, South Korea launched a nationwide mass testing campaign that was largely free and affordable to all its citizens. In the days following the Daegu outbreak, the country established 118 labs and 633 testing sites all over the country to screen people efficiently outside the health system, and had the capacity to run an average of 15,000 tests (and up to 20,000) per day, according to Nikkei Asia Review.
This comprehensive testing method led to quick detection of infected people and also helped trace and quarantine all their contacts. It 
further helped identify infection hotspots and trace and isolate mild and asymptomatic carriers before they could spread to the community.
South Korea also introduced ‘walk-in’ booths and ‘drive-through’ stations to conduct free, fast, and safe tests. Their innovative ways of conducting tests received global attention and the drive-through model was soon replicated in US, France, Spain, and other countries as a clever way to protect health workers.
Since tests were performed inside the car, drive-through stations reduced the contact between visitors and medical workers. These facilities also eliminated the need to sanitize the waiting rooms between visitors and saved time to conduct more tests. The test was completed in less than 10 minutes and results were texted a day after.
The country’s aggressively-launched mass rapid testing brought the outbreak under control in a month, allowing the government to successfully conduct a national election on April 15, in which 29 million voters participated, without any cases linked to the poll.
- Pandemic Preparedness
In South Korea’s case, early detection of potential cases was vital in containing the Daegu outbreak, and it wasn’t possible without widespread testing.
South Korea had learned from the 2015 MERS outbreak that early testing and isolation of infected patients were vital in preventing secondary infections. During MERS, the government was heavily criticized for not conducting enough tests in the early stage of infection.
It had failed to conduct extensive testing at that time, due to the lengthy approval process for the newly developed testing kits.
The new kits required passing the Ministry of Health and Welfare administrative protocols and obtaining approval from the Ministry of Food and Drug Safety. By the time the kits were approved, the virus had spread fast. After the MERS crisis, the country made several reforms to its health policies to respond more effectively in future epidemics. Korea developed a legal framework for fast-tracking approval of emergency test kits that enabled the country to give immediate approval to testing systems in an emergency, according to the Devpolicy Blog (Australian National University).
During the COVID-19 pandemic, as soon as the first case was reported, the government requested the biotech companies for mass production of new test kits. On Feb 4, the government gave “emergency approval” for Seoul-based Kogene Biotech to move ahead with the testing kits. The company developed the kits in just ten days after the World Health Organization disclosed the genome sequence of the virus.
According to the KBS WORLD Radio, Korea’s flagship public international broadcaster, the Kogene Biotech had been consistently monitoring information about new infectious diseases and their genes after HINI influenza and MERS outbreaks. And as soon as the genetic makeup of the COVID-19 virus was disclosed on the GISAID website on January 10, they started developing the test kits.
Many biotech companies had emerged in South Korea over the last five years and the robust biotech industry enabled the public-private partnership in developing the testing kits. The increase in the number of epidemiology investigators from just two to 100 since the MERS outbreak further strengthened the country to track the infection.
- Triage and treatment system
As cases surged in late February, the Daegu Medical Association developed and implemented a four-category risk-stratification system to care for COVID-19 patients while preventing community transmission by household contacts and solving the bed shortages in hospitals.
The health officials conducted telephone interviews to assess the symptoms of patients and based on the severity of illness (asymptomatic to mild, moderate, severe, and critical), they were isolated at designated facilities.
“Asymptomatic and mildly symptomatic patients were admitted at community treatment centers — often dormitories for training institutions of South Korean companies transformed into centers used for monitoring patients without utilizing acute care resources.Meanwhile, patients with a higher severity of illness were hospitalized at community or tertiary hospitals,” according to the NEJM Catalyst Innovations in Care Delivery.
In Daegu, 15 community treatment centers, including several dormitories for training institutes of Samsung and LG, served as temporary isolation wards for 3,033 people between March 3 and March 26, 2020.
More than a month after the start of the Daegu epidemic — a total of 121 health care workers were infected with COVID-19 in Daegu, including 14 doctors, 56 nurses, and 51 nurse aides, the NEJM reported.
The system of stratifying patients by risk led to the decline of home isolation and at the same time allowed hospital resources to focus on critical patients with round-the-clock treatment. It also helped in identifying and isolating cases, reduced the influx of potential cases into the hospital, and protected health workers from both outside infection and in-hospital transmission.
In the first week of March, more than 2,200 confirmed patients (40 percent of Daegu’s total cases) were awaiting a hospital bed, according to the Wall Street Journal. Two weeks later, that number dwindled to just 124, all of which were mild and asymptomatic cases
To solve the bed shortage, health officials further created 303 negative-pressure beds at the Armed Forces Daegu Hospital along with an additional 100 negative-pressure isolation rooms across the city. On February 21, they designated 10 hospitals for the care of COVID-19 patients who required hospital-level care.
By March end, the government had secured 1,828 beds in Daegu at 11 hospitals (including the Armed Forces Daegu Hospital) and 1,296 more beds at 24 hospitals in nearby cities and provinces.
The separate hospitals for COVID-19 patients and temporary isolation centers significantly reduced staff shortages, as only 10 medical staffs were required for a 200-patient facility. As a result of this system, only 81 of 3,033 (2.67 percent) cases were transferred to a hospital, the NEJIM reported.
4. Mass surveillance of data
South Korea used the contact tracing system developed for MERS epidemic to fight the current pandemic. In the MERS aftermath, the country had created another legal framework allowing the government to respond with aggressive contact tracing for prevention and control of infectious diseases. The government could follow the movements of infected individuals through their credit cards, bank records, CCTV footage, and GPS data to trace and isolate their contacts.
“South Korea’s Centers for Disease Control and Prevention (KCDC) runs the contact tracing system that uses data from 28 organizations such as National Police Agency, The Credit Finance Association, three smartphone companies, and 22 credit card companies to trace the movement of individuals with COVID-19,” according to The Conversation.
The officials trace the movements of infected individuals in the days before they tested positive so people who may have been in close contact with them can be alerted.
In the first weekend of May when the country had just eased its social distancing restrictions, several partygoers in Seoul nightclubs tested positive for coronavirus. This incident threatened for another nationwide outbreak as thousands of people had gone clubbing that weekend.
But, within two weeks, the officials tracked down more than 45,000 people who had come into contact with the infected partygoers. Of them, more than 160 people tested positive and they were isolated and treated accordingly. By May 18, the country’s new daily domestic cases had dropped back to nine, the Business Insider reported.
The government also published the information of infected cases on a public website to alert people if they had been exposed. They further sent phone alerts to people who had been near the clubs during the weekend to get free tests, even if they had no symptoms.
The country hospitalizes the confirmed cases at the COVID-19 special facilities, while suspected cases are asked to self-quarantine at home. The officials monitor them though a mobile app and if they venture outside the designated quarantine area, the alarm will go off informing the officials.
References:
1. Worldometer (www.worldometers.info/coronavirus/)
2. Taiwan Centers for Disease Control (www.cdc.gov.tw/en/Disease/SubIndex/)
3. “Legal preparedness as part of COVID-19 response: the first 100 days in Taiwan”, Tsung-Ling Lee, May 6, 2020, BMJ Global Health, (https://gh.bmj.com/content/5/5/e002608)
4. “The resilience of Taiwan’s health system to address the COVID-19 pandemic”, Emeline Han, Shu-Ti Chiou, Martin McKee and Helena Legido-Quigley, June 26, 2020, EClinicalMedicine vol. 24 100437, (https://www.thelancet.com/ journals/eclinm/article/PIIS2589-5370(20)30181-4/fulltext)
5. “Seoul and Taipei show the world how to contain pandemics”, Yosuke Onchi and Kensaku Ihara, April 21, 2020, Nikkei Asian Review, (https://asia.nikkei.com/Spotlight/Coronavirus/Seoul-and-Taipei-show-the-world-how-to-contain-pandemics)
6.”Response to COVID-19 in Taiwan Big Data Analytics, New Technology, and Proactive Testing”, C. Jason Wang, Chun Y. Ng, Robert H. Brook, March 3, 2020, JAMA Network, (https://jamanetwork.com/journals/jama/fullarticle/2762689)
7. “Determinants of Taiwan’s Early Containment of COVID-19 Incidence”, Wen-Ta Chiu, Ronald P. Laporte and Jonathan Wu, July 2020, American Journal of Public Health, (https://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.2020.305720)
8. “Maintaining mask stockpiles in the COVID-19 pandemic: Taiwan as a learning model,” Cho-Hung Chiang, Cho-Hsien Chiang and Cho-Han Chiang, May 11, 2020, Cambridge Core, (https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/maintaining-mask-stockpiles-in-the-covid19-pandemic-taiwan-as-a-learning model/9C49648687FD618DC11E3FC34EFFA0F9/core-reader)
9. “Lessons From Taiwan’s Experience With COVID-19”, Tu, Chang-Ching, April 7, 2020, Atlantic Council (https://www.atlanticcouncil.org/blogs/new-atlanticist/lessons-fromtaiwans-
experience-with-COVID-19/)
10. “A Timeline of South Korea’s Response to COVID-19”, Victor Cha and Dana Kim, March 27, 2020, Center for Strategic and International Studies, (https://www.csis.org/analysis/
timeline-south-koreas-response-COVID-19)
11. “How South Korea flattened the coronavirus curve with technology”, Michael Ahn, April 21, 2020, The Conversation, (https://theconversation.com/how-south-korea-flattened-thecoronavirus-curve-with-technology-136202)
12. “No cramming as new COVID rules take hold in South Korean capital”, Hyonhee Shin, August 31, 2020, Reuters, (https://www.reuters.com/article/health-coronavirus-southkorea/nocramming-as-new-covid-rules-take-hold-in-south-korean-capital-idUSL4N2FX14K)
13. “In Depth: Why South Korea is winning the coronavirus battle”, TiangJiawei, Ma Danmeng, Huang Shulun and Han Wei, April 1, 2020, Nikkei Asian Review, (https://asia.nikkei.com/Spotlight/Caixin/In-Depth-Why-South-Korea-is-winning-the-coronavirus-battle)
14. “South Korea’s COVID-19 response: hard lessons on saving lives”, Kwang Kim, Kyung-sook Lee and Jaemyung Lee, June 9, 2020, Devpolicy Blog,( https://devpolicy.org/south-koreas-COVID-19-response-20200609-1/)
15. “Kogene Biotech, Korea’s Leading Diagnostic Kit Developer”, March 23, 2020, KBC World Radio,(https://world.kbs.co.kr/service/contents_view.htm?lang=e&menu_cate=business&id=&board_seq=381751)
16. “How South Korea Responded to the COVID-19 Outbreak in Daegu”, June-Ho Kim, Julia Ah-Reum An, Pok-kee Min, AsafBitton and Atul A. Gawande, July-Aug, 2020, NEJM Catalyst Innovations in Care DeliveryVol 1, No.4, (https://catalyst.nejm.org/ doi/full/10.1056/ CAT.20.0159)
17. “How South Korea Solved Its Acute Hospital-Bed Shortage”, Dasl Yoon, March 22, 2020, The Wall Street Journal, (https://www.wsj.com/articles/how-south-korea-solved-its-acutehospital-bed-shortage-11584874801)
18. “South Korea just flexed its contact-tracing power: After partiers with the coronavirus went to nightclubs, it found and tested 46,000 exposed people”, Aylin Woodward, May 23,2020, Business Insider, (https://www.businessinsider.com/south-korea-contact-tracing-helped-control-nightclub-outbreak-2020-5)
