Taiwan’s reaction to Covid-19 has been fast and effective. Despite its proximity to China, it has seen just 395 cases and six deaths. In an exclusive interview, Chen Chien-jen, the country’s vice-President and renowned epidemiologist, explains Taiwan’s coronavirus battleplan and the lessons it holds for Britain and the WHO. Answers have been edited for space.

What did Taiwan learn from Sars in 2003?

We learned a lot about prudent action, rapid response and early deployment.

It’s important to monitor emerging infectious diseases, especially in this region because we are near to China. In addition to SARS, there was an H1N1 Avian Flu in 2005, an H7N9 Avian Flu and now Covid-19.

Secondly, we announce a travel alert if necessary and thirdly, we optimize border quarantine to identify imported cases. This time when we knew there was an atypical pneumonia – meaning an infectious lung disease without known cause, where the patient is isolated and there is likely human-to-human transmission – we implemented on-board quarantine for all passengers flying from Wuhan.

Then there is 14-day home quarantine for close contacts of passengers from affected areas. During SARS we found that hospital-acquired infection was very dangerous so we upgraded the healthcare system to provide isolation rooms and a national network of health care centres for infectious diseases. This strategy has to be planned before an outbreak.

An adequate supply of PPE is important. In 2002, we ran short of N95 face masks so we knew we needed a face mask rationing system and to increase production. We now produce more than 13 million a day and are expecting to push this up to 15m.

Then there’s health education about home quarantine or what children have to do at school. This and risk communication must be transparent.

How many critical care beds do you have?

At full capacity, we have 20,000 isolation rooms, and 14,000 ventilators.

We also set up a National Epidemic Command Centre because outbreak control is an inter-ministerial effort and it is essential to coordinate. It’s very important that everyone in the country has to be involved - the government and the people.

Can Taiwan’s pandemic strategy be successfully replicated in bigger countries? Can lessons still be learned?

Yes, sure. It will never be too late to control any kind of outbreak in any country. There are still a lot of chances for different countries to adopt good strategies developed here to help contain the outbreak. Social distancing and good health behaviour are definitely important – frequent handwashing, measuring body temperature, using a face mask if necessary. At home, close contacts [of the infected] shouldn’t dine together. The [patient] can live in a single room. It’s not necessary to stop all activities. As long as more than 50% of the population reduces 50% of their social contacts then the outbreak can be controlled. They can go to school, to work but must reduce non-essential recreation and social contact.

Home quarantine is important. Close contacts must stay at home for 14 days and check their health status.

Frontline healthcare workers must have adequate PPE. The UK and US are trying their best to do that and Taiwan is willing to help.

We need to collaborate to develop rapid diagnostics, anti-virals or even vaccines as soon as possible.

What recommendations do you have for the UK? Could mass testing help?

In Taiwan we didn’t practice mass testing because among 395 cases, only 55 were locally transmitted, and the infection source could not be traced in only ten cases. If many cases have no known infection sources then you have to do mass testing. But it is sometimes neither efficient nor cost effective. You have to test [patients’] close contacts as a first priority, then high-risk groups – healthcare workers, supermarket cashiers, taxi and public transport drivers. If they aren’t infected then others won’t be.

Western pandemic planning documents don’t envisage the lockdowns we’re seeing in Europe or the US. Why?

Asian countries are always in greater danger of emerging infectious disease. We face a biological timebomb, so we are well-prepared. Vietnam, Singapore, Hong Kong were severely affected by Sars. That’s why they are now also doing a very good job. In Korea they had Mers so they learned from it. We are in a much more dangerous situation than America and Europe and people always learn from disasters. Our world is getting smaller so we have to share information transparently and rapidly. This is the mission of the World Health Organisation.

After Sars the WHO set up an alert system – Public Health Emergency of International Concern. When there was an H1N1 new influenza in 2009, they announced the PHEIC around one month after the first case, when only three countries were affected. So we developed rapid diagnosis, prepared anti-virals, and developed the vaccine very quickly. For Covid-19, some say the first case was in early or mid-December 2019, but this time the PHEIC was announced at the end of January. Even worse, they still did not consider any kind of travel alert. Then why announce that it’s a PHEIC? 19 countries were already affected with more than 8,000 confirmed cases, so it was too late.

Why was the WHO’s response different to Covid-19? What has been the impact of Taiwan’s exclusion from the WHO?

I don’t know why the WHO did not take actions as quickly as they did for H1N1 or Sars. The WHO didn’t invite us to an emergency meeting on 22-23 January. Before that we already requested China’s CDC to send our two experts to Wuhan to look at the situation. Based on [their] observation and personal dialogue we found the situation was quite severe already in mid-January. They were discussing about whether to isolate the whole of Wuhan or not. The situation in the hospitals was really worse. We also discovered something very important – they were paying much more attention to hospitalised severe cases. When we asked about close contact tracing and the care of patients with mild symptoms, we didn’t get a very good response. If close contact tracing can be done then the disease won’t be spread by the patient.

What do you think of China’s response to this pandemic?

Wuhan’s frontline health workers were doing a very good job taking care of the severe cases of atypical pneumonia with unknown causes. They also tried their best to share the information with the Wuhan health authorities. I don’t know why this information was not taken very seriously. Usually epidemiologists or infectious diseases physicians consider that once there is a cluster of patients in hospitals this only represents the tip of the iceberg so there must be a lot of infected people. That’s why some doctors in Wuhan shared this warning to their colleagues but unfortunately it was not taken very seriously.

Do you think there was a political cover-up?

I really don’t know but if we compare it to the alert [from] the healthcare workers, I think that the alert did not get sent out to the public or to the entire world.

You said your CDC saw a notice from Wuhan on social media on December 31 and already the Chinese CDC and the WHO. What did that notice say?

The notice said there are seven cases of atypical pneumonia but it was not considered to be SARS and the specimen has been tested for possible causes. However, all these patients were isolated for treatment.

Do you believe the virus originated in a market?

They say that the virus originated from Huanan seafood market but if we look at the first 42 cases published in academic journals, around ten have no history of going there. This is a very important hint that the market may not be the origin of this infection. In early December, there were cases reported from Thailand, Hong Kong, and Japan – all patients who did not go to the market. There might be a cluster there but not all got the infection there. From an epidemiological viewpoint, once there is a patient or a cluster you have to find their contacts and then trace two things – infection sources and whether surrounding people have been infected. But they never paid attention to mild or asymptomatic cases.

Is there any indication of where the virus came from?

When we try to trace back to the [index] case it is very difficult. If the case had a mild disease you can never find it. And according to this so-called infection pyramid of Covid-19, there is only a small proportion of severe but a lot of mild and asymptomatic cases. So for Covid-19 it is much more difficult than for Sars to identify the index case.

What is the right exit strategy for the lockdowns?

Covid-19 is becoming flu-like. It means that since it is highly contagious with many mild or asymptomatic cases, and can be transmitted through droplets and contaminated areas, we won’t get rid of this virus totally. We need to develop rapid diagnostics and anti-virals then milder cases can be treated by private practitioners in the community. Severe cases can be treated in medical centres, also with rapid diagnosis and anti-virals. This will protect and cure the patient and protect close contacts from infection. In one or 1.5 years we may have the vaccine. Before that, we need to keep social distancing…living in a self-limited way but still semi-normally.

How do we open up travel and trade again?

To coordinate international transportation, all nations have to share data and make their outbreak status transparent. We need seroepidemiological studies to test blood samples to know the infection status of each country.

What is Taiwan’s contribution to diagnostics and vaccines?

We have three vaccine development teams in collaboration with the EU and US – Academia Sinica, the National Health Research Institute, and Medigen along with the US NIH.

There are two prototype rapid diagnostics. One to test antigens. Another to test the blood – the seromarkers – to test antibodies. We hope to soon get a licence and we’re happy to share all our new developments. On pharmaceuticals, we are involved in a clinical trial of Remdesivir, which seems quite good for severe but even better for milder cases.

Will life return to normal soon?

I once gave a prediction about the end of May, but it’s very difficult to predict accurately. Europe has reached the peak and it’s going down. In the US it’s still going up. All nations have mobilised and they are doing much better than one month ago. It’s a good phenomenon of globalisation, of Covid-19 containment.

READ MORE: