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Potential lessons from the Taiwan and New Zealand health responses to the COVID-19 pandemic

Authors:

Abstract

Approaches to preventing or mitigating the impact of the COVID-19 pandemic have varied markedly be- tween nations. We examined the approach up to August 2020 taken by two jurisdictions which had suc- cessfully eliminated COVID-19 by this time: Taiwan and New Zealand. Taiwan reported a lower COVID-19 incidence rate (20.7 cases per million) compared with NZ (278.0 per million). Extensive public health in- frastructure established in Taiwan pre-COVID-19 enabled a fast coordinated response, particularly in the domains of early screening, effective methods for isolation/quarantine, digital technologies for identifying potential cases and mass mask use. This timely and vigorous response allowed Taiwan to avoid the na- tional lockdown used by New Zealand. Many of Taiwan’s pandemic control components could potentially be adopted by other jurisdictions.
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The Lancet Regional Health - Wester n Pacific xxx (xxxx) xxx
Contents lists available at ScienceDirect
The Lancet Regional Health - Western Pacific
journal homepage: www.elsevier.com/locate/lanwpc
Review
Potential lessons from the Taiwan and New Zealand health responses
to the COVID-19 pandemic
, ✩✩
Dr Jennifer Summers
a , , Dr Hao-Yuan Cheng
b , c
, Professor Hsien-Ho Lin
d , e
,
Dr Lucy Telfar Barnard
f
, Dr Amanda Kvalsvig
f
, Professor Nick Wilson
a
,
Professor Michael G Baker
f
a
BODE
3
, Department of Public Health, University of Otago, Wellington, 23A Mein Street, Newtown, Wellington 6021, New Zealand
b
Epidemic Intelligence Center, Taiwan Centers for Disease Control, 2F, No. 6, Linsen Sth. Rd., Taipei 100 , Taiwan
c
Department of Pediatrics, National Taiwan University Children’s Hospital, Taipei, Taiwan
d
Global Health Program, Institute of Epidemiology and Preventive Medicine, National Taiwan University, Rm706, No.17, Xuzh ou Rd, Taipei 10 0, Taiwan
e
Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taiwan
f
Co-Search COVID -19 Research Collaborative, Department of Public Health, University of Otago, Wellington, New Zealand
a r t i c l e i n f o
Article history:
Received 13 August 2020
Revised 24 September 2020
Accepted 25 September 2020
Keywo rds:
COVID-19
Public health
Epidemiology
Health policy
Infectious diseases
Global health
a b s t r a c t
Approaches to preventing or mitigating the impact of the COVID-19 pandemic have varied markedly be-
tween nations. We examined the approach up to August 2020 taken by two jurisdictions which had suc-
cessfully eliminated COVID-19 by this time: Taiwan and New Zealand. Taiwan reported a lower COVID-19
incidence rate (20.7 cases per million) compared with NZ (278.0 per million). Extensive public health in-
frastructure established in Taiwa n pre-COVID-19 enabled a fast coordinated response, particularly in the
domains of early screening, effective methods for isolation/quarantine, digital technologies for identifying
potential cases and mass mask use. This timely and vigorous response allowed Taiw an to avoid the na-
tional lockdown used by New Zealand. Many of Taiwan’s pandemic control components could potentially
be adopted by other jurisdictions.
© 2020 The Author(s). Published by Elsevier Ltd.
This is an open access article under the CC BY-NC- ND license
( http://creativecommons.org/licenses/by-nc-nd/4.0/ )
Introduction
Several disease outbreaks since 190 0 have become global pan-
demics or threatened to become so. These events include the in-
fluenza pandemics of 1918 (H1N1), 1957 (H2N2), 1968 (H3N2) and
2009 (H1N1), the 1997 H5N1 influenza outbreak in Hong Kong,
Middle East Respiratory Syndrome (MERS-CoV) in 2012, and Sud-
den Acute Respiratory Syndrome (SARS-CoV) in 2003. They have
prompted many nations to develop protocols and infrastructure to
manage and respond to such threats. During the current COVID-
19 pandemic (caused by the SARS-CoV-2 virus), nations have re-
sponded with varying public health interventions, such as border
closures, quarantining and physical distancing.
Short List of Websi tes : https://www.cdc.gov.tw/En https://www.mohw.gov.tw/
mp-2.html https://covid19.govt.nz https://www.health.govt.nz
✩✩ Editor note: The Lancet Group takes a neutral position with respect to territorial
claims in published maps and institutional affiliations.
Corresponding au thor.
E-mail address: jennifer.summers@otago.ac.nz (D.J. Summers).
The Worl d Health Organization (WHO) was first alerted to a
novel coronavirus outbreak by Chinese authorities on the 31 De-
cember 2019 [1] . In the following weeks, an increasing number
of cases and deaths were reported outside China (the epicentre),
prompting WHO to declare COVID-19 a Public Health Emergency
of International Concern (PHEIC) on 30 January 2020 and a pan-
demic on 12 March 2020. By the end of August 2020, the SARS-
CoV-2 virus had spread worldwide, with confirmed cases in 216
countries/areas/territories totalling over 25 million COVID-19 cases
and over 844,0 0 0 deaths [2] .
The impact of the COVID-19 pandemic has been highly diverse
for high-income jurisdictions. Amongst members of the Organisa-
tion for Economic Co-operation and Development (OECD) mortality
rates have varied substantially. For example, by the end of August
2020, Belgium had the highest mortality rate in the OECD and the
United Kingdom, the highest mortality rate for an Anglophone na-
tion, with 860.9 and 621.3 deaths per million population respec-
tively [ 2 4 ]. Comparatively, New Zealand has reported some of the
lowest rate in the OECD, with 4.4 deaths per million population
[ 5 , 6 ]. Low COVID-19 mortality rates up to August 2020 have also
https://doi.org/10.1016/j.lanwpc.2020.10 0 044
2666-6065/© 2020 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
( http://creativecommons.org/licenses/by-nc-nd/4.0/ )
Please cite this article as: D.J. Summers, D.H.-Y. Cheng, P.H.-H. Lin et al., Potential lessons from the Taiwa n and New Zealand health
responses to the COVID-19 pandemic, The Lancet Regional Health - Western Pacific, https://doi.org/10.1016/j.lanwpc.2020.10 0 044
D.J. Summers, D.H.-Y. Cheng, P. H .- H. Lin et al. The Lancet Regional Health - Western Pacific xxx (xxxx) xxx
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been observed amongst non-OECD jurisdictions closer to the epi-
centre of China, such as Taiwan , Singapore and Hong Kong, with
0.3, 4.7 and 11. 9 deaths per million population respectively [ 2 , 7
11 ].
As Taiwan currently has one of lowest mortality burdens
amongst high-income jurisdictions and achieved elimination by
April 2020 (no confirmed cases in the community) without a lock-
down [12] , we examined the response employed in this jurisdic-
tion. We also examined a contrasting jurisdiction, New Zealand,
which initially achieved elimination of community transmission
of COVID-19 by May 2020 but had a particularly stringent lock-
down [13] , and a later lockdown after a subsequent outbreak in
August 2020. Specifically, we aimed to identify public health inter-
ventions used in Taiwan which may be relevant to pandemic re-
sponses in other high-income countries during the current COVID-
19 pandemic and in future pandemics.
Methods
Search strategy and selection criteria
Relevant websites of Government Agencies were searched in
Taiwan, including the Taiwan Centers for Disease Control [Taiwan
CDC], the Ministry of Health and Welfare, the National Health
Command centre [NHCC], and the Taiwan National Infectious Dis-
ease Statistics System [ 11 , 14 , 15 ]; and in New Zealand, including
the Ministry of Health – Manat
¯
u Hauora, and the Institute of En-
vironmental Science and Research [ESR] [ 16 , 17 ]. PubMed, Google
Scholar and preprint repositories (medRxiv and arXiv) were also
searched for the period of 1 September 2019 to 1 September 2020.
The search terms used were: ‘COVID-19
, ‘SARS-CoV-2 ‘, or ‘Coron-
avirus’; and ‘Taiwan’ or ‘New Zealand’ in the title and/or abstract of
the article. We identified a total of 1030 articles in the databases,
of which 998 were excluded as duplicates or not relevant, eg, clin-
ical trials, modelling, genetic studies or case notes. We included a
total of 32 articles which made reference to COVID-19 responses
at a public health level and also described pre-COVID-19 public
health preparations. In some instances, the authors drew on their
direct involvement with the pandemic response in their respective
countries.
Results
Summary of the COVID-19 status in Taiwan and New Zealand up to
August 2020
Taiwan announced its first confirmed case of COVID-19 on 21
January 2020, a 50 + year old woman returning to Taiwa n from her
teaching job in Wuhan [ 18 , 19 ]. New Zealand recorded its first case
of COVID-19 on 28 February 2020, a woman in her 60 s who ar-
rived on 26 February from Iran via Bali [ 20 , 21 ]. Both jurisdictions
have now experienced the first wave of COVID-19 ( Fig. 1 ), though
New Zealand, after a period of elimination, has subsequently also
experienced a localised outbreak in the Auckland region in August
2020.
Table 1 details the main epidemiological features of COVID-19
in the two island jurisdictions.
As of August 2020, Taiwa n had reported cases in 20 of its 22 ad-
ministrative divisions, with the more geographically isolated east-
ern counties of Taitung and Hualien reporting no cases, whereas
confirmed cases of COVID-19 were reported in all 20 District
Health Board regions in New Zealand [ 5 , 14 ]. Taiwan had reported,
up to 31 August 2020, a fairly even split of confirmed cases be-
tween sexes, with 51.2% recorded as male (250/488) [14] , while
New Zealand reported 47.0% (656/1397) confirmed cases amongst
males up to 31 August 2020. [21] In both jurisdictions the highest
Fig. 1. Epidemic curve of weekly newly notified confirmed cases and cumulative
total confirmed COVID-19 cases in Taiwan
and New Zealand
∗∗ up to August 2020
Taiw an confirmed cases based on date of notification as reported 31 August 2020
[14] .
∗∗New Zealand confirmed cases based on date notified as potential cases, as re-
ported 31 August 2020 [21] . Further probable cases in New Zealand total n = 351
(not included in total above) as of 31 August 2020 . A probable case is defined as
‘one without a positive laboratory result, but which is treated like a confirmed case
based on its exposure history and clinical symptoms’ [5] .
proportion of confirmed cases was in the 20 to 29 years age group
[ 14 , 21 ].
Public health interventions in Taiwan and New Zealand in response
to COVID-19
Each jurisdiction used different approaches to respond to the
COVID-19 pandemic (see Appendix 1 for detailed list of interven-
tions). In Taiwan , several factors, including its proximity (130 km)
to China (where the epicentre of Wuhan was); previous experi-
ence of the SARS pandemic in 2003; and its high population den-
sity triggered a coordinated national response in the early stages
of the pandemic [ 23 , 24 ]. The Taiw an CDC in conjunction with the
Central Epidemic Command centre (CECC) took the lead in manag-
ing the pandemic, as directed in the pre-COVID-19 pandemic plan
for Taiwan . Established event-based systems alerted Taiwa ne se of-
ficials to the outbreak in China, prompting an immediate response,
with screening of all airline passengers arriving from Wuhan. This
screening was eventually extended to all passengers entering Tai-
wan from high risk areas/countries in late January, and eventu-
ally extended to all passengers regardless of their location of ori-
gin in early February [25] . In addition, by mid-March, entry to
non-Taiwanese citizens or people with non-resident status was re-
stricted. The existing legislation in the Tai wa ne se Infectious Dis-
ease Control Act 2007 enabled officials to access information that
may aid in controlling/containing COVID-19 if necessary [26] . This
legal framework enabled the travel history of individuals to be
linked to their National Health Insurance (NHI) card so that hospi-
tals could be aware and identify potential cases in real-time. Close
contacts of confirmed cases or travellers returning from high-risk
countries were required to be quarantined at home for 14 days.
During this period, the person would be monitored through a com-
bination of personal or government-dispatched phones and on oc-
casion in-person checks [27] . A distinct feature of the Tai wa n re-
sponse was widespread use of face masks to reduce transmission
from infected people (regardless of symptoms) as well as providing
protection for wearers (mass masking). By February 2020, the start
2
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Tabl e 1
Key epidemiological features of COVID-19 and jurisdiction-specific features in Taiwa n and New Zealand.
Taiw an
New Zealand
∗∗
General overview
Tota l population –2020 estimate 23 million [10] 5 million [6]
Population density –2020 and 2018 estimates 652 people per km
2 [10] 18.4 people per km
2 [22]
COVID-19 epidemiological characteristics up to 31 August 2020
Tota l cases 488 [11] 1397
∗∗[5]
Tota l confirmed cases per million population 20.7 278.0
Tota l deaths from COVID-19 7 [11] 22 [5]
Tota l deaths from COVID-19 per million population 0.3 4.4
Case fatality risk (CFR) 1.4% 1.6%
Tota l tests performed for SARS-CoV-2 177,317 [12] 766,626 [5]
Tota l tests per million population 7520 152,562
Test positive rate 0.28% 0.18%
Only confirmed cases
∗∗ Does not include probable cases
[5]
of the new semester for schools and high schools was delayed for
two weeks, and by March there was a ban on large gatherings of
100 if indoors and 500 if outdoors. Notably, up to 31 August 2020,
there were no stringent restrictions on movement and no local or
national lockdown.
New Zealand’s initial response followed its existing influenza
pandemic plan revised in 2017, which was based on a mitigation
strategy of ‘flattening the curve’ and delaying the epidemic peak
to reduce the health impact of a pandemic [28] . Although entry
restrictions and self-isolation/quarantine requirements were intro-
duced for travellers from various COVID-19 hotspots from Febru-
ary onwards, cases in New Zealand were beginning to increase
markedly by early March. The government signalled a new di-
rection on 23 March when the Prime Minister announced a full
lockdown of the country (at the highest Alert Level 4) which
came into effect on 26 March, with exceptions for essential work-
ers/businesses. This lockdown and partial lockdown at Alert Level 3
continued until 13 May. Most workplaces, schools and public meet-
ing places were closed and travel stopped under Level 4 and highly
restricted under Level 3. Implementation of the lockdown was sup-
ported by a national state of emergency, declared on 25 March,
which, along with newly written law changes passed through Par-
liament, enabled special powers to address the pandemic situation.
Like Taiwa n, New Zealand introduced border restriction to non-
citizens/permanent residents from February onwards. New Zealand
went down to its lowest Alert Level ‘1
in June, with all arrivals (re-
gardless of origin or symptomology) required to go into managed
isolation/quarantine facilities for 14 days (mainly re-purposed ho-
tels) and with a later introduced requirement for each individual
to have two COVID-19 tests taken on days 3 and 12 of their time
in quarantine [29] .
Both jurisdictions have reported either potential outbreaks
and/or clusters of cases of COVID-19. An outbreak occurred on
a cruise ship that had previously visited Taiwan: the Diamond
Princess (a well-publicised cruise-ship outbreak in the early stages
of the COVID-19 pandemic) [30] . During this ship’s visit to Taiwan,
passengers were allowed to disembark on 31 January 2020 for a
day trip. This day trip fell five days before the first case was con-
firmed on-board [ 26 , 31 ]. The Taiwa n CDC, in response to news of
Diamond Princess cases from Japan, published the locations that all
the ship’s passengers had visited, and issued instructions to those
who might have been in contact with passengers to self-monitor
and home-quarantine if judged necessary. Of the individuals in Tai-
wan who were deemed to be possible close contacts of the passen-
gers, all tested negative to SARS-CoV-2 infection. A further cluster
of infection in Taiwa n in March 2020 occurred upon the Panshi fast
combat support ship, with 36 confirmed cases. These infections re-
sulted in extensive testing both on-board, and of potential contacts
on land [ 11 , 32 , 33 ].
During New Zealand’s first outbreak (from late February to
May), there were 16 reported clusters of 10 or more cases of
COVID-19 in New Zealand [34] . Of these clusters, many were out-
breaks in aged-care facilities and from private social functions,
with others linked to travel overseas, a secondary school and a
cruise ship visit. After a period of successful elimination, a further
outbreak occurred in Auckland City in August 2020. All the cases in
this August outbreak were infected by the exact same strain of the
virus, but New Zealand health officials have not yet identified the
source of the this outbreak [35] (though a failure in a quarantine
facility for incoming travellers seems most likely).
In both Taiwan and New Zealand, reported potential and con-
firmed outbreaks/clusters prompted public health officials to put
similar infection control procedures in place. Response measures
included contact tracing, testing and isolation of cases and quar-
antine of close contacts. Furthermore, both jurisdictions provided
social/financial support during the COVID-19 pandemic and have
existing universal health coverage.
Taiwan’s COVID-19 response: defining features and differences from
New Zealand’s response that could plausibly have contributed to
different outcomes
The responses of Taiwan and New Zealand to the COVID-19
pandemic varied as a result of pre-COVID infrastructure and plan-
ning, and may also have been influenced by the different timing
of first confirmed cases in the respective jurisdictions (as shown
in Appendix 1). These circumstances resulted in differential tim-
ing of the mandated use of case-based (eg, contact tracing and
quarantine) and population-based (eg, face mask use and physi-
cal distancing) interventions. A recent modelling analysis using the
detailed empirical case data in Taiwan concluded that population-
based interventions likely played a major role in Taiwan’s initial
elimination effort s, and case-based interventions alone were not
sufficient to control the epidemic [36] . Major features of the dif-
fering COVID-19 responses consist of the following:
Probably the most fundamental difference between the situa-
tion of Taiwa n and New Zealand was that in Taiwan responsive-
ness to pandemic diseases and similar threats is embedded in
its national institutions. Taiwan established a dedicated CDC in
1990 to combat the threat of communicable diseases. By con-
trast, the equivalent organisation in New Zealand (the NZ Com-
municable Disease Centre, a business unit within the Depart-
ment of Health) was closed in 1992 with its functions trans-
ferred to a newly formed Crown Research Institute (ESR) and
then contracted back to what became the Ministry of Health. In
addition, Taiwan established a National Health Command cen-
tre (NHCC) in 2004 following the SARS epidemic. This agency,
3
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working in association with the CDC, was dedicated to respond-
ing to emerging threats, such as pandemics, and given the
power to coordinate work across government departments and
draw on additional personnel in an emergency.
Taiwan’s pandemic response was largely mapped out through
extensive planning as a result of the SARS pandemic in 2003,
and was developed in such a way that it could be adapted to
new pathogens. By contrast, New Zealand was reliant on its
existing Influenza Pandemic Plan as a framework for respond-
ing to COVID-19, which has rather different disease character-
istics compared with pandemic influenza, (although the plan
does have some relevance for controlling any new respiratory
pathogen).
As in many Asian countries that had experience with SARS, Tai-
wan had an established culture of face mask use by the pub-
lic. It also has a very proactive policy of supporting production
and distribution of masks to all residents, securing the sup-
ply, and providing universal access to surgical masks during the
COVID-19 pandemic from February 2020 onwards. There were
also official requirements to wear masks in confined indoor en-
vironments (notably subways), even during periods when there
was no community transmission [37] . By contrast, health offi-
cials in New Zealand did not promote mass masking as part
of resurgence planning until August, despite science-based ad-
vocacy from a broad base of public health and clinical experts
[38] .
Taiwan’s well-developed pandemic approach, with extensive
contact tracing through both manual and digital approaches,
and access to travel histories, meant that potential cases could
be identified and isolated relatively quickly [39] . This ability
to track individuals or identify high-risk contacts resulted in
fewer locally acquired cases. In contrast, New Zealand’s con-
tact tracing methods varied by local authority level and until
May 2020 did not involve a centralised digital approach (e.g.,
did not have national approaches to the use of mobile phone
applications and telecommunications data) [40] . New Zealand’s
resulting lockdown period began in March and effectively lasted
for seven weeks (at Alert Levels 4 and 3).
Taiwanese officials began border management measures (ini-
tially health screening air passengers) the day the World Health
Organization was informed of the outbreak in Wuhan (31 De-
cember 2019) and more extensive border screening of all ar-
rivals occurred in late January, which coincided with the first
case in Taiwan. New Zealand’s first case occurred in late Febru-
ary 2020, and initially coincided with the first restrictions on
foreign nationals from China. Both jurisdictions imposed wider
entry restrictions to non-citizens in March 2020. The earlier in-
troduction of entry restrictions and health screening in Taiwan
is likely to have influenced the relatively lower case numbers in
Taiwan compared with New Zealand up to August 2020 (20.7 vs
278.0 confirmed COVID-19 cases per million population respec-
tively).
Discussion
With the extensive infrastructure it had established before
COVID-19, it appears Taiwan was in a better position than New
Zealand to respond effectively to the COVID-19 pandemic. De-
spite Taiwan s closer proximity to the source of the pandemic,
and its high population density, it experienced a substantially
lower case rate of 20.7 per million compared with New Zealand’s
278.0 per million. Rapid and systematic implementation of con-
trol measures, in particular effective border management (exclu-
sion, screening, quarantine/isolation), contact tracing, systematic
quarantine/isolation of potential and confirmed cases, cluster con-
trol, active promotion of mass masking, and meaningful public
health communication, are likely to have been instrumental in lim-
iting pandemic spread. Furthermore, the effectiveness of Tai wa n’ s
public health response has meant that to date no lockdown has
been implemented, placing Taiwan in a stronger economic posi-
tion both during and post-COVID-19 compared with New Zealand,
which had seven weeks of national lockdown (at Alert Levels 4
and 3). In comparison to Taiwan, New Zealand appeared to take
a less vigorous response to this pandemic during its early stages,
only introducing border management measures in a stepwise
manner.
New Zealand’s pandemic plan was entirely orientated to just
pandemic influenza and so this limited its applicability to other
pandemic diseases, such as COVID-19. It also had no established
infrastructure for addressing a pandemic like COVID-19 until at
least early March 2020. New Zealand’s plan did include an initial
“Stamp It Out” phase, but was largely orientated towards mitiga-
tion. However, early evidence from China indicated that a mitiga-
tion strategy for addressing COVID-19 may not have been optimal
given the high transmissibility and the relatively high infection fa-
tality ratio of SARS-CoV-2 infection (which probably would have
resulted in thousands of deaths and overwhelmed the health sys-
tem in a country such as New Zealand) [41] . There was also good
evidence from China indicating that the COVID-19 pandemic could
be contained with a sufficiently vigorous response [42] . These con-
siderations, along with a need to protect M
¯
aori and Pacific popu-
lations (who already suffer high health inequalities from both en-
demic [43] and pandemic infectious diseases [44] ), and the need to
scale up testing and contact tracing, led to New Zealand’s decision
to implement border controls and physical distancing measures at
high intensity (‘Lockdown’) to extinguish community transmission
of SARS-CoV-2.
An assessment of contact tracing in Taiwan describes how the
initial high transmissibility of SARS-CoV-2 at, or just before, the
onset of symptoms decreases with time, in contrast to the pattern
of the SARS-CoV-1 outbreak in 2003 with initial transmissibility of
cases remaining low until five days after onset of symptoms [45] .
The authors suggest that relying on identifying symptomatic cases
and contact tracing may not be sufficient as methods for contain-
ing COVID-19. A subsequent modelling analysis in Ta iwan based on
empirical data provided further evidence that case-based interven-
tions (contact tracing and quarantine) alone would not be suffi-
cient to contain the COVID-19 epidemic [36] . This issue may ex-
plain why the more aggressive approaches adopted by Taiwan and
New Zealand have enabled them to initially eliminate SARS-CoV-
2 in the community and avoid the high case numbers now occur-
ring in countries that initially relied on a mitigation approach, such
as the United Kingdom, the United States of America, and Swe-
den. New Zealand’s initial period of elimination with no commu-
nity transmission was sustained for 102 days from May 2020 [13] .
It ended with an outbreak in August 2020, which emphasises the
need for ongoing surveillance and resurgence planning in nations
which have achieved periods of elimination.
Taiwan’s management of and response to COVID-19 is not
without concerns. For example, allowing Diamond Princess pas-
sengers into Taiwan drew criticism, as did the limitation of Tai-
wanese public communications during the pandemic being pre-
dominantly provided in Mandarin Chinese and sign language [31] .
Although the Taiwan CDC website and some health education
videos provide translation in several languages, just some of them
include the languages of the 16 recognised indigenous Taiwa ne se
Austronesian-speaking tribes, which may have limited access to
important public health messages [ 31 , 46 , 47 ]. Daily press confer-
ences in New Zealand have been delivered in English and included
a New Zealand sign language interpreter. Translations of COVID-19
related materials on the main New Zealand COVID-19 related site
( https://covid19.govt.nz ) were also made available in Te Reo M
¯
aori
4
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(alongside other Te Reo M
¯
aori broadcasts), New Zealand Sign Lan-
guage, and 26 + other languages.
So what can countries (in particular high-income countries)
learn directly from the COVID-19 experience in Taiwa n and New
Zealand? There are many areas that need to be developed to in-
form the response to the current COVID-19 pandemic and to pre-
pare for the next pandemic, which could be even more severe [48] .
Our recommendations are as follows:
1 Establish or strengthen a dedicated national public health
agency to manage both prevention and control of pandemics
and other public health threats. Such an agency could take the
form of a centre for disease control and prevention or a more
broadly focused national public health agency, and would re-
quire the authority to coordinate other ministries/departments
(such as Taiwan’s CECC).
2 Formulate a generic pandemic plan that allows for responses to
different disease agents with diverse characteristics.
3 Provide further investment in resources and infrastructure that
will allow a government to quickly respond to future dis-
ease threats. Taiwan strengthened its public health response
through developing real-time surveillance methods pre-COVID-
19 and already had a national alert system in place, unlike New
Zealand. Specific recommendations include:
Enhance national and regional disease and outbreak surveil-
lance systems including sentinel surveillance and more spe-
cialised systems, such as wastewater testing [49] .
Develop effective border management policies and associ-
ated infrastructure that can be implemented quickly, such as
the 31 December 2020 Taiwanese reaction to the outbreak
notification with immediate air passenger health screening.
Establish more robust quarantining rules and more secure
facilities for incoming travellers. Previously in New Zealand,
quarantining rules granted exemptions to customs and air-
line crew, although these have now been updated with more
stringent guidelines [50] .
Further develop both conventional and digital solutions to
contact tracing, and isolation/quarantine monitoring. Unlike
Taiwan, New Zealand did not have these solutions substan-
tially in place [40] . Indeed, a digital solution to contact trac-
ing was only released in New Zealand in May 2020 and had
limited functionality with initially poor uptake by the pub-
lic.
Develop an effective means of face mask distribution and
promotion in case a border control failure occurs. The Tai-
wanese digital solution (such as the name-based mask dis-
tribution system, and distribution and sales controls imple-
mented by the Taiwan CECC) avoided hoarding and enabled
distribution to those most at need. This approach could also
be applied and extended to medicine distribution for a fu-
ture pandemic (eg, for antivirals).
4 Review workforce needs to support effective pandemic manage-
ment and public health development more generally and en-
hance training programmes accordingly. One outcome could be
establishment of a Field Epidemiology Training Program (FETP)
in countries such as New Zealand, which do not currently have
one.
5 Develop systems for evaluating and auditing pandemic re-
sponses, and exercising emerging infectious disease response
capabilities.
The Taiwan/New Zealand comparison indicates that it
would be valuable to conduct an official enquiry into New
Zealand’s response to help shape the necessary changes to
its laws, public health infrastructure, and institutions.
Pandemic response systems can be tested by running regu-
lar exercises and simulations. However, such exercises will
be ineffective unless recommendations arising from these
initiatives are communicated and adopted [51] .
6 Establish cultural, societal and legal acceptability for these pan-
demic response measures. There are legitimate concerns re-
garding the use of big data analytics, particularly with the use
of digital methods in public health responses [ 52 , 53 ], and per-
haps less cultural acceptability in some countries for regular
face mask use as a public courtesy by people with any respi-
ratory symptoms. Other populations may also be less inclined
than Taiwan ’s citizens to accept the imposition of stringent in-
terventions that limit personal rights and liberties. One way to
explore these privacy concerns would be to run citizen juries,
citizen panels, indigenous consultation, and surveys to clarify
at what levels of pandemic severity populations would be will-
ing to accept and comply with potential intrusions in privacy,
such as using digital technology to aid contact tracing. Public
health law needs to be updated to enable outbreak and pan-
demic control measures while balancing the needs to protect
personal rights and liberties.
Conclusions
Taiwan’s successful response to COVID-19 up to August 2020
has resulted in relatively low cases and mortality. This positive
outcome reflected pre-COVID-19 preparation for disease outbreaks
with a dedicated national public health agency and infrastructure
including integrated manual and digital solutions to support the
coordination of key functions. This pro-active response to COVID-
19 in Taiwan is in contrast to the more reactive pandemic response
in New Zealand. While some aspects of the Taiwan approach might
not be acceptable in other jurisdictions, the potential social and
economic benefits of avoiding a lockdown might alleviate some
objections. Therefore, the Taiwan es e model warrants further ex-
amination for transferable elements that could improve current re-
sponses to COVID-19, and prepare health systems and populations
for a timely and effective global response to the inevitable next
pandemic.
Authors Contribution:
Dr Jennifer Summers Literature search, figures, data collec-
tion, data analysis, data interpretation, writing. Professor Hsien-
Ho Lin Literature search, data interpretation, writing. Dr Hao-
Yuan Cheng Literature search, data interpretation, writing. Dr Lucy
Telfar-Barnard Literature search, data interpretation, writing. Dr
Amanda Kvalsvig Literature search, data interpretation, writing.
Professor Nick Wilson Literature search, data interpretation, writ-
ing. Professor Michael Baker Literature search, data interpretation,
writing.
Declaration of Competing Interest
The authors have no competing interests.
Acknowledgements/Funding
We acknowledge funding support from the Health Research
Council of New Zealand (20/10 6 6), which did not have any role in
paper design, data collection, data analysis, interpretation or writ-
ing of this paper. The corresponding author, Dr Jennifer Summers
has had full access to all data, which is publicly available, and has
final responsibility for the decision to submit for publication.
Supplementary materials
Supplementary material associated with this article can be
found, in the online version, at doi:10.1016/j.lanwpc.2020.10 0 044 .
5
D.J. Summers, D.H.-Y. Cheng, P. H .- H. Lin et al. The Lancet Regional Health - Western Pacific xxx (xxxx) xxx
ARTICLE IN PRESS
JID: LANWPC [m5G; October 21, 2020;0:4 ]
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6
... According to Summers et al. [25], there are several reasons for the success. Taiwan established a National Health Command Centre (NHCC) in 2004 following the SARS epidemic. ...
... Summers et al. [25] suggest that relying on identifying symptomatic cases and contact tracing may not be sufficient as methods for containing the virus. A subsequent analysis in Taiwan based on empirical data provided further evidence that case-based interventions (contact tracing and quarantine) alone would not be sufficient to contain the COVID-19 pandemic; however, many other studies suggest the systematic digital contact tracing has certainly contributed to the containment. ...
... This digital solution, such as the name-based mask distribution system, and distribution and sales controls implemented by the Taiwan Central Epidemic Command Centre, avoided hoarding and enabled distribution to those most at need. This could also be applied and extended to medicine distribution [25]. ...
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