https://www.thelancet.com/journals/lanwpc/article/PIIS2666-6065(20)30044-4/fulltext
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 planning, 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 timing of the mandated use of case-based (eg, contact tracing and quarantine) and population-based (eg, face mask use and physical 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 efforts, and case-based interventions alone were not sufficient to control the epidemic [36]. Major features of the differing COVID-19 responses consist of the following:
- Probably the most fundamental difference between the situation of Taiwan and New Zealand was that in Taiwan responsiveness 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 contrast, the equivalent organisation in New Zealand (the NZ Communicable Disease Centre, a business unit within the Department of Health) was closed in 1992 with its functions transferred 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 centre (NHCC) in 2004 following the SARS epidemic. This agency, working in association with the CDC, was dedicated to responding 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 responding to COVID-19, which has rather different disease characteristics 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, Taiwan had an established culture of face mask use by the public. It also has a very proactive policy of supporting production and distribution of masks to all residents, securing the supply, 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 environments (notably subways), even during periods when there was no community transmission [37]. By contrast, health officials in New Zealand did not promote mass masking as part of resurgence planning until August, despite science-based advocacy 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 contact 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 (initially health screening air passengers) the day the World Health Organization was informed of the outbreak in Wuhan (31 December 2019) and more extensive border screening of all arrivals occurred in late January, which coincided with the first case in Taiwan. New Zealand's first case occurred in late February 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 introduction 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 respectively).
From the Discussion
. . . Despite 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 control measures, in particular effective border management (exclusion, screening, quarantine/isolation), contact tracing, systematic quarantine/isolation of potential and confirmed cases, cluster control, active promotion of mass masking, and meaningful public health communication, are likely to have been instrumental in limiting pandemic spread.
Furthermore, the effectiveness of Taiwan's public health response has meant that to date no lockdown has been implemented, placing Taiwan in a stronger economic position both during and post-COVID-19 compared with New Zealand, which had seven weeks of national lockdown (at Alert Levels 4 and 3).(emphasis added) 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.