Learning from the past: Taiwan's responses to COVID-19 versus SARS

Abstract

Objectives: To evaluate the prevalence of infection prevention behaviors in Taiwan-wearing facemasks and alcohol-based hand hygiene (AHH)-and compare their practice rates during SARS and COVID-19.

Methods: We surveyed 2328 Taiwanese from July 29 to August 6, 2020, assessing demographics, information sources, and preventive behaviors during the 2003 SARS outbreaks, 2009 pandemic influenza H1N1, COVID-19, and with post-survey intentions. Characteristics associated with the practice of preventive behaviors in 2020 were identified through logistic regression.

Results: Preventive behaviors were conscientiously practiced by 70.2% of participants. Compared with 2003 SARS/2009 H1N1, the percentages of facemask use (66.6% vs 99.2% [indoors], P < 0.001) and on-person AHH (44.2% vs 65.4% [hand sanitizers], P < 0.001) significantly increasedduring 2020 COVID-19. Highest adherence to preventive behaviors in 2020 was among females (adjusted odds ratio [aOR], 1.72), those receiving government COVID-19 information (aOR, 1.52), participants recruited from primary-care clinics (aOR, 1.43), and those who practiced AHH during 2003 SARS/2009 H1N1 (aOR, 1.37).

Conclusions: Government leadership, healthcare providers risk communication, and public cooperation rapidly mitigated the spread of COVID-19 in Taiwan even before vaccination. Future global efforts must implement such population-based preventive behaviors at a level above the viral-transmission-threshold, particularly in areas with fast-spreading SARS-CoV-2 variants.

Keywords: Alcohol-based hand hygiene; COVID-19; Face mask; Public health policies; SARS-CoV-2; Taiwan; Threshold-based bundle strategy.

Figure 1

Countermeasures and an epidemic curve of the laboratory-confirmed SARS-CoV-2 cases in Taiwan from January 1 to December 31, 2020, based on the dates of illness onset for most cases. The bottom parts involve the 4 major public health policies, which are shown as “B” for border control, “T” for policies related to traffic control bundle or enhanced TCB (TCB or eTCB), “M” for mask-related policies, and “A” for alcohol-based hand hygiene. All the numbers are based on the order of calendar dates from when the policy started to be implemented (Taiwan Ministry of Health and Welfare, 2020). The top 3 arrow-shaped text boxes represent the 3 major leaks (see details in the Introduction section). The overall public health prevention measures involve 3 tiers: 1st tier with border control, 2nd tier with eTCB, and 3rd tier with public cooperation in terms of wearing masks and exercising alcohol-based hand hygiene. Border control involves all travelers entering Taiwan requiring 14 days for quarantine plus an additional 7 days of self-health-management (effective March 19, 2020). The surge of medical demand for surgical masks and the prohibition on exports of surgical masks after the lockdown in Wuhan, China, on January 23, 2020, provoked social panic, resulting in Taiwanese citizens rushing to stand in long lines to buy facemasks until a massive increase in facemask production was achieved. We used the dates of illness onset for most cases (529/808, 65.5%) with clear information. However, 279 cases (279/808, 34.5%) without clear onset dates of illness, including 258 asymptomatically infected SARS-CoV-2 cases (258/ 279, 92.5% [identified by antibody test]) were plotted by laboratory-confirmation dates because onset dates of illness were not available for asymptomatic SARS-CoV-2 cases and a small proportion of the cases were identified either from contact tracing with time delays or from retrospective laboratory tests of SARS-CoV-2 for the reported human influenza severe cases with influenza-negative laboratory results, based on the recommendations from the Taiwan COVID-19 advisory group meeting. All these data were released by Taiwan CDC and were accessible on January 16, 2021 (National Center for High-performance Computing (NCHC, 2021).

Figure 2

A flow chart of participant enrollment for investigating their practice of prevention behaviors during COVID-19 (2020). Finally, we excluded 7 persons younger than 18 years old, 7 non-citizens, and 74 participants who had not experienced the 2003 and 2009 epidemics (due to using McNemar’s tests for the paired data of those who experienced both epidemics—of 2003/2009 and 2020). The remaining 2328 individuals were included in the data analysis.

Figure 3

Percentages of Taiwanese citizens practicing (A) wearing of facemasks, and (B) alcohol-based hand hygiene during the 2003 SARS/2009 H1N1 pandemics versus during the COVID-19 pandemic in 2020. The proportion of participants wearing facemasks and the proportion of those disinfecting hands with alcohol-based hand sanitizer (ABHS) significantly increased from the 2003 SARS/2009 H1N1 pandemics to the COVID-19 pandemic from January 23 to June 7, 2020, in Taiwan.

Figure 4

The number of cases originating in the 5 major sources of the risk groups during the 2003 SARS outbreak and COVID-19. The 5 risk groups in Taiwan during the 2003 SARS outbreak (shown in brown) versus COVID-19 (shown in blue) were: (1) imported cases; (2) family, friends, and other contact cases infected directly from the imported cases; (3) healthcare facility-associated cases, including 3(A) healthcare workers (HCWs) and 3(B) others; (4) community cases (i.e., cases in which the sources of the SARS-CoV-2 infections were schools, stores, apartments, commercial buildings, and transportation); and (5) unidentified-source cases (i.e., cases without clear sources of infection, even after thorough contact tracing and epidemiological investigations by public health professionals at local departments of health with joint efforts of local Taiwan CDC branches). All these data were released from Taiwan CDC and were accessible on January 16, 2021 (National Center for High-performance Computing (NCHC, 2021).