Taiwan’s Transition from Zero-COVID to Living- with-COVID-Safely

Written by Chunhuei Chi

Image credit: Guan Zhen Chen, CC BY-SA 4.0 https://creativecommons.org/licenses/by-sa/4.0, via Wikimedia Commons

The COVID-19 pandemic has caused catastrophic damage to lives and livelihoods for over two years. As we moved into the 3rd year of this pandemic, most nations have entered the transitional phase of the pandemic. This is when control measures are gradually relaxed, people can live with fewer restrictions, and where there are very low COVID-19 fatalities and hospitalisations. This critical phase is essential for nations to move into the post-pandemic phase to live normally and safely with COVID-19. Transitional phases are facilitated by fully vaccinating a high proportion of the population and a sizeable population acquiring natural immunity from infection. In addition, nations that enter this transitional phase need a well-developed monitoring and surveillance system, including rapid testing capacity, effective and adaptable isolation-quarantine measures, adequate healthcare capacity, and pharmaceutical treatments. Further, people are well-informed with a high level of compliance and are mentally ready to face a small risk of new infections.

These preconditions to enter the transitional phase present an immense challenge to nations practising “Zero-COVID,” such as China (including Hong Kong and Macao), Taiwan, and a few Pacific Island nations. While the Zero-COVID policy served those nations well with low prevalence and mortality during the first two years of the pandemic, people often neglected its costs. Aside from economic costs, there are many examples of collateral damage caused by the Zero-COVID policy, such as social relationships, education, mental health, unemployment, and overall socio-economic development. Further, the strict restrictions necessary to maintain Zero-COVID exacerbate health inequity and social inequity.

Taiwan’s repeated successes in controlling domestic outbreaks, including successfully controlling the new outbreak in May of 2021 by mid-July, ironically contributed to Taiwan’s challenge to move into the transitional phase. This success enabled Taiwanese residents to enjoy a normal life with a low tolerance for domestic outbreaks and caused a unique form of vaccine hesitancy, especially among the elderly. When there is little to no risk of infection, many people associate vaccination with risks and few potential benefits. Further, the low tolerance for domestic cases also compelled the government to continue closing its borders to visitors and requiring strict quarantine to enter the nation. These policies and attitudes also contributed to the barricade mentality that these Zero-COVID policies are essential for the Taiwanese to live a normal life.

Then came the Omicron variant (and its sub-variants), changing the landscape of this pandemic. The US-Japan Omicron study and the Hong Kong University study identified the virologic-pathological nature of the Omicron variant that explained its extremely high transmissibility and low severity and fatality compared to all previous strains of the SARS-CoV-2 virus. This unique combination changed everything. The Omicron variant caused a new surge of COVID-19 cases worldwide, starting in South Africa in November 2021. According to Our World in Data, most nations experienced a rise of

patients in 6 weeks up to 3 months, with a few exceptions. This pattern suggests that most countries encountered an exponential surge with a large average daily new case per million (e.g., 10,968 for Israel, 8,764 for Hong Kong, 7,970 for Denmark, and 2,426 for the U.S.), followed by levelling off after that. Numerous empirical studies found that immunity from prior infection provides long-lasting immunity.

Further, the latest CDC study on COVID-19 immunity found strong evidence that infection-elicited immunity is stronger than vaccine-induced immunity alone. This concludes that the strongest immunity is the hybrid immunity from infection and vaccine-elicited immunities, followed by infection-elicited immunity, and vaccine-induced immunity comes third. Moreover, numerous studies published in Nature, Science, and The Lancet also showed strong evidence that hybrid exemption provides much stronger protection against severe symptoms or deaths than vaccination alone.

With Omicron’s high transmissibility and low severity, these new findings provided public health professionals and policymakers with an exit strategy to end this pandemic. That is, prioritising the protection of the vulnerable population (the elderly, the immunocompromised, and those who cannot be vaccinated) while reducing the intensity of previous control measures. Many nations began to modify their pandemic control measures during the Omicron surge. Once the surge was over and the healthcare capacity was deemed adequate, most countries began to significantly relax their pandemic control measures. For example, they opened their borders for tourists without quarantine or testing.

Countries practising Zero-COVID, such as Taiwan and China, are very slow to respond to (Taiwan) or are having difficulty adapting to (China) this nature of Omicron and changing their perception of COVID-19. One particular factor that makes the mindset shifting difficult is associating COVID-19 infection with a high risk of severe illness or death – the images of the spring of 2020. In addition, Taiwan’s media sensation on reporting government officials’ and celebrities’ confirmed infections did not help, and neither did the focus on the increasing number of daily confirmed cases.

At the beginning of 2022, Taiwan’s daily new cases per million (measured as a 7-day rolling average) was 0.95 – extremely low compared to most nations considering most were imported cases. However, the Omicron surge started in late March, increasing the case per million statistics from 4.13 on 22 March to 91.28 on 22 April in just one month, and continued to grow significantly to 751.44 by 4 May. During the spring outbreaks of 2021, when the peak was 25.01 per million daily new cases, there was already panic, which pushed the government to elevate its control measure to an unprecedented Level-3. Unsurprisingly, the government and the people have been shocked by the current case counts.

Taiwan’s remarkable achievement with extremely low prevalence and mortality was attributed to its early planning and implementation of the pandemic control measures. In contrast, Taiwan lacks a well-planned exit strategy for ending this pandemic. Since the Omicron surge this year, Taiwan’s Central Epidemic Command Center (CECC) has been slow to adapt. Initially, it put patients with asymptomatic or mild symptoms in hospital isolation wards. As the speed of infections accelerated, they began to put those patients and others exposed to centralised isolation-quarantine facilities. While the daily new cases continued to rise, the CECC shifted the policy and moved patients to home quarantine, coupled with home tests. By 25 April, when the daily new cases reached 3,671 (7-day average), the CECC further relaxed its isolation requirement for those

infected to “3+4” (3 days of home-isolation plus 4 days of restrictions from public gathering or public transportation) while also dramatically reducing its contact tracing efforts. On 27 April, Taiwan began to replace its contact tracing with a Bluetooth-based mobile phone Taiwan Social Distance App. On 1 May, the CECC introduced the online voluntary case registration system to supplement the previous active case registration system.

To relieve the healthcare facilities from massive testing needs, the CECC also began distributing a limited number of free COVID home testing kits in mid-April. However, the severe shortage of rapid test kits is an example of the CECC’s inadequate advanced planning for the transitional phase. Its slow response can also be attributed to the continuing challenges of disinformation attacks. Moreover, a small segment of politicians and citizens who are wilful accomplices to China’s propaganda relentlessly criticise the government’s policy, similar to the spring outbreak of 2021.

Taiwan’s unique type of vaccine hesitancy did not help. By 4 May, while 80.3% of Taiwan’s residents were fully vaccinated, only 72.9% of those 75 and older were fully vaccinated. The elderly’s lower vaccination rate further complicated the CECC’s new “living with COVID” policy. While Taiwan’s key policymakers and most public health experts share consensus on the policies to live with COVID safely, protecting the under-vaccinated elderly has been a key roadblock. The CECC’s control measures continue to treat everyone equally irrespective of their vaccination status, implying vaccines are useless, which contradicts its promotion for vaccination. Furthermore, any vaccine mandate should also consider the comparable protective effects of immunity from infection. The CECC’s lack of adaptability resulted in some contradictory policies, including outdoor mask mandates while allowing dining in restaurants and strict border quarantine. At the same time, the domestic spread was far more severe than in most nations.

Taiwan needs to re-examine its outdated and contradictory policies based on previous SARS-CoV-2 strains, which are ineffective in facing the Omicron variant, which should be treated as a different disease. Instead of tracking cases and containing the spread that has been proven futile for most nations, Taiwan should prioritise its resources to protect the vulnerable from developing severe symptoms or death by early treatment of symptomatic vulnerable patients. At the same time, reserve testing for health workers or those living with the vulnerable while minimising disruptions to work and schools. Singapore’s plan for the “living with COVID” strategy, from its introduction in 2021 of the 1-2-3 protocol on how to live with COVID in relaxed control measures and its adaptation to the Omicron wave in early 2022, provided a helpful model for Taiwan to adopt.

Taiwan has some catching up and needs to rapidly develop a new exit strategy to cruise through the transitional phase safely. However, suppose Taiwan can invigorate its policy of early planning to embrace the transitional phase. In that case, it can again transform the nation toward a post-pandemic era and become a global pioneer in living with COVID safely and equitably to reconstruct the pandemic shattered world.

Chunhuei Chi is the Director at the Center for Global Health and Professor in the Global Health Programme and Health Management and Policy Programme at Oregon State University

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