The first four reported cases of the novel Coronavirus Disease (COVID-19) were seen on December 29, 2019 from local hospitals in Wuhan, Hubei Province, China . Within 24 hours, Taiwan officials went on to check arriving planes from Wuhan to assess passengers with fever, respiratory symptoms, and stringent contact history before deplaning in active effort to mitigate the spread of the disease . From these initial cases, the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has grown to become a pandemic, has reached 200 countries worldwide and has more than 3.4 million confirmed cases, causing almost 240,000 deaths . International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) have recommended postponement of all elective Bariatric and Metabolic Surgery (BMS) during the pandemic . It was recommended to use only essential items for emergency and urgent cases to minimize the risk of Healthcare workers (HCW) transmission. As of April 8, 2020, nearly 22,073 cases of infected HCW from 52 countries had been reported by the World Health Organization (WHO) .
In this study, we review the impact of an evolving pandemic on our elective operations, the timely and necessary precautions made by our government and institution to prevent and contain its spread and finally, suggestions to adapt to these critical times.
Preparations for the Pandemic
Containing an outbreak at an early stage affords a greater chance of success than does a delayed response and clearly puts less strain on the healthcare system. In 2004, the year after the SARS outbreak, the Taiwan government established the National Health Command Center (NHCC). It includes the Central Epidemic Command Center (CECC), the Biological Pathogen Disaster Command Center, the Counter-Bioterrorism Command Center, and the Central Medical Emergency Operations Center . It is part of a disaster management center that focuses on large-outbreak response and acts as the operational command point for direct communications among central, regional, and local authorities. Taiwan from its experience, has a head start of 16 years in terms of pandemic protocols, chain of command and systematic network of communications among government agencies and hospitals .
Early key decisions, Detection and Mitigation
On January 05, 2020, CECC had started reporting passengers from Wuhan with fever and/or upper respiratory tract infections with issuance of flight Alert Level 2 and 3. On January 20, the CECC was fully activated and all its agencies had started analyzing data coming inside and outside of Taiwan. On 21st January, the CECC confirmed its first case of COVID19, a 55-year-old female born in Southern Taiwan with a history of travel from Wuhan, making her the world’s first non-Chinese national diagnosed with the disease . On 23rd January, Wuhan residents were banned and travellers from China were made to submit electronic declaration of health prior to entry. This was followed by bans of direct flights from provinces of Guangdong and Zhejiang and tour groups to Hongkong and Macau were suspended. By 6th February, all Chinese nationals and International cruise ships were banned. Foreign nationals with travel to China, Hong Kong, or Macau in the past 14-days were likewise banned .
On 31st January, Taiwan government hastened production of surgical masks in anticipation of its increase in demand, to protect the HCW and most importantly to prevent the spread of the virus. They distributed and limited 3 surgical mask per person per week to all citizens. By February 02, they were able to produce 10 million mask/day. Commercial stores and pharmacies are not allowed to sell surgical masks . Taiwan was one of the first nations to ban its HCW from non-essential travel overseas by February 24th. They have not only timely prevented the possible exposure of HCWs from other countries who might have early COVID-19 cases or asymptomatic carriers but likewise anticipated the increase in need of this essential human resources in time of pandemic. All HCWs in BMIMC are provided with official scrub suits that are solely maintained by the hospital itself. Upon entry in the hospital, they must change their attires. Upon exit from the operating room, they are to leave with a different color coded scrub suits. Upon end of rounds, clinic and/or ward work, scrub suits are left in the hospitals. These measures minimize possible viral load both going inside and outside the center from our HCWs attires. All HCWs are required to wear surgical masks both inside and outside the hospital (depending on Taiwan government daily advisory). The Infectious Control Committee of the China Medical University Hospital (CMU) gathered travel history of all HCWs for the past 14 days beginning February 24. All HCWs with any risk factors and/or having signs and symptoms of fever, difficulty of breathing and upper respiratory tract infection (URTI) are advised to go to the CMUH-Emergency Room (ER)-Isolation Tents. Mandatory COVID-19 testing via Reverse transcription polymerase chain reaction (RT-PCR) were likewise done for HCWs with travel history to Alert Level 3 countries. If found positive results, they are managed accordingly and if found negative, they are advised home quarantine for 14 days, record their temperatures twice a day and watch out for signs and symptoms of URTI before returning to work.
One Entrance: One Exit. CMUH building has directed the inflow and outflow of all patients in a single designated entrance and exit. This has narrowed the possibility of missing a possible COVID-19 suspected case if there were multiple entrance and exits. Thermal scanners were strategically placed, a confirmatory individual checking of body temperature via contactless thermometer. Patients with more than 36.80C are not allowed to enter the building and directed to the CMUH ER as mentioned. All patients and their companion’s hands are sprayed with 70% alcohol. Taiwan has only 429 confirmed cases, 6 deaths (1.39% case fatality rate), 322 recoveries (75.05% recovery rate) and has no documented “community transmission” of COVID-19 . On April 30, 2020, Taiwan CECC has reported 6 consecutive days without a new confirmed case and a total of 19 days for April without local transmission . Part of the success behind Taiwan’s fight against COVID-19 is the positive outlook, dynamism, learning from the past experience and initiative of the people of Taiwan and compliance with the government's efforts to fight the disease according to Premier Su . Using Big Data Analytics, Taiwan has successfully contained the spread of the SARS-COV-2 by mobile position data (Contact Tracing). In conjunction with GPS, credit card transaction, and health record they are able to locate a COVID-suspect person and they are able to identify those who had contact with him/her within 500 meters leading to an effective contact tracing. Taiwan has likewise intensified its search for possible unidentified COVID-19 cases. By reviewing all medical health record of patients in National Health Insurance database, they can establish who were hospitalized due to pneumonia. For those hospitalized but had not been tested for SARS-CoV- 2, the local health care providers were informed and screening for SARS-CoV-2 was suggested .