Taiwan 's Coronavirus Disease 2019 Research Articles

Clinical Features and Vaccination Effects among Children with Post-Acute Sequelae of COVID-19 in Taiwan.

Post-acute sequelae of SARS-CoV-2 infection (PASC) affects patients after recovering from acute coronavirus disease 2019 (COVID-19). This study investigates the impact of SARS-CoV-2 vaccination on PASC symptoms in children in Taiwan during the Omicron pandemic. We enrolled children under 18 years with PASC symptoms persisting for more than 4 weeks. Data collected included demographics, clinical information, vaccination status, and symptom persistence. We used logistic regression models to compare symptoms in the acute and post-COVID-19 phases and to assess the association between vaccination and these symptoms. Among 500 PASC children, 292 (58.4%) were vaccinated, 282 (52.8%) were male, and the mean (SD) age was 7.6 (4.6) years. Vaccinated individuals exhibited higher odds of experiencing symptoms in the previous acute phase, such as cough (adjusted odds ratio [AOR] = 1.57; 95% confidence interval [CI]: 1.02-2.42), rhinorrhea/nasal congestion (AOR = 1.74; 95% CI: 1.13-2.67), sneezing (AOR = 1.68; 95% CI: 1.02-2.76), sputum production (AOR = 1.91; 95% CI: 1.15-3.19), headache/dizziness (AOR = 1.73; 95% CI: 1.04-2.87), and muscle soreness (AOR = 2.33; 95% CI: 1.13-4.80). In contrast, there were lower odds of experiencing abdominal pain (AOR = 0.49; 95% CI: 0.25-0.94) and diarrhea (AOR = 0.37; 95% CI: 0.17-0.78) in children who had received vaccination during the post-COVID-19 phase. This study revealed clinical features and vaccination effects in PASC children in Taiwan. Vaccination may reduce some gastrointestinal symptoms in the post-COVID-19 phase.

The experiences of public health nurses during the COVID-19 in Taiwan: A qualitative study.

The coronavirus disease 2019 (COVID-19) pandemic has had a substantial effect on frontline health care workers and caused public health nurses (PHNs) to come under various forms of pressure. PHNs face high-risk challenges in their work environment, and their professional commitment and adaptability are key concerns. The aim of this qualitative study was to describe the experiences of PHNs during the COVID-19 outbreak. Twenty PHNs who worked during the COVID-19 outbreak were recruited from seven public health centres through posters. Data were collected through in-depth interviews that comprised semi-structured and open-ended questions; subsequently, the data were analysed through content analysis. Three themes emerged from the study findings, namely (1) the disorderliness of COVID-19 pandemic prevention work, (2) managing stress and fear, and (3) the establishment of a new normal. Because of the severity of the pandemic, the workload and stress associated with epidemic prevention policies continue to increase. PHNs may infect their family members and experience a sense of alienation and distance. They must also deal with irrationality and reactions in the people within their community. Health department directors and policymakers should provide the necessary support and assistance to frontline pandemic prevention workers to increase the efficiency of pandemic prevention efforts. The participants agreed to participate in the qualitative study during the study period.

To PCR or not? The impact of shifting policy from PCR to rapid antigen tests to diagnose COVID-19 during the omicron epidemic: a nationwide surveillance study.

Coronavirus disease 2019 (COVID-19) had caused huge impacts worldwide. Polymerase chain reaction (PCR) is the mainstay diagnostic modality. In most hospitals in Taiwan, samples for PCR are collected at emergency department (ER) or outdoor clinics to avoid virus spread inside hospitals. Home rapid antigen test (RAT) is a feasible, low-cost, and convenient tool with moderate sensitivity and high specificity, which can be performed at home to reduce hospital visits. Due to comparably low severity of omicron variant and high vaccine coverage (~80% residents fully vaccinated with AstraZeneca, Moderna, or Pfizer BioNTech COVID-19 vaccines as of March 2022), the policy was shifted from containment to co-existing with COVID-19 in Taiwan. Virus spread rapidly in the community after the ease of social restrictive measurements. To acquire a confirmed diagnosis, PCR testing was requested for people with suspected COVID-19 infection. As a consequence, people with respiratory symptoms or contact history surged into hospitals for PCR testing, thus, the medical capacity was challenged. The diagnostic policy was altered from PCR to RAT, but the impact of diagnostic policy change remains unclear. We conducted this study to investigate the number of COVID-19 cases, PCR testing, hospitalizations, mortalities, and hospital visits during the epidemic and evaluate the impact of diagnostic policy change on hospital visits. The diagnostic policy change was implemented in late May 2022. We used nationwide and hospital-based data of COVID-19 cases, PCR testing, hospitalizations, mortalities, and hospital visits before and after policy change as of 31 Jul 2022. During the omicron epidemic, significant and synchronous increase of COVID-19 patients, PCR testing, hospital visits were observed. COVID-19 cases increased exponentially since April 2022 and the COVID-19 patients peaked in June (1,943, 55,571, and 61,511 average daily new cases in April, May, and June, respectively). The PCR testing peaked in May (85,788 daily tests) with high positive rate (81%). The policy of RAT as confirmatory diagnosis was implemented on 26 May 2022 and a substantial decline of PCR testing numbers occurred (85,788 and 83,113 daily tests in May and June). People hospitalized for COVID-19 peaked in June (821.8 patients per day) and decreased in July (549.5 patients). The mortality cases also peaked in June (147 cases/day). This trend was also validated by the hospital-based data with a significant decrease of emergency department visits (11,397 visits in May while 8,126 visits in June) and PCR testing (21,314 in May and 6,158 in June). The proportion of people purely for PCR testing also decreased (10-26 vs. 5-14%, before and after policy change, respectively). The impact of diagnostic policy change was a complicated issue and our study demonstrated the huge impact of diagnostic policy on health seeking behavior. The PCR testing numbers and emergency department visits had substantial decrease after diagnostic policy change, and the plateau of epidemic peak eased gradually in ~1 month later. Widespread RAT application may contribute to the decreased hospital visits and preserve medical capacity. Our study provides some evidences for policy maker's reference.

Correlates ofthe Veterans Visiting Emergency Departments inTaiwan: A Comparison Before andAfter the Coronavirus Disease 2019 Pandemic.

Taiwan has a substantial number of veterans, but knowledge regarding their emergency department (ED) visits during the coronavirus disease 2019 (COVID-19) pandemic remains limited. This study examined the characteristics of veterans' ED visits during Taiwan's COVID-19 epidemic. This was a cross-sectional study conducted at the ED of a large veteran medical center located in Taipei, Taiwan, from May 2018 to October 2021. We analyzed the numbers and features of visits in summer and autumn according to the first wave of the COVID-19 epidemic in Taiwan in 2021. Medical institutions were positively associated with veteran status. Emergency department complaints of trauma (adjusted odds ratio [AOR] = 1.15, 95% CI: 1.06-1.25; summer P < .01) and chest pain/tightness (AOR = 1.65, 95% CI: 1.45-1.87; summer P < .01; AOR = 1.4, 95% CI: 1.26-1.55; P < .01) were associated with increased odds of being a veteran. Triage levels above 2 were positively associated with veteran status in the autumn model (AOR = 1.14, 95% CI: 1.07-1.22; P < .01). Patients hospitalized after ED visits were associated with reduced odds of veteran status (P < .01). Those who spent a long time in the ED were more likely to be veterans than those who spent a shorter time in the ED (P < .01). Veterans were less likely to visit the ED regardless of the time frame of the study period (P < .01), except during the COVID-19 outbreak in the autumn (2019-2020). The distinctions in ED visits highlighted the individuality of veterans' medical needs. Our findings suggest that the veteran medical system can add to the focus on improving senior-friendly care, fall prevention, quality of life of institutionalized veterans, access for homeless veterans, and care for ambulatory care-sensitive conditions.

Impact of COVID-19 Outbreak on Influenza and Pneumococcal Vaccination Uptake: A Multi-Center Retrospective Study.

During the coronavirus disease 2019 (COVID-19) pandemic, global vaccination efforts declined due to the burden on health systems and community resistance to epidemic control measures. Influenza and pneumococcal vaccines have been recommended for vulnerable populations to prevent severe pneumonia. We investigated community response towards influenza and pneumococcal vaccines (pneumococcal conjugate vaccine and pneumococcal polysaccharide vaccine) after the COVID-19 outbreak in Taiwan. We retrospectively included adults who visited Chang Gung Memorial Hospital (CGMH) institutions for influenza or pneumococcal vaccination from January 2018 to December 2021. The first case of COVID-19 in Taiwan was detected in January 2020; therefore, in this study, hospitalized cases from January 2018 to December 2019 were defined as "before COVID-19 outbreak," and hospitalized cases from January 2020 to December 2021 were defined as "after COVID-19 outbreak". A total of 105,386 adults were enrolled in the study. An increase in influenza vaccination (n = 33,139 vs. n = 62,634) and pneumococcal vaccination (n = 3035 vs. n = 4260) were observed after the COVID-19 outbreak. In addition, there was an increased willingness to receive both influenza and pneumococcal vaccinations among women, adults without underlying disease and younger adults. The COVID-19 pandemic may have increased awareness of the importance of vaccination in Taiwan.

Disease burden due to COVID-19 in Taiwan: Disability-adjusted life years (DALYs) with implication of Monte Carlo simulations

BackgroundThe novel coronavirus disease 2019 (COVID-19) has affected a large number of countries. Informing the public and decision makers of the COVID-19′s economic burdens is essential for understanding the real pandemic impact. MethodsCOVID-19 premature mortality and disability impact in Taiwan was analyzed using the Taiwan National Infectious Disease Statistics System (TNIDSS) by estimating the sex/age-specific years of life lost through death (YLLs), the number of years lived with disability (YLDs), and the disability-adjusted life years (DALYs) from January 2020 to November 2021. ResultsTaiwan recorded 1004.13 DALYs (95% CI: 1002.75–1005.61) per 100,000 population for COVID-19, with YLLs accounting for 99.5% (95% CI: 99.3%99.6%) of all DALYs, with males suffering more from the disease than females. For population aged ≥ 70 years, the disease burdens of YLDs and YLLs were 0.1% and 99.9%, respectively. Furthermore, we found that duration of disease in critical state contributed 63.9% of the variance in DALY estimations. ConclusionsThe nationwide estimation of DALYs in Taiwan provides insights into the demographic distributions and key epidemiological parameter for DALYs. The essentiality of enforcing protective precautions when needed is also implicated. The higher YLLs percentage in DALYs also revealed the fact of high confirmed death rates in Taiwan. To reduce infection risks and disease, it is crucial to maintain moderate social distancing, border control, hygiene measures, and increase vaccine coverage levels.

Clinical features and characteristics of pediatric patients with COVID-19 infection: Experiences in a Tertiary Taiwan Hospital.

Coronavirus disease 2019 (COVID-19) patients have distinct clinical features in the pediatric groups. However, there is a paucity of research focused on clinical manifestation within pediatric group in Taiwan. This study is to conduct a retrospective study of the clinical features of COVID-19 in Taiwan pediatric patients.A retrospective study was conducted on pediatric patients (Aged ≤ 18 years) in a Northern Taiwan hospital from May 1st, 2021 to June 30th, 2021. Thirty-eight patients were included from emergency room. They were laboratory confirmed COVID-19 through specimens from nasopharyngeal swab by real-time reverse-transcription polymerase chain reaction (RT-PCR). Data including RT-PCR cycle threshold (Ct) values, clinical and epidemiological features were collected and analyzed.Thirty-eight patients aged from 7-month to 18-year-old were included. The median age of patients was 15-year-old. The patients had sex ratio of 23 males to 15 females. More than half patients were infected from family members. Asymptomatic patients were 47.37%. In the symptomatic patients, fever (34.21%) was the most predominant symptom. Cough, nasal obstruction and sore throat were also common. Asymptomatic children had significantly higher Ct-values than symptomatic children, and diagnosed patients with Ct-values more than 19 were associated with asymptomatic infection (P = .0084).Ct-values higher than 19 were associated with asymptomatic infection, which may be a predictor of pediatric disease severity. Our results highlight the distinct clinical manifestations and outcomes in pediatric COVID-19 patients. Compared to the adults, pediatric patients aged ≤ 18 years with COVID-19 in Taiwan mainly had mild disease.

Comparison of Clinical Characteristics and Outcomes of Hospitalized Patients Infected with the D614G Strain or Alpha Variant of COVID-19 in Taiwan: A Multi-Center Cohort Study

Objective: Direct comparison of the clinical traits of coronavirus disease 2019 (COVID-19) in strain D614G, which originated from Wuhan, China, and the Alpha variant, which contains 17 mutations, infected patients could help physicians distinguish between strains and make clinical decisions accordingly. This study sought to compare the clinical characteristics and outcomes of the D614G strain and Alpha variant of SARS-COV-2 and identify the predictors for viral RNA clearance and in-hospital mortality in patients with COVID-19. Methods: This study recruited consecutive patients from four hospitals between March 1, 2020, and July 31, 2021. Demographic characteristics, laboratory results, and clinical outcomes were determined. Results: Among the 239 enrolled patients, 11.2% (27/239) were infected with strain D614G and 88.7% (212/239) were infected with the Alpha variant. There were no significant differences in disease progression, rate of respiratory failure, subsequent development of acute respiratory distress syndrome (ARDS), acute kidney injury, cardiac injury, duration of stay in the intensive care unit or hospital, discharge rate, mortality rate, or viral RNA clearance time between the two groups. Multivariate Cox regression revealed that antibiotic therapy reduced the risk of delayed viral RNA clearance (hazard ratio [HR], 0.26; 95% confidence interval [CI], 0.13-0.55), while autoimmune disease increased the risk of delayed viral RNA clearance (HR, 3.98; 95% CI, 1.21-13.04). Elderly patients (age > 65 years) and patients with a history of cerebrovascular accident (CVA) were at increased risk of in-hospital mortality (HR, 5.14; 95% CI, 1.06-24.72 and HR, 3.62; 95% CI, 1.25-10.42, respectively). Conclusions: There were no significant differences between the D614G strain and Alpha variant of COVID-19 in terms of clinical characteristics and outcomes. However, factors affecting viral RNA clearance and the risk of in-hospital mortality were identified. These results could help to inform the future prioritization of resource allocation and identify patients in need of intense monitoring.

Integrated Chinese herbal medicine and Western medicine successfully resolves spontaneous subcutaneous emphysema and pneumomediastinum in a patient with severe COVID-19 in Taiwan: A case report

CaseSerious complications of severe coronavirus disease 2019 (COVID-19) include subcutaneous emphysema (SE) and pneumomediastinum, which are complicated to treat with conventional Western medicine. We report how combining Chinese herbal medicine (CHM) with Western medicine quickly resolved a patient's COVID-19-associated pulmonary complications, shortened hospital stay and improved quality of life. Clinical features and outcomeA 59-year-old male with a history of smoking and tumors was diagnosed with COVID-19 in May 2021. At hospitalization, his oxygen saturation (SpO2) was 80%, he had a continuous severe cough, rapid shallow breathing, spontaneous SE and pneumomediastinum. By Day 4 of hospitalization, his condition was worsening despite standard care, so CHM was added. After 3–5 days, his coughing had lessened and supplementary oxygen therapy was de-escalated. Nine days after starting CHM, the SE had completely resolved and the patient avoided intubation. His WHO OS 10-point Scale score had fallen from 6 to 3 points and the modified Medical Research Council Dyspnea Scale score from 4 to 2 points. He was hospitalized for 19 days. At 1 week post-discharge, the patient could handle most of his daily activities and experienced minor shortness of breath only when performing labor-intensive tasks. At 1 month, his work output was restored to pre-COVID-19 levels. ConclusionCHM combined with standard Western medicine improved pulmonary function, respiratory rate, blood oxygen saturation and shortened the hospital stay of a patient with severe COVID-19 complicated by SE and pneumomediastinum.

Epidemiological features of domestic and imported cases with COVID-19 between January 2020 and March 2021 in Taiwan.

Coronavirus disease-2019 (COVID-19) is a global pandemic affecting numerous countries around the world. This study elaborates Taiwan's epidemiological characteristics from the 2020 to 2021 COVID-19 pandemic from human, temporal, and geographical dimensions. Big data for cases were obtained from a public database from the Taiwan Centers for Disease Control (CDC) in April 2021. The data were analyzed and used to compare differences, correlations, and trends for human, temporal, and geographical characteristics for imported and domestic COVID-19 cases. During the study period, 1030 cases were confirmed and the mortality rate of 1.0%. The epidemiological features indicated that most cases (953/1030, 92.5%) were imported. A comparison of the domestic confirmed and imported cases revealed the following findings: No significant difference of COVID-19 between males and females for sex was observed; For age, the risk of domestic transmission was significantly lower for 20 to 29 years old, higher for 50 to 59 years old, and >60 years old with odds ratios (ORs) (P value < .05) of 0.36, 3.37, and 2.50, respectively; For the month of infection, the ORs (P value < .05) of domestic confirmed cases during January and February 2020 were 22.428; and in terms of area of residence, the ORs (P value < .05) for domestic confirmed cases in northern and southern Taiwan were 4.473 and 0.033, respectively. Thus, the increase in domestic cases may have been caused by international travelers transmitting the virus in March 2020 and December 2020, respectively. Taiwan has been implementing effective screening and quarantine measures at airports. Moreover, Taiwan has implemented and maintained stringent interventions such as large-scale epidemiological investigation, rapid diagnosis, wearing masks, washing hands frequently, safe social distancing, and prompt clinical classifications for severe patients who were given appropriate medical measures. This is the first report comparing imported and domestic cases of COVID-19 from surveillance data from the Taiwan Centers for Disease Control during January 2020 and March 2021. It illustrates that individuals infected during overseas travel are the main risk factors for the spread of COVID-19 in Taiwan. The study also highlights the importance of longitudinal and geographically extended studies in understanding the implications of COVID-19 transmission for Taiwan's population.

Factors Related to Caregiver Intentions to Vaccinate Their Children with Attention-Deficit/Hyperactivity Disorder against COVID-19 in Taiwan.

The aims of this study were to examine the proportion of caregivers who were hesitant to vaccinate their children with attention-deficit/hyperactivity disorder (ADHD) against coronavirus disease 2019 (COVID-19) and the factors related to caregiver intentions to vaccinate their children against COVID-19. In total, 161 caregivers of children with ADHD were recruited in this study. The caregivers completed an online questionnaire to provide data regarding their intention to vaccinate their children against COVID-19, concerns about the effectiveness and safety of vaccines, unfavorable family attitudes toward vaccines, and children’s medication use for ADHD and comorbid psychopathology. The factors related to caregiver intentions to vaccinate their child were examined using linear regression analysis. The results indicated that 25.5% of caregivers were hesitant to vaccinate their children with ADHD, and 11.8% refused to vaccinate their children against COVID-19. The caregivers’ concerns about the safety of vaccines and children’s regular use of medication for ADHD were negatively associated with caregiver intentions to vaccinate, whereas the children’s comorbid conduct or oppositional defiant problems were positively associated with the caregiver intentions to vaccinate. An intervention that enhances caregiver intentions to vaccinate their children with ADHD against COVID-19 by addressing the related factors found in this study is warranted.

Differences in the Protection Motivation Theory Constructs between People with Various Latent Classes of Motivation for Vaccination and Preventive Behaviors against COVID-19 in Taiwan.

The present study aimed to identify the distinct classes of motivations to get vaccinated and to adopt preventive behaviors against the coronavirus disease 2019 (COVID-19) among people in Taiwan and to examine the roles of Protection Motivation Theory (PMT) cognitive constructs in these unique classes of motivations to get vaccinated and to adopt preventive behaviors. We recruited 1047 participants by using a Facebook advertisement. Participants’ motivations to get vaccinated and to adopt preventive behaviors against COVID-19, PMT constructs of threat appraisal (perceived severity and perceived vulnerability), and PMT constructs of coping appraisal (self-efficacy, response efficacy, response cost, knowledge, and previous vaccination for seasonal influenza) were determined. We analyzed participants’ motivations to get vaccinated and to adopt preventive behaviors against COVID-19 by using latent profile analysis. The present study identified three latent classes, including the participants with high motivation for vaccination and preventive behaviors (the class of Both High), those with low motivation for vaccination and preventive behaviors (the class of Both Low), and those with high motivation for vaccination but low motivation for preventive behaviors (the class of High Vaccination but Low Preventive Behaviors). Compared with the participants in the class of Both High, participants in the class of Both Low had lower levels of perceived vulnerability, perceived severity, self-efficacy to have vaccination, response efficacy of vaccination, knowledge about vaccination, and previous vaccination for seasonal influenza; participants in the class of High Vaccination but Low Preventive Behaviors had lower levels of perceived vulnerability and perceived severity but higher levels of response cost of vaccination. We concluded that varieties of motivations, threat, and coping appraisals should be considered in intervention programs aiming to increase motivation to adopt recommended protective behaviors against COVID-19.

Taiwan's COVID-19 response: Timely case detection and quarantine, January to June 2020

The coronavirus disease 2019 (COVID-19) pandemic has become severe threats to economic, societal, and healthcare systems. To analyze the epidemiological characteristics of the COVID-19 outbreak in Taiwan and evaluate the key interventions, we conducted a retrospective cohort study during January 17–June 30, 2020. As of June 30, the COVID-19 outbreak, including 447 laboratory-confirmed cases, was eliminated by mixed approaches: border control, enhanced surveillance, case detection with contact tracing, quarantine, and population-based interventions like face mask use. The improvement of median time from disease onset to notification (5 days [range −3 to 27] before March 1 to 1 day [range −8 to 22] after March 1) suggested the timeliness and comprehensiveness of surveillance and contact tracing. Travel restrictions with quarantine, resulting in fewer clusters, were also complementary to minimize disease spread. Under combined interventions, Taiwan successfully contained the COVID-19 spread within the country and minimized its impact on the society.

Preparedness and Contingency Responses of Healthcare System to COVID-19 in Taiwan, 2020

The outbreak of pneumonia caused by novel coronavirus in Wuhan, China began at the end of 2019. World Health Organization named the virus as coronavirus disease 2019 (COVID-19). Afterwards, the pandemic of COVID-19 hit countries worldwide and outbreaks of healthcare-associated infection occurred. The pandemic of COVID-19 is a rigorous challenge to public health and healthcare system in Taiwan. To strengthen the preparedness and response capacity of healthcare system, Taiwan developed 10 contingency strategies for healthcare facilities, long-term care facilities, and laboratories, to reach three major goals: ＂mitigation of the transmission＂, ＂maintenance of the healthcare system operation＂, and ＂reduction of severe and death cases＂. The 10 contingency strategies included: (1) strengthening infection control and biosafety; (2) conducting un-notified on-site inspections and drills on medical responses; (3) tracing and identifying persons at-risk via National Health Insurance database; (4) implementing patient triage and decentralizing in-patients; (5) preparing response hospitals and designated wards; (6) constructing national testing networks; (7) monitoring capacity of healthcare system; (8) expanding capacity of quarantine places; (9) managing visitors to hospitals; and (10) monitoring health status of healthcare workers.

Diabetes care during the outbreak of 2019 novel coronavirus disease (COVID‐19) in Taiwan

Coronavirus disease 2019 (COVID-19) is now a global pandemic which is imposing a heavy burden on medical resources. The total number of reported COVID-19 cases as of April 16, 2020 is more than 2.07 million with 137 666 deaths worldwide, including a total of 395 cases and 6 deaths in Taiwan.1 The first fatal case of COVID-19 in Taiwan occurred on February 16, 2020, and was a taxi driver with no history of travel who was infected by a passenger who had just arrived back from Wuhan, China. This case raised the concerns of clinicians about a higher risk of severe complications and mortality in patients with diabetes mellitus.2 Patients with diabetes are considered to be at high risk of acquired infections, possibly due to poor glucose control. In addition, patients with diabetes have an impaired immune-response to infection both in relation to changes in cytokine profile, T-cell and macrophage activation. Hyperglycemia reduces chemotaxis and the activation of polymorphonuclear neutrophils, and thus diabetic patients have higher rates of morbidity and mortality due to infections. In addition, most patients with diabetes develop co-morbidities over time, including hypertension, dyslipidemia, obesity and cardiovascular disease. The number of comorbidities is a predictor of mortality in patients with COVID-19. Taiwan is one of few nations where the outbreak is still under control, and the Taiwan Centers for Disease Control (CDC) has played an important role by implementing a series of public health policies.1 In this article, we discuss how these policies have affected the routine standard care of diabetes. As there is currently no validated therapy for COVID-19 besides supportive care, preventing infection is the major concern. According to the CDC prevention guidelines, washing hands and wearing a medical-grade face mask if experiencing respiratory symptoms and going to see a doctor are recommended. To decrease the patient's exposure in an institutional setting, clinicians can defer non-urgent laboratory tests in patients with good compliance and stable clinical condition. For those in whom examinations are necessary, clinicians can arrange to have blood drawn on the same day as the return visit or when collecting a repeat prescription. Furthermore, clinicians can consider deferring medical examinations which need close contact, such as funduscopic examinations. It is common in clinical practice for patients to neglect chronic disease control such as diabetes mellitus, causing the condition to become more severe. For example, they may stop taking anti-diabetic medications resulting in acute complications such as diabetic ketoacidosis and hyperosmolarity hyperglycemic crisis. Coronavirus binds to target cells through ACE2, which is expressed in epithelial cells in the lungs, blood vessels and intestine. In patients treated with ACE and angiotensin II receptor blockers, a first-line anti-hypertensive medication for patients with diabetes, the expression of ACE2 is increased,3 which can then accelerate COVID-19 infection and increase the progression of the disease and mortality. Concerned patients may also discontinue anti-hypertensive medication. Therefore, patient education must emphasize the importance of consulting a physician if they have any concerns, and not interrupt diabetes or hypertension treatment on their own. To minimize the possibility of acquiring in-hospital infections in these immunocompromised patients, we set up a temporary outpatient clinic outside the main building with a video call assisted consulting system. We also established an outdoor drive-through pharmacy service to provide medication refills for chronic diseases. Self-monitoring of blood glucose (SMBG) can help clinicians to prescribe medication. If the patient is home quarantined, the results of SMBG can be uploaded to the hospital's platform via a mobile application such as Health2Sync or Rightest CARE, which will then remind the clinical caregiver to give advice to the patients through telemedicine. Although personal protective equipment such as a mask or alcohol-based hand sanitizers are relative available in Taiwan, some patients with diabetes still complain that they cannot buy enough alcohol wipes for sanitization before SMBG or insulin injections. In fact, soapy water is an effective alternative in this situation.4 Flu or pneumococci vaccinations have shown benefits including decreasing hospitalization and death in patients with diabetes.5 In the long term, diabetologists should do their best to encourage their patients to maintain good glycemic control and receive influenza and pneumococci vaccinations to ameliorate the risk of severe complications if they become infected with COVID-19. Social distancing is the mainstream of current public health policy. Diabetologists can achieve this by educating their patients with regards to adequate self-care techniques, maintaining good glycemic control, and timely vaccinations. All authors declare no conflict of interest.

How to Defend COVID-19 in Taiwan? Talk about People's Disease Awareness, Attitudes, Behaviors and the Impact of Physical and Mental Health.

This study explored awareness, attitudes, and behavior in relation to Coronavirus Disease 2019 (COVID-19) prevention among Taiwanese citizens and their physical and mental health statuses. Through collection of 2132 questionnaire responses in field research, the present researchers analyzed the data using descriptive statistics and various approaches. In conclusion, the public’s high level of willingness to share information, sufficient knowledge of and consensus on epidemic prevention between individuals and families, strict compliance with relevant regulations, effective preventive measures, and adequate public facilities have contributed to control of COVID-19. However, vigilance and awareness of the pandemic in some individuals, epidemic-prevention campaigns, and community-based preventive measures were insufficient. Some citizens subsequently suffered from headaches, anxiety, and mood instability. Furthermore, demographic variables (place of residence, sex, age, and occupation) and physical and mental health status produced various effects on citizens’ awareness, attitude, and behavior regarding epidemic prevention as well as the perceived effect of COVID-19 on physical and mental health.

Challenge and strategies of infection control in psychiatric hospitals during biological disasters-From SARS to COVID-19 in Taiwan.

Psychiatric hospitals play an important role in supporting patients with mental illness to relieve symptoms and improve functioning in a physically and psychologically safe environment. However, these hospitals are also vulnerable to emerging infectious diseases. In early 2020, a psychiatric hospital and a psychiatric unit were reported to have nosocomial coronavirus disease 2019 (COVID-19) infection. A large number of patients and staff were severely impacted. This type of nosocomial infection threatens patient safety and quality of care.By learning from previous experiences of severe acute respiratory syndrome (SARS) and previous studies, psychiatric hospitals can provide safeguards to prevent nosocomial infection among patients and staff during an epidemic or biological disaster. These strategies include a series of actions such as following national guidelines for infection control, reserving adequate support for disinfection equipment, providing relevant and sufficient pro-service and in-service education and training, establishing regular surveillance of hand hygiene habits, proper communication and health education, and providing opportunities for vaccination if possible. Based on the harm reduction concept, staff division of office breaks and ward classification and shunting are recommended and should be further implemented.

How is the digestive system affected by coronavirus disease?

How is the digestive system affected by coronavirus disease?

Epidemiological And Clinical Characteristics of The First 18 Patients with COVID-19 in Taiwan

To understand the epidemiological and clinical characteristics of patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection in Taiwan, we analyzed data from the National Notifiable Disease Surveillance System and epidemiological case investigation reports. We included all real-time reverse-transcription polymerase chain reaction (real-time RT-PCR) confirmed cases of coronavirus disease-2019 (COVID-19) from Jan 21 to Feb 14, 2020, and followed up until Feb 27, 2020. Eighteen cases were confirmed and all survived. Median follow-up period was 24.5 days (range: 14-35). Of them, 16 (88.9%) were imported cases, and 2 (11.1%) were infected by imported cases within household. Their median age was 52 years (range: 21-74); 8 (44.4%) were men, and 9 (50%) had comorbidities. Symptoms included cough (72.2%), fever (66.7%), rhinorrhea (22.2%) and diarrhea (11.1%); one patient (5.5%) was asymptomatic. According to the WHO definition of clinical syndromes associated with SARS-CoV-2, there were 8 (44.4%), 9 (50.0%), and 1 (5.6%) categorized as mild, moderate, and severe illness, respectively. At the end of follow-up, 9 cases met the criteria of discontinuation of isolation and 8 of them were discharged. The median time from admission to discontinuation of isolation was 21 days (range: 13-31) and the median duration of persistent RT-PCR positivity was 14 days (range: 4- 22) and 15 days (range: 4-24) for upper and lower respiratory samples, respectively. The first 18 cases of COVID-19 in Taiwan were all imported or importation related, which were related to the early phase of COVID-19 epidemic. Because viral clearance may take more than 2 weeks, management plans for patients with mild illness is necessary to ensure the best use of medical care capacities during the ongoing COVID-19 pandemic.

Intensive Care During a Global Epidemic

The global spread of coronavirus disease 2019 (COVID-19) is rapidly increasing the number of patients who are critically ill with this disease, with the related rate of mortality expected to peak in 2020 (Alhazzani et al., 2020). As severe acute respiratory syndrome is the major cause of mortality after COVID-19 infection, patients with COVID-19 who are prone to severe acute respiratory problems may require mechanical ventilation or extracorporeal membrane oxygenation (ECMO; Alhazzani et al., 2020). Ongoing advances in intensive care medicine are continuing to improve survival in critically ill patients (Kaukonen, Bailey, Suzuki, Pilcher, & Bellomo, 2014). However, intensive care unit (ICU) survivors may experience complications and problems related to their disease and treatment such as critical illness polyneuropathy, critical illness myopathy, and post intensive care syndrome (PICS; Alhazzani et al., 2020). Harvey (2012) reported that 85%-95% of ICU patients have ICU-acquired weakness after ICU discharge and 74% of ICU patients with acute respiratory distress syndrome have cognitive impairment after ICU discharge. Physical disabilities, cognitive impairment, and mental or psychological distress (e.g., anxiety, depression, and post-traumatic stress disorder) after ICU discharge may be symptoms of PICS, and may continue to affect surviving patients for several years after ICU discharge (Elliott et al., 2014; Held & Moss, 2019; Jackson et al., 2014; Jubran et al., 2010). Efforts to prevent and treat COVID-19 in Taiwan have proven more effective compared to most other places in the world. In addition to the low number of diagnosed cases, the mortality rate (seven of 440 confirmed cases) in Taiwan has been significantly lower than in most other countries (Taiwan Centers for Disease Control, ROC, 2020, May 14). However, post-discharge care for ICU survivors, especially those hospitalized after a sudden onset of severe disease symptoms and then discharged after a long ICU stay or after receiving mechanical ventilation, require specialized care to minimize PICS. Nurses are responsible not only for treating patients with the disease but also for preventing the further spread of disease. Therefore, providing continued care to patients discharged from the ICU is essential. Specifically, interventions to avoid PICS must be implemented rapidly by multidisciplinary medical teams during and immediately after ICU discharge.