The Coronavirus Disease 2019 (COVID-19) is caused by a highly transmissible and pathogenic coronavirus, which is known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that emerged in China in late 2019, and now has five major variants: Alpha, Beta, Gamma, Delta, and Omicron.

The COVID-19 pandemic has lasted for two and a half years since it was declared as a Public Health Emergency of International Concern (PHEIC) on January 30, 2020, and has registered about 576.3 million cases and 6.4 million deaths worldwide as of July 31, 2022. In this article, I used COVID-19 statistics reported by OurWorldInData.org to describe pandemic response outcomes.

Deaths from Alpha and BA.2 Omicron outbreaks

First, I used a seven-day rolling average of daily COVID-19 deaths to describe pandemic response outcomes over the past two and a half years in Taiwan. A seven-day rolling average was used to obtain a more stable estimate of daily deaths irrespective of any actual variation of COVID-19 deaths from day to day by OurWorldInData.org.

I, then, used the cumulative number of COVID-19 deaths per million people to compare Taiwan’s pandemic response outcome against the world's and Asia's averages and key Asia-Pacific countries. To account for differences in the population size between different countries, the number of COVID-19 deaths per million people was used to compare statistics between countries by OurWorldInData.org.

Taiwan reported a total of 4.59 million COVID-19 cases and 8,927 deaths as of July 31, 2022. Taiwan has had two major COVID-19 outbreaks so far, the Alpha outbreak from May to Sept. 2021, and the BA.2 Omicron outbreak from May 2022, which is still going on.

The seven-day rolling average of daily COVID-19 deaths ranged from 1.57 on May 23 to 1.29 on Sept. 25, with a peak of 26.29 on June 6 during the 2021 Alpha wave in Taiwan, according to OurWorldInData.org. There were about 830 COVID-19 deaths in four months during this Alpha variant outbreak in Taiwan. The seven-day rolling average of daily COVID-19 deaths ranged from 1.29 on April 30 to 50.71 on July 31, with a peak of 192.14 on June 11 during the 2022 Omicron wave in Taiwan, according to OurWorldInData.org.

There were about 8,000 COVID-19 deaths in 3 months during this BA.2 Omicron variant outbreak in Taiwan. How does Taiwan's pandemic response outcomes compare to other countries? As of July 31, 2022, cumulative COVID-19 deaths were 374.14 per million in Taiwan, which is lower than the world’s average of 809.21 per million, but higher than Asia’s average of 309.62 per million.

Deaths per million among Asia-Pacific countries

As of July 31, 2022, cumulative COVID-19 deaths per million are all lower than the world’s average for 10 major Asia-Pacific countries, Indonesia (573.48), Philippines (533.25), South Korea (483.66), Australia (457.74), Vietnam (442.12), India (373.98), New Zealand (292.8), Singapore (275.05), Japan (261.68), and China (3.67).

Among these 10 major Asia-Pacific countries, cumulative COVID-19 deaths per million in New Zealand, Japan, Singapore, and China are all lower than Asia’s average. Regardless of strict control measures, prolonged border controls, and universal mask mandates, Taiwan’s pandemic response outcomes do not match with regional average performance and fall behind several neighboring countries after two and a half years of the pandemic.

Why is the COVID-19 pandemic response outcome in Taiwan higher than Asia’s average and those in New Zealand, Japan, Singapore, and China in terms of cumulative COVID-19 deaths per million? This is mostly due to the around 100 times increase in COVID-19 deaths during this ongoing BA.2 Omicron outbreak in 2022 compared to the Alpha outbreak in 2021.

Taiwan’s cumulative COVID-19 deaths per million surpassed China’s figures on May 28, 2021 during the Alpha outbreak; Asia’s average on June 10, 2022; Singapore’s and Japan’s figures on June 27, 2022; and India's figures on July 31, 2022 for the ongoing BA.2 Omicron outbreak. If Taiwan’s COVID-19 mortality continues to stay at such levels for another month, Taiwan’s cumulative COVID-19 deaths per million will soon match those of South Korea, Australia, and Vietnam.

Why lag behind

What are the reasons for Taiwan’s mediocre performance in containing its COVID-19 deaths in comparison to peer countries in the Asia-Pacific region? One probable explanation is that population immunization status was insufficient to protect Taiwan’s population when the Alpha and BA.2 Omicron outbreaks occurred. The government’s late procurement of effective vaccines led to comparatively low vaccination coverage among the population, especially the vulnerable population of elderly and children, at the beginning of these two outbreaks in Taiwan.

Another possibility is that COVID-19 cases were not fully and timely confirmed by incomprehensive and infrequent disease surveillance during these two outbreaks. Late deployment of community-based active surveillance programs using PCR and ART testing kits led to delayed case findings and timely and proper medical care among infected patients.

The other reason could be attributed to the government's complacency and citizens’ fatigue in COVID-19 response and control measures in this protracted pandemic. Government over-confidence in continuously tightening border controls to fend off intrusion of new variants of SARS-CoV-2 virus to Taiwan, and unpreparedness to loosen non-pharmaceutical interventions have led to fast spread of BA.2 Omicron in the community and into a spike in COVID-19 cases, and eventually turned into high COVID-19 mortality during the BA.2 Omicron outbreak.

Countries with past pandemic experience can usually do better to meet the challenge of new disease outbreaks by putting lessons into pandemic preparedness. Taiwan was able to react quickly to COVID-19 early in 2020 because we learned tragic lessons from the 2003 SARS epidemic. What lessons can we learn from Taiwan’s mediocre performance in containing BA.2 when we are facing the threat of BA.5 in coming months?

Take the right actions against BA.5

The next step of COVID-19 control should take a more aggressive approach that Taiwan has not used before, while maintaining measures that have been effective so far. To achieve the pandemic control goal of low infection and low mortality, I recommend the following effective actions to be taken now to prepare for a probable BA.5 outbreak in the fall and winter of 2022.

First, vaccinating the entire population fully by completing 3-dose vaccines for children and 4-dose vaccines for adults as early as possible. Second, expanding SARS-CoV-2 virus surveillance by conducting PCR testing for children at nurseries, kindergartens, elementary schools, and elderly at long-term care facilities daily; and wastewater in cities and counties weekly; and increasing genomic surveillance among COVID-19 confirmed cases.

Third, providing antiviral treatments to confirmed cases at point-of-care facilities nationwide. Fourth, harmonizing testing, quarantine, and isolation guidelines for confirmed cases, close contact and overseas arrivals by requiring universal PCR/ART testing for 2 weeks to redesign quarantine and isolation duration and location.

Lastly, requirements for masking should remain for indoor public spaces and outdoor crowded gatherings, and building ventilation should be improved to keep indoor CO2 concentrations below 600 ppm for restaurants, gyms, nurseries, long-term care facilities, and hospitals.