Assistant Professor Shih-Chi Ku

Director of Medical Intensive Care Units

Department of Internal Medicine

National Taiwan University Hospital, Taiwan

Since the World Health Organization (WHO) announcement on the classification of coronavirus disease 2019 (COVID-19) outbreak as a pandemic in March 2020, more than 12 million positive cases and 549,000 deaths have been reported worldwide (as of 9 July 2020).¹ Despite Taiwan’s close proximity to the outbreak’s epicentre in China, Taiwan has maintained a strikingly lower number of confirmed cases (449 cases and 7 deaths, as of 9 July 2020) compared with its neighbouring countries.²

Assistant Professor Shih-Chi Ku, the Director of Medical Intensive Care Units at the National Taiwan University Hospital, shares his experience as one of those on the frontline in the fight against the devastating COVID-19.

Q1: What are the characteristics and clinical outcomes of adult and paediatric patients hospitalised with COVID-19 at your institution? What about elderly patients?

In Taiwan, the majority of patients hospitalised with COVID-19 are adult patients, and 80% of cases presented with mild symptoms. These patients are also relatively younger in age and do not have comorbidities. The most common symptoms are the loss of taste and smell, as well as diarrhoea; the majority did not have respiratory symptoms.

We have managed three elderly patients at our medical centre who were critically ill and intubated and were admitted to the intensive care unit (ICU). Two of them were aged over 50 years and one over 65 years old. Similar to COVID-19 cases in other countries, old age and presence of comorbidities such as diabetes, hypertension and history of smoking are risk factors for severe disease. Two of the mentioned cases at our institution had hypertension and history of smoking.

The youngest COVID-19 patients at our institution was 16 years old. It is inferred that the lower expression of angiotensin converting enzyme 2 (ACE2) receptors amongst younger population offers protection against COVID-19.

Q2: As patients with COVID-19 may present with concurrent community-acquired pneumonia, are empiric antibiotics given for suspected cases?

Patients with COVID-19 pneumonia often present with respiratory symptoms and abnormal findings on chest X-ray with the presence of pulmonary infiltration. There may be atypical presentations including scanty production of sputum, low-grade fever, and normal white blood cell count. In such cases, physicians would prescribe a broad-spectrum antibiotic to cover atypical pathogens such as Mycoplasma pneumoniae or the antiviral agent oseltamivir for influenza. Essentially, physicians would usually prescribe empiric antibiotics for suspected community-acquired pneumonia.

Q3: Given the absence of licensed vaccines or antivirals for the prevention and treatment of COVID-19, how has Taiwan – or your institution in particular – managed patients with COVID-19? Are there any specific guidelines for the management of these patients?

The antiviral agent remdesivir has just been approved for COVID-19 treatment. During the clinical trial phase, our institution was one of the participating institutions and seven out of our 17 confirmed COVID-19 cases have received remdesivir treatment according to the criteria set.

In Taiwan, we adopt the interim guidelines developed by experts in our country – which refer to international guidelines. While most guidelines serve as a reminder for clinicians to be cautious in managing patients, the standard-of-care according to evidence-based medicine is crucial in patient management.

Our COVID-19 guideline being ‘interim’ is a struggle for clinicians as it is not a finalised version. Ultimately, clinicians should weigh up the benefits and risks of treatment and find a balance. For instance, one of our critically ill COVID-19 patients experienced a cytokine storm and was given anti-IL-6 therapy because of the devastating clinical course.

Q4: How are patients with underlying or comorbid conditions being managed? Are there any changes to their treatment plan?

I am a pulmonologist and specialise in intensive care medicine. We have encountered issues concerning the use of inhaled corticosteroid for asthmatic patients or patients with chronic obstructive pulmonary disease (COPD). During the COVID-19 pandemic, the media have reported concerns about patients who use steroids being more susceptible to COVID-19.

However, from the perspective of disease control, patients should remain on their existing treatment and not withdraw/discontinue due to fear of COVID-19 infection. As such, it is important for patients to continue receiving treatment for their underlying conditions. For instance, hypertensive patients should continue receiving ACE2 inhibitors even though this class of drugs might pose a higher risk of COVID-19 infection. In this case, the benefits of disease control outweigh the risk of getting infected. An exception would be for patients with autoimmune diseases or cancer because they receive immunosuppression therapy or chemotherapy. These are patients who are truly more susceptible to COVID-19 infection. While clinicians should be more cautious when treating COVID-19 patients with comorbidities, their treatment strategy should remain unchanged and focus on educating patients on self-management.

For the rest of the community, it is important to adhere to the advisories on maintaining social distance, mask wearing, and hand hygiene.

Q5: Taiwan has been lauded as a role model for its pandemic management. What are the key success factors of Taiwan in controlling the COVID-19 pandemic? Could you share your experience from the perspective of a medical centre in Northern Taiwan?

Firstly, Taiwan has done well early in the pandemic with border control and entry ban on visitors from China. These were implemented as early as the beginning of February 2020. In fact, many experts have estimated that Taiwan would have the second highest number of cases in the world due to the country’s proximity to China. Secondly, Taiwan has an active surveillance for all incoming visitors – they were required to report their health condition; those who were feeling unwell were also attended to immediately at the airport for virus testing. In the community, Taiwan has learnt from the severe acute respiratory syndrome (SARS) experience 17 years ago to ensure that the everyone maintains social distancing and wears mask at all times.

Furthermore, citizens hold a National Insurance card in which travel history is recorded – a crucial piece of information during doctor-patient consultation. Clinicians would be alerted and pay more attention to patients who have travelled to countries affected by COVID-19. Another key successful factor is the compliance of the public to the government’s advisories to minimise the risk of COVID-19 spread.

In the context of our institution, outpatients with travel history to high-risk countries and those presenting with symptoms will be referred to special clinics that treat suspected COVID-19 cases. Testing will be done at these clinics – patients will be advised to self-monitor health conditions and stay home until test results become available. While positive cases will be admitted to the hospital for further treatment, those who tested negative will be required to self-quarantine for 14 days. I would say our outpatient clinic is well organised in the surveillance of patients.

As for patients presenting with travel history and fitting clinical features at the emergency department (ED), frontline experts will convene to discuss whether these are suspected cases and isolate them accordingly. By means of isolating suspected cases, the risk of spread in the hospital will be minimised. Therefore, infection control is important. Learning from our SARS experience, some cases started from the ED because patients were not isolated immediately, resulting in hospital spread. Hence, this time around, we take the approach to isolate suspected cases to reduce spread. This is done similarly at all our referral centres.

In addition, while patients needed to test negative twice consecutively before being discharged in some countries, Taiwan has a stricter measure of having patients test negative thrice consecutively. However, this has resulted in longer hospital stay – with the longest being 80 days. Later on, when patients are discharged, they are still required to self-monitor for 14 days. This is to ensure minimal community spread.

We have done a good job on containing the COVID-19 infection. However, the challenge we now face is to reconcile between international exchange and resurgence of COVID-19.

References:

1. Johns Hopkins University. COVID-19 dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University. Available at: https://coronavirus.jhu.edu/map.html. Accessed 9 July 2020.
2. Ministry of Foreign Affairs, Republic of China (Taiwan). Coronavirus disease (COVID-19) outbreak. Available at: https://www.mofa.gov.tw/en/theme.aspx?n=635352E3900FFF8E&s=8A33013523400F35&sms=BCDE19B435833080. Accessed 9 July 2020.