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Since long-term exposure to PM2.5 is a growing concern in Taiwan, therefore, our study aimed to investigate the association between different PM2.5 concentrations and cause-specific mortalities, as well as explore the influence of demographic, socio-economic, and geographic determinants on mortality. Utilizing a Distributed Lag Non-Linear Model (DLNM), we estimated the PM2.5-attributable mortality burden among the elderly population (above 65 years) in Taiwan from 2005 to 2018. Our analysis considered various thresholds defined by the World Health Organization (WHO) to assess the impact of PM2.5 concentrations, ranging from standard Air Quality Guidelines (AQG) levels (0–15 μg/m3) to higher interim targets (up to 80 μg/m3). Our study reveals that achieving AQG levels (< 15 μg/m3) in Taiwan could potentially prevent 5571 elderly deaths, including 889 deaths from CVDs, 934 deaths from RTIs, and 680 deaths from chronic diseases. We observed a rapid increase in attributable deaths at lower PM2.5 concentrations, with a subsequent marginal increase at higher levels of exposure. We also identified several factors that modify the effects of PM2.5 exposures among elderly. For example, we found that higher elderly population ratios and high-income households were associated with an elevated risk of PM2.5-related deaths. In contrast, higher social welfare expenditure, better availability of medical practitioners per square kilometer, and higher forest-to-land ratios were associated with positive effects, indicating their potential in reducing mortality risk. This study fills a knowledge gap by examining the health consequences of varying PM2.5 levels and explored the complex interplay between demographic, socio-economic, and geographic factors in relation to PM2.5-related mortality. [ABSTRACT FROM AUTHOR]

During 2012–2017, a total of 1,144 highly pathogenic avian influenza (HPAI) H5 outbreaks were reported in Taiwan. We conjectured the current 3‐km radius of the post‐outbreak containment policy could fail to effectively alleviate the current ongoing epidemics of HPAI H5 in Taiwan. The high intensity of localized transmission of HPAI H5 at certain focal hotspots was identified to follow the spatial distribution of poultry‐raising locations through our hotspot analyses on the HPAI H5 outbreak locations from 2015 to 2017. We then applied 3‐, 5‐ and 7‐km circular buffer zones to 15,444 registered poultry‐raising locations to inspect the characteristics of the poultry‐raising neighbourhood. Three spatial regression models using Bayesian inference were established to infer the risks attributable to poultry‐raising characteristics in the corresponding buffer areas. The different buffer radii were treated as a sensitivity analysis of the influential range of neighbouring farms on the HPAI H5 outbreak occurrence, so as to evaluate the effective radius for post‐outbreak containment. Evidence showed that the risks of outbreak occurrence were associated with increasing numbers of poultry‐raising locations in both 3‐km (relative risk [RR] 1.005, 95% confidence interval [CI] 1.002–1.008) and 5‐km buffer areas (RR 1.005, 95% CI 1.004–1.007), whereas in the 7‐km buffer model, no association between densely populated locations and increasing risks of outbreaks was observed (RR 1.000, 95% CI 0.999–1.001). Therefore, an extension to a 7‐km radius for the post‐outbreak containment policy (rather than a 3‐km radius as in the current policy) is recommended to effectively mitigate further spreading of HPAI H5 outbreaks among neighbouring farms. Overall, we demonstrated that the densely populated locations with multiple poultry species raised in proximity as defined with 3‐, 5‐ and 7‐km buffer areas facilitated H5 HPAI outbreak diffusion and shaped the scale of HPAI H5 epidemics in Taiwan. [ABSTRACT FROM AUTHOR]

A resurgence of scarlet fever has caused many pediatric infections in East Asia and the United Kingdom. Although scarlet fever in Taiwan has not been a notifiable infectious disease since 2007, the comprehensive national health insurance data can still track its trend. Here, we used data from the open data portal of the Taiwan Centers for Disease Control. The scarlet fever trend was measured by outpatient and hospitalization rates from 2009 to 2017. In order to elucidate the spatio-temporal hotspots, we developed a new method named the spatio-temporal Gi* statistic, and applied Joinpoint regression to compute the annual percentage change (APC). The overall APCs in outpatient and hospitalization were 15.1% (95% CI: 10.3%-20.2%) and 7.7% (95%CI: 4.5% -10.9%). The major two infected groups were children aged 5–9 (outpatient: 0.138 scarlet fever diagnoses per 1,000 visits; inpatient: 2.579 per 1,000 visits) and aged 3–4 (outpatient: 0.084 per 1,000 visits; inpatient: 1.469 per 1,000 visits). We found the counties in eastern Taiwan and offshore counties had the most hotspots in the outpatient setting. In terms of hospitalization, the hotspots mostly occurred in offshore counties close to China. With the help of the spatio-temporal statistic, health workers can set up enhanced laboratory surveillance in those hotspots. [ABSTRACT FROM AUTHOR]

Employment of migrant care workers (MCWs) is increasing, globalising, and is feminised, but the style, nature and extent of MCW policy in Taiwan is very different. This study explores the specific path for MCW policies amidst the globalisation of MCWs and analyses the intersection of the care, migration and employment regimes and compares these to South Korea’s and Japan’s migrant worker policies. This gives a deeper understanding of the formation and transition for Taiwan’s MCW policy. The similarities and uniqueness of Taiwan MCW policy are discussed in this study. [ABSTRACT FROM PUBLISHER]

The increasing dengue burden and epidemic severity worldwide have highlighted the need to improve surveillance. In non-endemic areas such as Taiwan, where outbreaks start mostly with imported cases from Southeast Asia, a closer examination of surveillance dynamics to detect cases early is necessary. To evaluate problems with dengue surveillance and investigate the involvement of different factors at various epidemic stages, we investigated 632 laboratory-confirmed indigenous dengue cases in Kaohsiung City, Taiwan during 2009–2010. The estimated sensitivity of clinical surveillance was 82.4% (521/632). Initially, the modified serological surveillance (targeting only the contacts of laboratory-confirmed dengue cases) identified clinically unrecognized afebrile cases in younger patients who visited private clinics and accounted for 30.4% (35/115) of the early-stage cases. Multivariate regression indicated that hospital/medical center visits [Adjusted Odds Ratio (aOR): 11.6, 95% confidence interval (CI): 6.3–21.4], middle epidemic stage [aOR: 2.4 (1.2–4.7)], fever [aOR: 2.3 (2.3–12.9)], and musculo-articular pain [aOR: 1.9 (1.05–3.3)] were significantly associated with clinical reporting. However, cases with pruritus/rash [aOR: 0.47 (0.26–0.83)] and diarrhea [aOR: 0.47 (0.26–0.85)] were underreported. In conclusion, multiple factors contributed to dengue surveillance problems. To prevent a large-scale epidemic and minimize severe dengue cases, there is a need for integrated surveillance incorporating entomological, clinical, serological, and virological surveillance systems to detect early cases, followed by immediate prevention and control measures and continuous evaluation to ensure effectiveness. This effort will be particularly important for an arbovirus, such as Zika virus, with a high asymptomatic infection ratio. For dengue- non-endemic countries, we recommend serological surveillance be implemented in areas with high Aedes mosquito indices or many breeding sites. Syndromic surveillance, spatial analysis and monitoring changes in epidemiological characteristics using a geographical information system, as well as epidemic prediction models involving epidemiological, meteorological and environmental variables will be helpful for early risk communication to increase awareness. [ABSTRACT FROM AUTHOR]

The largest nosocomial outbreak of Middle East respiratory syndrome (MERS) occurred in South Korea in 2015. Health Care Personnel (HCP) are at high risk of acquiring MERS-Coronavirus (MERS-CoV) infections, similar to the severe acute respiratory syndrome (SARS)-Coronavirus (SARS-CoV) infections first identified in 2003. This study described the similarities and differences in epidemiological and clinical characteristics of 183 confirmed global MERS cases and 98 SARS cases in Taiwan associated with HCP. The epidemiological findings showed that the mean age of MERS-HCP and total MERS cases were 40 (24~74) and 49 (2~90) years, respectively, much older than those in SARS [SARS-HCP: 35 (21~68) years, p = 0.006; total SARS: 42 (0~94) years, p = 0.0002]. The case fatality rates (CFR) was much lower in MERS-HCP [7.03% (9/128)] or SARS-HCP [12.24% (12/98)] than the MERS-non-HCP [36.96% (34/92), p<0.001] or SARS-non-HCP [24.50% (61/249), p<0.001], however, no difference was found between MERS-HCP and SARS-HCP [p = 0.181]. In terms of clinical period, the days from onset to death [13 (4~17) vs 14.5 (0~52), p = 0.045] and to discharge [11 (5~24) vs 24 (0~74), p = 0.010] and be hospitalized days [9.5 (3~22) vs 22 (0~69), p = 0.040] were much shorter in MERS-HCP than SARS-HCP. Similarly, days from onset to confirmation were shorter in MERS-HCP than MERS-non-HCP [6 (1~14) vs 10 (1~21), p = 0.044]. In conclusion, the severity of MERS-HCP and SARS-HCP was lower than that of MERS-non-HCP and SARS-non-HCP due to younger age and early confirmation in HCP groups. However, no statistical difference was found in MERS-HCP and SARS-HCP. Thus, prevention of nosocomial infections involving both novel Coronavirus is crucially important to protect HCP. [ABSTRACT FROM AUTHOR]

• This is a large cohort study consisting of 385,650 adults aged ≥18 years in Taiwan. • PM 2.5 was associated with higher risk of gastrointestinal cancer mortality. • PM 2.5 was associated with higher risk of liver and colorectal cancers mortality. Information on the association between long-term exposure to PM 2.5 and gastrointestinal cancer mortality is scarce. This study investigated the association between long-term exposure to PM 2.5 and deaths from gastrointestinal cancer and its subtypes in adults in Taiwan. A total of 385,650 Taiwanese adults (≥18 years old) jointed a standard medical examination program between 2001 and 2014 and were followed up until 2016. Their vital data were obtained from the National Death Registry maintained by the Ministry of Health and Welfare in Taiwan. We estimated the ambient PM 2.5 concentration at individual's address utilising a satellite-based spatiotemporal model at a resolution of 1 km2. Cox proportional hazard regression model was used to investigate the associations between ambient PM 2.5 and deaths from gastrointestinal, stomach, colorectal and liver cancers. We found that each 10 µg/m3 increase in PM 2.5 was associated with an increased hazard risk (HR) of 1.09 (95% confidence interval (CI): 1.03–1.16) and 1.13 (95%CI: 1.02–1.24) in deaths from gastrointestinal and liver cancers, respectively. The association between PM 2.5 and death from colorectal cancer was marginally statistically significant [HR: 1.13 (95%CI: 1.00–1.26)]. We did not find significant associations between PM 2.5 and mortality from stomach cancer. Long-term exposure to ambient PM 2.5 was associated with an increased risk of deaths from gastrointestinal cancers, liver cancer and also potentially colorectal cancer. Air pollution control strategies are necessary to reduce the burden of gastrointestinal cancer. [ABSTRACT FROM AUTHOR]

To evaluate class suspension and mass vaccination implemented among Taipei schoolchildren during the 2009 influenza pandemic and investigate factors affecting antibody responses. We conducted 2 cohort studies on: (1) 972 schoolchildren from November 2009–March 2010 to evaluate pandemic policies and (2) 935 schoolchildren from November 2011–March 2012 to verify factors in antibody waning. Anti-influenza H1N1pdm09 hemagglutination inhibition antibodies (HI-Ab) were measured from serum samples collected before vaccination, and at 1 and 4 months after vaccination. Factors affecting HI-Ab responses were investigated through logistic regression and generalized estimating equation. Seroprevalence of H1N1pdm09 before vaccination was significantly higher among schoolchildren who experienced class suspensions than those who did not (59.6% vs 47.5%, p<0.05). Participating in after-school activities (adjusted odds ratio [aOR]=2.47, p=0.047) and having ≥3 hours per week of exercise (aOR=2.86, p=0.019) were significantly correlated with H1N1pdm09 infection. Two doses of the H1N1pdm09 vaccine demonstrated significantly better antibody persistence than 1 dose (HI-Ab geometric mean titer: 132.5 vs 88.6, p=0.047). Vaccine effectiveness after controlling for preexisting immunity was 86% (32%-97%). Exercise ≥3 hours per week and preexisting immunity were significantly associated with antibody waning/maintenance. This study is the first to show that exercise and preexisting immunity may affect antibody waning. Further investigation is needed to identify immune correlates of protection. [ABSTRACT FROM AUTHOR]

• Prior infection and vaccination enhance post-vaccination influenza antibody responses. • Pre-vaccination antibody levels determine the effect of booster immunization. • Annual TIV vaccination for schoolchildren prevents influenza virus infection. The objective of this study was to evaluate the effects of prior-infection and repeated vaccination on post-vaccination antibody titers. A(H1N1)pdm09 strain was included in 2009 pandemic monovalent, 2010–2011, and 2011–2012 trivalent influenza vaccines (MIVpdm09, TIV10/11, TIV11/12) in Taiwan. During the 2011–2012 influenza season, we conducted a prospective sero-epidemiological cohort study among schoolchildren from grades 1 – 6 in the two elementary schools in Taipei with documented A(H1N1)pdm09 vaccination records since 2009. Serum samples were collected at pre-vaccination, 1-month, and 4-months post-vaccination (T1, T2, T3). Anti-A(H1N1)pdm09 hemagglutination inhibition titers (HI-Ab-titers) were examined. We also investigated the impact of four vaccination histories [(1) no previous vaccination (None), (2) vaccinated in 2009–2010 season (09v), (3) vaccinated in 2010–2011 season (10v), and (4) vaccinated consecutively in 2009–2010 and 2010–2011 seasons (09v + 10v)] and pre-vaccination HI-Ab levels on post-vaccination HI-Ab responses as well as adjusted vaccine effectiveness (aVE) against serologically-defined infection from T2 to T3. TIV11/12 had zero serious adverse events reported. A(H1N1)pdm09 strain in TIV11/12 elicited seroprotective Ab-titers in 98% of children and showed promising protection (aVE: 70.3% [95% confidence interval (CI): 51.0–82.1%]). Previously unvaccinated but infected children had a 3.96 times higher T2 geometric mean titer (T2-GMT) of HI-Ab than those naïve to A(H1N1)pdm09 (GMT [95% CI]: 1039.7[585.3–1845.9] vs. 262.5[65.9–1045], p = 0.046). Previously vaccinated children with seroprotective T1-Ab-titers had a higher T2-GMT and a greater aVE than those with non-seroprotective T1-Ab-titers. Repeatedly vaccinated children had lower T2-GMT than those receiving primary doses of TIV11/12. However, after controlling prior infection and T1-Ab-titers, differences in T2-GMT among the four vaccination histories became insignificant (p = 0.16). This study supports the implementation of annual mass-vaccination with A(H1N1)pdm09 in schoolchildren for three consecutive influenza seasons when vaccine and circulating strains were well matched, and found that prior infection and pre-vaccination HI-Ab levels positively impacted post-vaccination HI-Ab responses. [ABSTRACT FROM AUTHOR]

• Taiwan avoided lockdowns while most citizens adopted preventive behaviors. • Public health responses to 2020 COVID-19 are more effective than those to 2003 SARS. • Facemask-wearing, hand hygiene, and immunity bundled can serve as population-blockade. • Preventive behaviors and vaccination must exceed viral transmission threshold. To evaluate the prevalence of infection prevention behaviors in Taiwan—wearing facemasks and alcohol-based hand hygiene (AHH)—and compare their practice rates during SARS and COVID-19. We surveyed 2328 Taiwanese from July 29 to August 6, 2020, assessing demographics, information sources, and preventive behaviors during the 2003 SARS outbreaks, 2009 pandemic influenza H1N1, COVID-19, and with post-survey intentions. Characteristics associated with the practice of preventive behaviors in 2020 were identified through logistic regression. Preventive behaviors were conscientiously practiced by 70.2% of participants. Compared with 2003 SARS/2009 H1N1, the percentages of facemask use (66.6% vs 99.2% [indoors], P < 0.001) and on-person AHH (44.2% vs 65.4% [hand sanitizers], P < 0.001) significantly increasedduring 2020 COVID-19. Highest adherence to preventive behaviors in 2020 was among females (adjusted odds ratio [aOR], 1.72), those receiving government COVID-19 information (aOR, 1.52), participants recruited from primary-care clinics (aOR, 1.43), and those who practiced AHH during 2003 SARS/2009 H1N1 (aOR, 1.37). Government leadership, healthcare providers risk communication, and public cooperation rapidly mitigated the spread of COVID-19 in Taiwan even before vaccination. Future global efforts must implement such population-based preventive behaviors at a level above the viral-transmission-threshold, particularly in areas with fast-spreading SARS-CoV-2 variants. [ABSTRACT FROM AUTHOR]