Taiwan hit its target of administering the first dose of a coronavirus vaccine to 25% of the population before the end of July, but herd immunity remains a long way off.
In roughly eight weeks, Taiwan’s vaccination rate has increased from less than 1% to more than 30%. Large donations from Japan (3.34 million doses of the AstraZeneca vaccine) and the U.S. (2.5 million doses of Moderna) have been instrumental to the campaign, as have government efforts to inoculate the most vulnerable among the population.
The vaccination drive has come alongside a semi-lockdown that has helped corral Taiwan’s first severe local COVID-19 outbreak. Cases have fallen from around 500 a day in late May to less than 20. The Central Epidemic Command Center (CECC) lowered the national alert level from Level 3 to Level 2 on July 27.
Yet much work remains to reach herd immunity, the point when enough of a country’s population is protected from an infectious disease – either through inoculation or immunity acquired from a prior infection – that it no longer poses a serious public health danger. Dr. Anthony Fauci, director of the U.S.’ National Institute of Allergies and Infectious Diseases, has said that at least 75% of the U.S. population would need to be vaccinated for the country to reach herd immunity. The number might be as high as 85%.
In inoculating its own population, Taiwan faces some particular obstacles. Unlike the U.S., a major vaccine producer with a large surplus of shots, Taiwan lacks sufficient vaccines. To fully vaccinate (two shots) 75% of the population, it needs about 35 million doses, or nearly 40 million for 85%.
However, prior to the government’s announcement in late July of a new order of 36 million Moderna shots, Taiwan had only ordered 20 million vaccines from global manufacturers and taken delivery of 3 million of them. Delivery from COVAX, the World Health Organization’s (WHO) vaccine initiative, has been severely delayed globally due to production interruptions, such as the one in the Serum Institute of India. The severity of the COVID-19 outbreak in India this spring caused the Indian government to ban vaccine exports.
In addition, a failed deal to order vaccines from BioNTech earlier in the year temporarily left Taiwan more than 5 million doses short of what it had originally planned, although non-governmental actors have since stepped in to procure a collective 15 million doses from the German biotech firm’s official distributor in China.
Since Taiwan initially did not order many vaccines, it is feeling the supply shortage acutely. “Compared to the U.S. or Canada, where advanced purchase agreements have been made with many vaccine manufacturers in larger volumes, Taiwan’s approach in procuring vaccines is quite conservative,” says Dr. Jason Wang, director of the Center for Policy, Outcomes and Prevention at Stanford University.
While Taiwan has committed to developing domestic COVID-19 vaccines, that process has challenges of its own. Of the two local vaccine makers, United Biomedical Inc. (UBI) and Medigen, the latter has received emergency use authorization (EUA) from the Taiwanese government, but neither of the vaccines has yet gone through phase III clinical trials. Provided that the trials prove successful, the vaccines will still need to be authorized internationally.
Dr. Chan Chang-chuan, dean of the College of Public Health at National Taiwan University and an epidemiologist, says that Taiwan made several miscalculations in its vaccine strategy. On the one hand, the government was hesitant to bet big on new and as yet unproven mRNA vaccines from global producers. On the other, he believes that it went ahead with a domestic vaccine program without allocating sufficient resources.
“No small companies like our domestic vaccine producers can run a very efficient phase III clinical trial by themselves,” he says. “That’s not an easy task.”
Chan notes that the Pfizer-BioNTech, AstraZeneca, and Moderna vaccines all involve partnerships between large medical companies and the federal governments of major developed countries. Pointing to Pfizer and BioNTech’s decision to team up, he says that “BioNTech has the technology and backing of the German federal government, but they don’t know how to conduct a large-scale phase III trial. Pfizer does though.”
While AstraZeneca’s vaccine was developed in collaboration with the University of Oxford, Chan notes that the UK government provided considerable funding – £84 million (US$115.5 million) – to Oxford to undertake the project.
In Moderna’s case, the U.S. government invested about US$6 billion in the vaccine produced by the Cambridge, Massachusetts-based biotechnology firm. That government support has been vital to Moderna’s success, Chan says. “They have the whole NIH [the National Institutes of Health] behind them. It’s one of the world’s top medical research centers.”
Given the pandemic’s severity in the U.S. and Europe, policymakers in those places felt a sense of urgency about launching vaccines. The situation was different in Taiwan. In late February, Premier Su Tseng-chang said that Taiwan was not in a hurry to purchase COVID-19 vaccines because it had contained the pandemic well, allowing people to carry on normal lives. At the time, the island had recorded less than 1,000 cases – almost all of them imported – and had a seven-day case average of fewer than three cases per day.
Such was the sense of safety in Taiwan that the AstraZeneca vaccine had few takers among the first priority group of medical workers when the first orders arrived in the late winter and early spring. The government opened vaccination to all age groups in late April to prevent the doses from expiring and going to waste. Many Taiwanese at the time worried more about possible side effects of the vaccine than being infected with SARS-CoV-2, the virus that causes COVID-19.
“The perceived risk from the vaccine was magnified by various media reports,” says Wang of Stanford. “This changed soon after the May outbreak.”
One doctor with many years of experience in Taiwan’s healthcare sector told Taiwan Business TOPICS that the government should have done more to dispel misleading information about the AstraZeneca vaccine. “According to the data, the risk of suffering adverse effects [from the vaccine] is not so high. But the government did very little to educate the public about vaccines,” said the doctor, who requested anonymity because of the sensitivity of the subject matter.
Before Taiwan began experiencing community transmission of COVID-19, a gradualist vaccine approach may have seemed feasible. But the virus’s volatile nature and ability to breach even the strongest defenses meant that a major local outbreak was likely only a matter of time.
When it finally came in mid-May, Taiwan had vaccinated just 0.1% of the population. “We were in a mentality of complacency. We were so proud of our border control policy,” Chan says.
The art of procurement
Taiwan’s border controls remain strict, with all arrivals required to quarantine for 14 days in a government-approved hotel and take three different COVID-19 tests. However, unlike in earlier stages of the pandemic, Taiwan feels a sense of urgency to vaccinate its population.
To that end, the government has allowed private companies and non-profit organizations to assist with vaccine procurement. Hon Hai Precision Industry (commonly known as Foxconn) and Taiwan Semiconductor Manufacturing Co. (TSMC), Taiwan’s two largest listed companies, said in mid-July that they would each buy 5 million doses of the Pfizer-BioNTech vaccine for US$175 million directly from the manufacturer and donate them to the government. The vaccines will be shipped directly to Taiwan from Germany with the original labeling intact, as required by the Taiwanese government. The deal was announced in a statement by Shanghai Fosun Pharmaceutical Group (Fosun), BioNTech’s Chinese sales agent. Fosun has exclusive rights to distribute BioNTech’s vaccine in China, Hong Kong, Macau, and Taiwan.
The announcement ended a nearly five-month standoff during which the Taiwanese government alleged that interference from China caused BioNTech to scupper the original deal it had reached with the government in February for 5.5 million vaccines. In May, Minister of Health and Welfare Chen Shih-chung said that although a transaction was close to completion, there was a last-minute dispute over how to refer to Taiwan in the Chinese and English press releases, after which negotiations stalled. Media in Taiwan named a specific executive at BioNTech as being the key person who blocked Taiwan’s purchases on Beijing’s behalf.
Some observers were less than satisfied with that explanation. “The Taiwan government could build a stronger case by providing additional proof such as written evidence,” says Ross Darrell Feingold, a Taipei-based political risk analyst and lawyer. “Otherwise, the public is left to rely on verbal statements by government officials and anonymously sourced media reports.”
According to remarks posted on Facebook by Foxconn founder Terry Gou, his company’s procurement of the BioNTech vaccine was smooth. “Since we proposed the vaccine donation and started negotiating for the purchase, there had been no guidance or interference from Beijing over the acquisition,” Gou wrote in a July 12 post.
Less than two weeks after Foxconn and TSMC reached their respective agreements with BioNTech, the Hualien-based Buddhist humanitarian organization Tzu Chi Foundation announced it had signed a deal with Fosun to purchase 5 million doses of the vaccine. Like the two contract electronics manufacturing giants, Tzu Chi will donate the vaccines to the government.
Taiwan plans to use the 15 million Pfizer-BioNTech jabs to first inoculate students aged 12-18 as it is currently the only vaccine approved for adolescents in the U.S. and Europe. Cabinet spokesman Lo Ping-cheng said in mid-July that those shots will be sufficient until late this year or early 2022 and that the government will not provide ad hoc approval for any further procurement plans.
Meanwhile, many questions remain about Taiwan’s domestic COVID-19 vaccines, especially as the government has signed contracts to purchase 5 million doses from each of the manufacturers. Both Medigen and UBI declined to comment for this report.
On July 20, Medigen announced it had received permission from Paraguay’s top medical regulator to conduct a 1,000-person phase III clinical trial in the South American country for its COVID-19 vaccine. The trial will compare recipients of the Medigen and AstraZeneca vaccines by measuring the concentration of neutralizing antibodies in each group.
This technique, first proposed by the WHO earlier this year and known as immunobridging, has been criticized as an inadequate substitute for traditional efficacy data. Taiwan is the first country to use it in lieu of phase III trial data, although the European Union and South Korea are both considering using the technique. The U.S. FDA has not expressed an official stance on the matter.
The trial size, meanwhile, is small relative to others carried out for COVID-19 vaccines. Moderna’s phase III trial had 30,000 participants while Pfizer-BioNTech’s had 44,000.
“Safety and efficacy need to be established for a massive population rollout to reassure the public and to prevent vaccine hesitancy,” Stanford’s Wang says of Taiwan’s domestic COVID-19 vaccines. “Smaller-scale vaccination with a domestic vaccine may be necessary if there is a domestic outbreak and Taiwan runs out of U.S. and UK vaccines. The Taiwan FDA and CDC would need to decide on this based on scientific evidence.”
The road to reopening
As of late July, Taiwan is awaiting delivery of tens of millions of vaccines. More deals could yet be signed. Johnson & Johnson, whose single-dose COVID-19 vaccine is authorized for emergency use in the U.S., Europe, and some other countries, said in a statement to Taiwan Business TOPICS that the company is in ongoing discussions with the Taiwanese government and is “exploring how best to accelerate our ability to deliver our COVID-19 vaccine to the people of Taiwan.”
The sooner Taiwan obtains sufficient vaccines, the sooner it can reduce COVID-19 to a manageable threat and begin reopening the country. But because of slow delivery, it has to stretch out the time between the first and second doses it gives to its people. For instance, the current time between shots of Moderna in Taiwan is up to 10 weeks, compared to the 28 days recommended by the U.S. CDC.
One dose of any of the COVID-19 vaccines offers limited protection against the highly transmissible Delta variant of the virus, first detected in India. According to a study published in May by Public Health England, a single dose of either the AstraZeneca or Pfizer-BioNTech vaccine is just 33% effective against symptomatic disease caused by the Delta variant.
Former Vice President Chen Chien-jen, an epidemiologist who played an instrumental role in Taiwan’s early success containing COVID-19, said in late July that Taiwan should accelerate its inoculation campaign. Speaking at the BIO Asia-Taiwan 2021 online event, Chen said that he hoped 65% of Taiwan’s population could get the first shot within three months.
Full vaccination could take much longer to achieve, unless vaccine supply stabilizes and orders arrive more expeditiously. Currently, just 1.34%% of the Taiwanese population is fully vaccinated.
Still, Taiwan should start thinking now about reopening, experts say. Although the Taiwanese economy is expected to grow more than 5% this year on the back of strong export growth, the travel industry and others that support it – taxis, for instance – are hurting. Taiwan is also largely cut off from the world at a time when its star is rising on the global stage.
A key first step would be revision of the current 14-day hotel quarantine for all arrivals, which makes no distinction between the vaccinated and unvaccinated. Fully vaccinated arrivals, if given multiple COVID-19 tests that all yield negative results, could potentially leave quarantine after five days, says NTU’s Chan.
“Our vitality relies on having a lot of international exchanges. We have to be more flexible,” says NTU’s Chan.
Taiwan previously experimented with five-day quarantines for short-term business travelers from countries deemed as low risk for COVID-19.
“Taiwan needs to consider shortening quarantine for those who are fully vaccinated with Pfizer, Moderna, or AZ,” says Stanford’s Wang, adding that other WHO-approved vaccines could also be accepted.
“The risks for those who are fully vaccinated in getting or spreading the disease is very low,” he says. “The decision needs to be made based on both the scientific evidence on vaccine efficacy and the economic impact of prolonged border closures.”