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1.  The impact on neonatal mortality of shifting childbirth services among levels of hospitals: Taiwan's experience 
There is considerable discussion surrounding whether advanced hospitals provide better childbirth care than local community hospitals. This study examines the effect of shifting childbirth services from advanced hospitals (i.e., medical centers and regional hospitals) to local community hospitals (i.e., clinics and district hospitals). The sample population was tracked over a seven-year period, which includes the four months of the 2003 severe acute respiratory syndrome (SARS) epidemic in Taiwan. During the SARS epidemic, pregnant women avoided using maternity services in advanced hospitals. Concerns have been raised about maintaining the quality of maternity care with increased demands on childbirth services in local community hospitals. In this study, we analyzed the impact of shifting maternity services among hospitals of different levels on neonatal mortality and maternal deaths.
A population-based study was conducted using data from Taiwan's National Health Insurance annual statistics of monthly county neonatal morality rates. Based on a pre-SARS sample from January 1998 to December 2002, we estimated a linear regression model which included "trend," a continuous variable representing the effect of yearly changes, and two binary variables, "month" and "county," controlling for seasonal and county-specific effects. With the estimated coefficients, we obtained predicted neonatal mortality rates for each county-month. We compared the differences between observed mortality rates of the SARS period and predicted rates to examine whether the shifting in maternity services during the SARS epidemic significantly affected neonatal mortality rates.
With an analysis of a total of 1,848 observations between 1998 and 2004, an insignificantly negative mean of standardized predicted errors during the SARS period was found. The result of a sub-sample containing areas with advanced hospitals showed a significant negative mean of standardized predicted errors during the SARS period. These findings indicate that despite increased use of local community hospitals, neonatal mortality during the SARS epidemic did not increase, and even decreased in areas with advanced hospitals.
An increased use of maternity services in local community hospitals occurred during the SARS epidemic in Taiwan. However, we observed no increase in neonatal and maternity mortality associated with these increased demands on local community hospitals.
PMCID: PMC2703635  PMID: 19505330
2.  Quarantine for SARS, Taiwan 
Emerging Infectious Diseases  2005;11(2):278-282.
Quarantine for SARS during the 2003 Taiwan outbreak expedited case detection, thereby indirectly preventing infections.
During the 2003 outbreak of severe acute respiratory syndrome (SARS) in Taiwan, >150,000 persons were quarantined, 24 of whom were later found to have laboratory-confirmed SARS-coronavirus (SARS-CoV) infection. Since no evidence exists that SARS-CoV is infective before the onset of symptoms and the quarantined persons were exposed but not symptomatic, we thought the quarantine's effectiveness should be investigated. Using the Taiwan quarantine data, we found that the onset-to-diagnosis time of previously quarantined confirmed case-patients was significantly shortened compared to that for those who had not been quarantined. Thus, quarantine for SARS in Taiwan screened potentially infective persons for swift diagnosis and hospitalization after onset, thereby indirectly reducing infections. Full-scale quarantine measures implemented on April 28 led to a significant improvement in onset-to-diagnosis time of all SARS patients, regardless of previous quarantine status. We discuss the temporal effects of quarantine measures and other interventions on detection and isolation as well as the potential usefulness of quarantine in faster identification of persons with SARS and in improving isolation measures.
PMCID: PMC3320446  PMID: 15752447
SARS; emerging infectious disease; quarantine; intervention; Taiwan; research
3.  Impact of an outbreak of severe acute respiratory syndrome on a hospital in Taiwan, ROC 
Emergency Medicine Journal : EMJ  2004;21(3):311-316.
Study objective: To estimate the impact of the severe acute respiratory syndrome (SARS) outbreak in early 2003 on a tertiary care hospital in Taiwan, ROC.
Methods: The study estimated the utilisation of resources related to infection control, SARS related medical services, and routine medical services, and SARS related medical outcomes at National Cheng Kung University Hospital (NCKUH) from 25 March to 16 June 2003 through a cross sectional survey of hospital records.
Results: A mean of 5100 persons per day (95%CI 4580 to 5610) underwent fever screening at the outpatient and emergency department (ED) entrances to the hospital, of which 35 per day (95% CI 30 to 40) were referred for further evaluation for suspected or probable SARS. ED isolation surge capacity was created via 12 new beds outside the ED: eight for SARS assessment, three for patients awaiting inhospital bed assignment, and one for resuscitation. A total of 382 patients were fully evaluated for suspected or probable SARS outside the ED, of which 27 were admitted. The mean numbers of outpatient clinic patient visits, ED visits, ED trauma patient visits, ED admissions, hospital admissions, and operative procedures decreased during the outbreak. Thirty eight patients were hospitalised with suspected SARS, of which three received the final diagnosis of probable SARS. Two patients with probable SARS died. No cases of nosocomial SARS transmission occurred.
Conclusions: This SARS outbreak was associated with substantial use of hospital and ED resources aimed at infection control, comparatively less use of resources related to the medical care of patients with suspected or probable SARS, and decreased use of routine medical services.
PMCID: PMC1726342  PMID: 15107369
4.  The immediate effects of the severe acute respiratory syndrome (SARS) epidemic on childbirth in Taiwan 
BMC Public Health  2005;5:30.
When an emerging infectious disease like severe acute respiratory syndrome (SARS) strikes suddenly, many wonder the public's overwhelming fears of SARS may deterred patients from seeking routine care from hospitals and/or interrupt patient's continuity of care. In this study, we sought to estimate the influence of pregnant women's fears of severe acute respiratory syndrome (SARS) on their choice of provider, mode of childbirth, and length of stay (LOS) for the delivery during and after the SARS epidemic in Taiwan.
The National Health Insurance data from January 01, 2002 to December 31, 2003 were used. A population-based descriptive analysis was conducted to assess the changes in volume, market share, cesarean rate, and average LOS for each of the 4 provider levels, before, during and after the SARS epidemic.
Compared to the pre-SARS period, medical centers and regional hospitals dropped 5.2% and 4.1% in market share for childbirth services during the peak SARS period, while district hospitals and clinics increased 2.1% and 7.1%, respectively. For changes in cesarean rates, only a significantly larger increase was observed in medical centers (2.2%) during the peak SARS period. In terms of LOS, significant reductions in average LOS were observed in all hospital levels except for clinics. Average LOS was shortened by 0.21 days in medical centers (5.6%), 0.21 days in regional hospitals (5.8%), and 0.13 days in district hospitals (3.8%).
The large amount of patients shifting from the maternity wards of more advanced hospitals to those of less advanced hospitals, coupled with the substantial reduction in their length of maternity stay due to their fears of SARS could also lead to serious concerns for quality of care, especially regarding a patient's accessibility to quality providers and continuity of care.
PMCID: PMC1084353  PMID: 15804368
5.  Epidemiological and Genetic Correlates of Severe Acute Respiratory Syndrome Coronavirus Infection in the Hospital with the Highest Nosocomial Infection Rate in Taiwan in 2003†  
Journal of Clinical Microbiology  2006;44(2):359-365.
Taiwan experienced a series of outbreaks of nosocomial severe acute respiratory syndrome (SARS) infections in 2003. Two months after the final outbreak, we recruited 658 employees from the hospital that suffered the first and most severe SARS infections to help us investigate epidemiological and genetic factors associated with the SARS coronavirus (SARS-CoV). SARS-CoV infections were detected by using enzyme immunoassays and confirmed by a combination of Western blot assays, neutralizing antibody tests, and commercial SARS tests. Risk factors were analyzed via questionnaire responses and sequence-specific oligonucleotide probes of human leukocyte antigen (HLA) alleles. Our results indicate that 3% (20/658) of the study participants were seropositive, with one female nurse identified as a subclinical case. Identified SARS-CoV infection risk factors include working in the same building as the hospital's emergency room and infection ward, providing direct care to SARS patients, and carrying a Cw*0801 HLA allele. The odds ratio for contracting a SARS-CoV infection among persons with either a homozygous or a heterozygous Cw*0801 genotype was 4.4 (95% confidence interval, 1.5 to 12.9; P = 0.007).
PMCID: PMC1392693  PMID: 16455884
6.  The Impact of Matching Vaccine Strains and Post-SARS Public Health Efforts on Reducing Influenza-Associated Mortality among the Elderly 
PLoS ONE  2010;5(6):e11317.
Public health administrators do not have effective models to predict excess influenza-associated mortality and monitor viral changes associated with it. This study evaluated the effect of matching/mismatching vaccine strains, type/subtype pattern changes in Taiwan's influenza viruses, and the impact of post-SARS (severe acute respiratory syndrome) public health efforts on excess influenza-associated mortalities among the elderly. A negative binomial model was developed to estimate Taiwan's monthly influenza-associated mortality among the elderly. We calculated three winter and annual excess influenza-associated mortalities [pneumonia and influenza (P&I), respiratory and circulatory, and all-cause] from the 1999–2000 through the 2006–2007 influenza seasons. Obtaining influenza virus sequences from the months/years in which death from P&I was excessive, we investigated molecular variation in vaccine-mismatched influenza viruses by comparing hemagglutinin 1 (HA1) of the circulating and vaccine strains. We found that the higher the isolation rate of A (H3N2) and vaccine-mismatched influenza viruses, the greater the monthly P&I mortality. However, this significant positive association became negative for higher matching of A (H3N2) and public health efforts with post-SARS effect. Mean excess P&I mortality for winters was significantly higher before 2003 than after that year [mean ± S.D.: 1.44±1.35 vs. 0.35±1.13, p = 0.04]. Further analysis revealed that vaccine-matched circulating influenza A viruses were significantly associated with lower excess P&I mortality during post-SARS winters (i.e., 2005–2007) than during pre-SARS winters [0.03±0.06 vs. 1.57±1.27, p = 0.01]. Stratification of these vaccine-matching and post-SARS effect showed substantial trends toward lower elderly excess P&I mortalities in winters with either mismatching vaccines during the post-SARS period or matching vaccines during the pre-SARS period. Importantly, all three excess mortalities were at their highest in May, 2003, when inter-hospital nosocomial infections were peaking. Furthermore, vaccine-mismatched H3N2 viruses circulating in the years with high excess P&I mortality exhibited both a lower amino acid identity percentage of HA1 between vaccine and circulating strains and a higher numbers of variations at epitope B. Our model can help future decision makers to estimate excess P&I mortality effectively, select and test virus strains for antigenic variation, and evaluate public health strategy effectiveness.
PMCID: PMC2892467  PMID: 20592764
7.  SARS in Hospital Emergency Room 
Emerging Infectious Diseases  2004;10(5):782-788.
Thirty-one cases of severe acute respiratory syndrome (SARS) occurred after exposure in the emergency room at the National Taiwan University Hospital. The index patient was linked to an outbreak at a nearby municipal hospital. Three clusters were identified over a 3-week period. The first cluster (5 patients) and the second cluster (14 patients) occurred among patients, family members, and nursing aids. The third cluster (12 patients) occurred exclusively among healthcare workers. Six healthcare workers had close contact with SARS patients. Six others, with different working patterns, indicated that they did not have contact with a SARS patient. Environmental surveys found 9 of 119 samples of inanimate objects to be positive for SARS coronavirus RNA. These observations indicate that although transmission by direct contact with known SARS patients was responsible for most cases, environmental contamination with the SARS coronavirus may have lead to infection among healthcare workers without documented contact with known hospitalized SARS patients.
PMCID: PMC3323223  PMID: 15200809
Severe acute respiratory syndrome; healthcare workers; environmental contamination; real-time reverse transcriptase–polymerase chain reaction
8.  The psychological effect of severe acute respiratory syndrome on emergency department staff 
The severe acute respiratory syndrome (SARS) outbreak in 2003 affected 29 countries. The SARS outbreak was unique in its rapid transmission and it resulted in heavy stress in first‐line healthcare workers, particularly in the emergency department.
: To determine the influence of SARS on the psychological status, including post‐traumatic stress disorder (PTSD) symptoms, of the staff in the emergency department.
To investigate whether different working conditions in the hospital led to different psychological effects on healthcare workers, the psychological effect on emergency department staff in the high‐risk ward was compared with that on psychiatric ward staff in the medium‐risk ward. Davidson Trauma Scale‐Chinese version (DTS‐C) and Chinese Health Questionnaire‐12 (CHQ‐12) items were designed to check the psychological status of the staff in the month after the end of the SARS outbreak.
86 of 92 (93.5%) medical staff considered the SARS outbreak to be a traumatic experience. The DTS‐C scores of staff in the emergency department and in the psychiatric ward were significantly different (p = 0.04). No significant difference in CHQ score was observed between the two groups. Emergency department staff had more severe PTSD symptoms than staff in the psychiatric ward.
SARS was a traumatic experience for healthcare providers in Taiwan. Most staff in the emergency department and in the psychiatric ward had PTSD. Emergency department staff had more severe PTSD symptoms than staff in the psychiatric ward.
PMCID: PMC2658141  PMID: 17183035
9.  SARS Outbreak, Taiwan, 2003 
Emerging Infectious Diseases  2004;10(2):201-206.
We studied the severe acute respiratory syndrome (SARS) outbreak in Taiwan, using the daily case-reporting data from May 5 to June 4 to learn how it had spread so rapidly. Our results indicate that most SARS-infected persons had symptoms and were admitted before their infections were reclassified as probable cases. This finding could indicate efficient admission, slow reclassification process, or both. The high percentage of nosocomial infections in Taiwan suggests that infection from hospitalized patients with suspected, but not yet classified, cases is a major factor in the spread of disease. Delays in reclassification also contributed to the problem. Because accurate diagnostic testing for SARS is currently lacking, intervention measures aimed at more efficient diagnosis, isolation of suspected SARS patients, and reclassification procedures could greatly reduce the number of infections in future outbreaks.
PMCID: PMC3322921  PMID: 15030683
severe acute respiratory syndrome; SARS-CoV; infectious diseases; epidemiology; Taiwan; nosocomial infections; quarantine and isolation; prevention and control; theoretical model; effective reproductive number
10.  Dissemination of imipenem-resistant Acinetobacter baumannii with new plasmid-borne blaOXA-72 in Taiwan 
BMC Infectious Diseases  2013;13:319.
The systemic surveillance of imipenem-resistant Acinetobacter baumannii (IRAB) from multicenters in Taiwan revealed the emergence of isolates with blaOXA-72. This study described their genetic makeup, mechanism of spread, and contribution to carbapenem resistance.
Two hundred and ninety-one non-repetitive isolates of A. baumannii were collected from 10 teaching hospitals from different geographical regions in Taiwan from June 2007 to September 2007. Minimal inhibitory concentrations (MICs) were determined by agar dilution. Clonality was determined by pulsed-field gel electrophoresis. Plasmid was extracted and digested by restriction enzymes, and subsequently analyzed by electrophoresis and Southern blot for blaOXA-72. The flanking regions of blaOXA-72 were determined by inverse PCR. The contribution of blaOXA-72 to imipenem MIC was determined by transforming plasmids carrying blaOXA-72 into imipenem-susceptible A. baumannii.
Among 142 IRAB in Taiwan, 27 harbored blaOXA-72; 22 originated from Southern Taiwan, 5 from Central Taiwan, and none from Northern Taiwan. There were two major clones. The blaOXA-72 was identified in the plasmids of all isolates. Two genetic structures flanking plasmid-borne blaOXA-72 were identified and shared identical sequences in certain regions; the one described in previous literature was present in only one isolate, and the new one was present in the remaining isolates. Introduction of blaOXA-72 resulted in an increase of imipenem MIC in the transformants. The overexpression of blaOXA-72 mRNA in response to imipenem further supported the contribution of blaOXA-72.
In conclusion, isolates with new plasmid-borne blaOXA-72 were found to be disseminated successfully in Southern Taiwan. The spread of the resistance gene depended on clonal spread and dissemination of a new plasmid. BlaOXA-72 in these isolates directly led to their imipenem-resistance.
PMCID: PMC3728158  PMID: 23849336
Imipenem-resistant; Acinetobacter baumannii; Carbapenemase; BlaOXA-72
11.  Molecular Epidemiology of the Coronavirus Associated with Severe Acute Respiratory Syndrome: A Review of Data from The Chinese University of Hong Kong 
The Clinical Biochemist Reviews  2004;25(2):143-147.
The epidemic of the severe acute respiratory syndrome (SARS) has swept through the globe with more than 8000 reported probable cases. In Hong Kong, the hardest hit areas included our teaching hospital and the Amoy Gardens apartment complex. A novel coronavirus, SARS-coronavirus (SARS-CoV), with a single-stranded plus sense RNA genome, was promptly implicated as the causative agent and subsequently fulfilled Koch's postulates. To aid the understanding of SARS-CoV, groups of investigators rapidly sequenced viral isolates around the world. We were the third group in the world to release the complete SARS-CoV genome sequence (isolate CUHK-W1) on the world-wide web. With other isolates from patients of distinct epidemiological backgrounds, we additionally sequenced four complete (CUHK-Su10, CUHK-AG01, CUHK-AG02, CUHK-AG03) and two partial SARS-CoV genomes. The reviewed data obtained from representative patients from the hospital and community outbreaks has documented the evolution of the virus in this epidemic. Their sequence variations also revealed a remarkable epidemiological correlation. We demonstrate that sequence variations in the SARS-CoV genome can be applied as a powerful molecular tool in tracing the route of transmission, when used adjunctively with standard epidemiology.
PMCID: PMC1904414  PMID: 18458710
12.  Hospice utilization during the SARS outbreak in Taiwan 
The severe acute respiratory syndrome (SARS) epidemic threw the world into turmoil during the first half of 2003. Many subsequent papers have addressed its impact on health service utilization, but few have considered palliative (hospice) care. The aim of the present study was to describe changes in hospice inpatient utilization during and after the SARS epidemic in 2003 in Taiwan.
The data sources were the complete datasets of inpatient admissions during 2002 and 2003 from the National Health Insurance Research Database. Before-and-after comparisons of daily and monthly utilizations were made. Hospice analyses were limited to those wards that offered inpatient services throughout these two years. The comparisons were extended to total hospital bed utilization and to patients who were still admitted to hospice wards during the peak period of the SARS epidemic.
Only 15 hospice wards operated throughout the whole of 2002 and 2003. In 2003, hospice utilization began to decrease in the middle of April, reached a minimum on 25 May, and gradually recovered to the level of the previous November. Hospices showed a more marked reduction in utilization than all hospital beds (e.g. -52.5% vs. -19.9% in May 2003) and a slower recovery with a three-month lag. In total, 566 patients were admitted to hospice wards in May/June 2003, in contrast to 818 in May/June 2002. Gender, age and diagnosis distributions did not differ.
Hospice inpatient utilization in Taiwan was indeed more sensitive to the emerging epidemic than general inpatient utilization. A well-balanced network with seamless continuity of care should be ensured.
PMCID: PMC1559606  PMID: 16889656
13.  SARS Antibody Test for Serosurveillance 
Emerging Infectious Diseases  2004;10(9):1558-1562.
A standardized and rapid peptide-based SARS assay is characterized for sensitivity and specificity.
A peptide-based enzyme-linked immunosorbent assay (ELISA) can be used for retrospective serosurveillance of severe acute respiratory syndrome (SARS) by helping identify undetected chains of disease transmission. The assay was developed by epitope mapping, using synthetic peptides from the spike, membrane, and nucleocapsid protein sequences of SARS-associated coronavirus. The new peptide ELISA consistently detected seroconversion by week 2 of onset of fever, and seropositivity remained through day 100. Specificity was 100% on normal blood donor samples, on serum samples associated with infection by other pathogens, and on an interference panel. The peptide-based test has advantages of safety, standardization, and automation over previous immunoassays for SARS. The assay was used for a retrospective survey of healthy healthcare workers in Taiwan who treated SARS patients. Asymptomatic seroconversions were detected in two hospitals that had nosocomial disease.
PMCID: PMC3320307  PMID: 15498156
research; SARS-CoV; serologic test; enzyme-linked immunosorbent assay; synthetic peptide; S protein; M protein; N protein; specificity; sensitivity; retrospective study
14.  The rationale of fever surveillance to identify patients with severe acute respiratory syndrome in Taiwan 
Emergency Medicine Journal : EMJ  2006;23(3):202-205.
Study objective
To establish a predictive scoring system and to determine its effectiveness for severe acute respiratory syndrome (SARS) cases confirmed by RT‐PCR in patients with fever.
A study was conducted of 484 consecutive patients seen in the emergency department (ED) of our tertiary care center during the SARS outbreak in Taiwan. The scoring system was divided into triage and screening station stages. Data were analysed with multivariable and logistic regression analysis.
Of 737 patients who presented to our ED for possible SARS from March to June 2003, we enrolled 484 patients with a temperature >38.0°C (>100.3°F) (age >18 years). Dyspnoea, diarrhoea, travel, close contact, hospital exposure, and household history were identified as predictive indicators in the triage stage. The triage score was the total of six items. With a one‐point cutoff value, the sensitivity and specificity were 81.8% (18/22) and 73.6% (340/462). Leukocytosis, thrombocytopenia, lymphopenia, and CXR were identified as predictive indicators in the fever screening stage. Screening station scores (the sum of 10 items) consisted of triage scores, white blood cell count, and CXR. With a three‐point cutoff value, the sensitivity and specificity were 95.5% (21/22) and 87.2% (403/462).
Syndromic and traditional surveillance play a role in early identification of SARS in an endemic area. The SARS scoring system described is easily applicable and highly effective in screening patients during outbreaks.
PMCID: PMC2464446  PMID: 16498157
SARS; RT‐PCR; scoring system; fever; triage
15.  Association of HLA class I with severe acute respiratory syndrome coronavirus infection 
The human leukocyte antigen (HLA) system is widely used as a strategy in the search for the etiology of infectious diseases and autoimmune disorders. During the Taiwan epidemic of severe acute respiratory syndrome (SARS), many health care workers were infected. In an effort to establish a screening program for high risk personal, the distribution of HLA class I and II alleles in case and control groups was examined for the presence of an association to a genetic susceptibly or resistance to SARS coronavirus infection.
HLA-class I and II allele typing by PCR-SSOP was performed on 37 cases of probable SARS, 28 fever patients excluded later as probable SARS, and 101 non-infected health care workers who were exposed or possibly exposed to SARS coronavirus. An additional control set of 190 normal healthy unrelated Taiwanese was also used in the analysis.
Woolf and Haldane Odds ratio (OR) and corrected P-value (Pc) obtained from two tails Fisher exact test were used to show susceptibility of HLA class I or class II alleles with coronavirus infection. At first, when analyzing infected SARS patients and high risk health care workers groups, HLA-B*4601 (OR = 2.08, P = 0.04, Pc = n.s.) and HLA-B*5401 (OR = 5.44, P = 0.02, Pc = n.s.) appeared as the most probable elements that may be favoring SARS coronavirus infection. After selecting only a "severe cases" patient group from the infected "probable SARS" patient group and comparing them with the high risk health care workers group, the severity of SARS was shown to be significantly associated with HLA-B*4601 (P = 0.0008 or Pc = 0.0279).
Densely populated regions with genetically related southern Asian populations appear to be more affected by the spreading of SARS infection. Up until recently, no probable SARS patients were reported among Taiwan indigenous peoples who are genetically distinct from the Taiwanese general population, have no HLA-B* 4601 and have high frequency of HLA-B* 1301. While increase of HLA-B* 4601 allele frequency was observed in the "Probable SARS infected" patient group, a further significant increase of the allele was seen in the "Severe cases" patient group. These results appeared to indicate association of HLA-B* 4601 with the severity of SARS infection in Asian populations. Independent studies are needed to test these results.
PMCID: PMC212558  PMID: 12969506
16.  Identification of vancomycin-resistant enterococci clones and inter-hospital spread during an outbreak in Taiwan 
BMC Infectious Diseases  2013;13:163.
In 2003, nosocomial infections caused by vancomycin-resistant enterococci (VRE) occurred rarely in Taiwan. Between 2003 and 2010, however, the average prevalence of vancomycin resistance among enterococci spp. increased from 2% to 16% in community hospitals and from 3% to 21% in medical centers of Taiwan. We used molecular methods to investigate the epidemiology of VRE in a tertiary teaching hospital in Taiwan.
Between February 2009 and February 2011, rectal samples and infection site specimens were collected from all inpatients in the nephrology ward after patient consent was obtained. VRE strain types were determined by pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST).
A total of 59 vanA gene-containing VRE isolates (1 per patient) were obtained; 24 originated from rectal sample surveillance of patients who exhibited no symptoms (22 Enterococcus faecium and 2 Enterococcus faecalis), and 35 had developed infections over 3 days after admission (32 E. faecium, 2 E. faecalis, and 1 Enterococcus durans). The 59 VRE isolates demonstrated vancomycin minimum inhibitory concentrations (MICs) of ≥256 μg/m. The MIC range for linezolid, tigecycline, and daptomycin was 0.25–1.5 μg/mL, 0.032–0.25 and 1–4 μg/mL, respectively. For 56 isolates, the MIC for teicoplanin was >8 μg/mL. The predominant types in the nephrology ward were MLST types 414, 78, and18 as well as PFGE types A, C, and D.
VREs are endemic in nephrology wards. MLST 414 is the most predominant strain. The increase VRE prevalence is due to cross-transmission of VRE clones ST 414,78,18 by undetected VRE carriers. Because similar VRE STs had been reported in a different hospital of Taiwan, this finding may indicate inter-hospital VRE spread in Taiwan. Active surveillance and effective infection control policies are important controlling the spread of VRE in high risk hospital zones. All endemic VRE strains are resistant to teicoplanin but are sensitive to daptomycin, linezolid, and tigecycline.
PMCID: PMC3623712  PMID: 23556473
VRE; MLST; Outbreak; Inter-hospital spread
17.  Constructing core competency indicators for clinical teachers in Taiwan: a qualitative analysis and an analytic hierarchy process 
BMC Medical Education  2014;14:75.
The objective of this study was to construct a framework of core competency indicators of medical doctors who teach in the clinical setting in Taiwan and to evaluate the relative importance of the indicators among these clinical teachers.
The preliminary framework of the indicators was developed from an in-depth interview conducted with 12 clinical teachers who had previously been recognized and awarded for their teaching excellence in university hospitals. The framework was categorized into 4 dimensions: 1) Expertise (i.e., professional knowledge and skill); 2) Teaching Ability; 3) Attitudes and Traits; and 4) Beliefs and Values. These areas were further divided into 11 sub-dimensions and 40 indicators. Subsequently, a questionnaire built upon this qualitative analysis was distributed to another group of 17 clinical teachers. Saaty’s eigenvector approach, or the so-called analytic hierarchy process (AHP), was applied to perform the pairwise comparisons between indicators and to determine the ranking and relative importance of the indicators.
Fourteen questionnaires were deemed valid for AHP assessment due to completeness of data input. The relative contribution of the four main dimensions was 31% for Attitudes and Traits, 30% for Beliefs and Values, 22% for Expertise, and 17% for Teaching Ability. Specifically, 9 out of the 10 top-ranked indicators belonged to the “Attitudes and Traits” or “Beliefs and Values” dimensions, indicating that inner characteristics (i.e., attitudes, traits, beliefs, and values) were perceived as more important than surface ones (i.e., professional knowledge, skills, and teaching competency).
We performed a qualitative analysis and developed a questionnaire based upon an interview with experienced clinical teachers in Taiwan, and used this tool to construct the key features for the role model. The application has also demonstrated the relative importance in the dimensions of the core competencies for clinical teachers in Taiwan.
PMCID: PMC3989776  PMID: 24726054
Medical education; Clinical teachers; Core competency; Questionnaires; Analytic hierarchy process
18.  Arsenic, vinyl chloride, viral hepatitis, and hepatic angiosarcoma: A hospital-based study and review of literature in Taiwan 
BMC Gastroenterology  2011;11:142.
Hepatic angiosarcoma (HAS) is a rare type of liver cancer that is often fatal, and arsenic and vinyl chloride monomer (VCM) are two major causal agents. Whereas Taiwan is an endemic area of liver cancer, epidemiologic data on HAS are limited. We reviewed the cases observed at a teaching hospital to evaluate the roles of VCM, arsenic, and viral hepatitis in the occurrence of HAS.
We reviewed the medical records of patients with pathological proof of HAS from January 2000 to August 2010 at a teaching hospital which is adjacent to the major VCM processing area in Taiwan and nearby an endemic area of arsenic exposure from drinking water. We also conducted a literature review and included all patients of HAS reported in Taiwan.
Six male and three female cases aged from 56 to 83 years (64.6 ± 8.2 years) were identified at the hospital. The differences in clinical features between men and women were not statistically significant. None of them had exposure to VCM or arsenic in drinking water. Two had evidence of hepatitis C infection, but none had evidence of hepatitis B infection. Five male and four female cases aged 30 to 82 years (58.6 ± 15.5 years) were identified in the literature, including two with arsenic exposure and one with chronic hepatitis B infection.
HAS is rare in Taiwan, and we found no evidence supporting a major role of VCM, arsenic in drinking water, or viral hepatitis in its occurrence.
PMCID: PMC3280174  PMID: 22200164
hepatic angiosracoma; vinyl chloride; arsenic; viral hepatitis
19.  Population-based Post-crisis Psychological Distress: An Example From the SARS Outbreak in Taiwan 
As a result of the severe acute respiratory syndrome (SARS) pandemic, the World Health Organization placed Taiwan on the travel alert list from May 21 to July 5, 2003. The aim of this study was to explore the post-crisis psychological distress among residents in Taiwan after the SARS epidemic.
The target population consisted of a nationwide representative sample of residents aged ≥ 18 years. Data were collected using computer assisted telephone interview systems by stratified random sampling according to geographic area. The survey (n = 1278) was conducted in November 2003, about 4 months after resolution of the SARS crisis in Taiwan. The maximum deviation of sampling error at the 95% confidence level was ± 2.74%. Psychological distress was measured by a question related to subject’s changes in perception of life, plus the five-item Brief Symptom Rating Scale. Multivariate logistic regression was used to examine the correlation of psychological distress.
About 9.2% of the participants reported that their perceptions of life became more pessimistic following the SARS crisis. The prevalence of psychiatric morbidity was 11.7%. Major predictors of higher levels of pessimism after the SARS epidemic included demographic factors, perception of SARS and pre-paredness, knowing people or having personal experiences of SARS-related discrimination, and individual worries and psychiatric morbidity. The correlates of symptomatic cases, as indicated by the five-item Brief Symptom Rating Scale, included age ≥ 50 years, senior high school graduate, and worries about recurrence of SARS.
Psychological distress was significantly correlated with demographic factors and perception regarding the SARS epidemic. It is suggested that marketing of mental health education should be segmented according to age and education level, which should enhance crisis communication for newly emerging infectious diseases among community populations.
PMCID: PMC3106105  PMID: 20654792
post-crisis; psychiatric morbidity; psychological distress; severe acute respiratory syndrome
20.  Interpretation of diagnostic laboratory tests for severe acute respiratory syndrome: the Toronto experience 
An outbreak of severe acute respiratory syndrome (SARS) began in Canada in February 2003. The initial diagnosis of SARS was based on clinical and epidemiological criteria. During the outbreak, molecular and serologic tests for the SARS-associated coronavirus (SARS-CoV) became available. However, without a “gold standard,” it was impossible to determine the usefulness of these tests. We describe how these tests were used during the first phase of the SARS outbreak in Toronto and offer some recommendations that may be useful if SARS returns.
We examined the results of all diagnostic laboratory tests used in 117 patients admitted to hospitals in Toronto who met the Health Canada criteria for suspect or probable SARS. Focusing on tests for SARS-CoV, we attempted to determine the optimal specimen types and timing of specimen collection.
Diagnostic test results for SARS-CoV were available for 110 of the 117 patients. SARS-CoV was detected by means of reverse-transcriptase polymerase chain reaction (RT-PCR) in at least one specimen in 59 (54.1%) of 109 patients. Serologic test results of convalescent samples were positive in 50 (96.2%) of 52 patients for whom paired serum samples were collected during the acute and convalescent phases of the illness. Of the 110 patients, 78 (70.9%) had specimens that tested positive by means of RT-PCR, serologic testing or both methods. The proportion of RT-PCR test results that were positive was similar between patients who met the criteria for suspect SARS (50.8%, 95% confidence interval [CI] 38.4%–63.2%) and those who met the criteria for probable SARS (58.0%, 95% CI 44.2%–70.7%). SARS-CoV was detected in nasopharyngeal swabs in 33 (32.4%) of 102 patients, in stool specimens in 19 (63.3%) of 30 patients, and in specimens from the lower respiratory tract in 10 (58.8%) of 17 patients.
These findings suggest that the rapid diagnostic tests in use at the time of the initial outbreak lack sufficient sensitivity to be used clinically to rule out SARS. As tests for SARS-CoV continue to be optimized, evaluation of the clinical presentation and elucidation of a contact history must remain the cornerstone of SARS diagnosis. In patients with SARS, specimens taken from the lower respiratory tract and stool samples test positive by means of RT-PCR more often than do samples taken from other areas.
PMCID: PMC305313  PMID: 14707219
21.  Evaluation of blunt abdominal trauma: current practice in Taiwan 
Emergency Medicine Journal : EMJ  2005;22(2):113-115.
Objective: To gain an overview of the current practice of different major institutions in Taiwan in the evaluation of abdominal injuries. A further comparison was made between general surgeons and emergency physicians in this aspect.
Method: A telephone survey was conducted of all emergency departments of 58 major institutions (14 medical centres, 44 district hospitals) that are capable of providing definitive care for trauma victims in Taiwan in June 2002. Respondents were asked to select the diagnostic modality of choice in the evaluation of a haemodynamically abnormal blunt trauma victim with suspected intra-abdominal injuries. In the same study period, this particular telephone scenario was also used to survey 109 individual doctors (45 emergency physicians, 64 general surgeons).
Results: Most respondents preferred ultrasound (also known as focused assessment with sonography for trauma or "FAST") instead of diagnostic peritoneal lavage (DPL) because DPL is invasive and most doctors in Taiwan have limited experience in performing DPL or interpreting the results.
Conclusions: It seems reasonable to devote greater resources for emergency departments to incorporate a FAST based algorithm into their initial management of trauma victims, and to improve training in its use. It is also suggested that future ATLS teaching in Taiwan should include didactic material on FAST.
PMCID: PMC1726674  PMID: 15662061
22.  Factors associated with tocolytic hospitalizations in Taiwan: evidence from a population-based and longitudinal study from 1997 to 2004 
The use of tocolytic hospitalization in antenatal care is controversial and worthy of more research. We investigated individual, institutional, and area factors that affect the use of tocolytic hospitalizations in Taiwan where fertility has rapidly declined.
Longitudinal data from the 1996 to 2004 National Health Insurance Research Database in Taiwan were used to identify tocolytic hospitalizations. The probit model was used to estimate factors associated with tocolytic hospitalizations.
The decline in fertility was significantly associated with the probability of tocolytic hospitalizations. Several physician and institutional factors-including physician's age, hospital ownership, accreditation status, bed size, and teaching status-were also significantly correlated to the dependent variables.
The provision of inpatient tocolysis is influenced not only by clinical considerations but also by physician, institutional, and area factors unrelated to clinical need. Fertility declines in Taiwan may have led obstetricians/gynecologists to provide more tocolysis to make up for their lost income. If the explanation is further validated, reimbursement policies may need to be reviewed to correct for overuse of inpatient tocolysis. The correlation could also be explained by the increasing use of artificial reproductive technologies and higher social value of newborns. In addition, the physician and institutional variations observed in the study indicate potential misuse of inpatient tocolysis that warrant further investigation.
PMCID: PMC2806362  PMID: 20021650
23.  Developing 21st century accreditation standards for teaching hospitals: the Taiwan experience 
The purpose of this study is to establish teaching hospital accreditation standards anew with the hope that Taiwan's teaching hospitals can live up to the expectations of our society and ensure quality teaching.
The development process lasted two years, 2005-2006, and was separated into three stages. The first stage centered on leadership meetings and consensus building, the second on drafting the new standards with expert focus groups, and the third on a pilot study and subsequent revision.
Our new teaching hospital accreditation standards have six categories and 95 standards as follows: educational resources (20 items), teaching and training plans and outcomes (42 items), research and results (9 items), development of clinical faculty and continuing education (8 items), academic exchanges and community education (8 items), and administration (8 items).
The new standards have proven feasible and posed reasonable challenges in the pilot study. We hope the new standards will strengthen teaching and research, and improve the quality of hospital services at the same time.
PMCID: PMC2801490  PMID: 20003505
24.  What Internet Services Would Patients Like From Hospitals During an Epidemic? Lessons From the SARS Outbreak in Toronto 
International health organizations and officials are bracing for a pandemic. Although the 2003 severe acute respiratory syndrome (SARS) outbreak in Toronto did not reach such a level, it created a unique opportunity to identify the optimal use of the Internet to promote communication with the public and to preserve health services during an epidemic.
The aim of the study was to explore patients’ attitudes regarding the health services that might be provided through the Internet to supplement those traditionally available in the event of a future mass emergency situation.
We conducted “mask-to-mask” surveys of patients at three major teaching hospitals in Toronto during the second outbreak of SARS. Patients were surveyed at the hospital entrances and selected clinics. Descriptive statistics and logistic regression models were used for the analysis.
In total, 1019 of 1130 patients responded to the survey (90% overall response rate). With respect to Internet use, 70% (711/1019) used the Internet by themselves and 57% (578/1019) with the help of a friend or family member. Of the Internet users, 68% (485/711) had already searched the World Wide Web for health information, and 75% (533/711) were interested in communicating with health professionals using the Internet as part of their ongoing care. Internet users expressed interest in using the Web for the following reasons: to learn about their health condition through patient education materials (84%), to obtain information about the status of their clinic appointments (83%), to send feedback to the hospital about how to improve its services (77%), to access screening tools to help determine if they were potentially affected by the infectious agent responsible for the outbreak (77%), to renew prescriptions (75%), to consult with their health professional about nonurgent matters (75%), and to access laboratory test results (75%). Regression results showed that younger age, higher education, and English as a first language were predictors of patients’ interest in using Internet services in the event of an epidemic.
Most patients are willing and able to use the Internet as a means to maintain communication with the hospital during an outbreak of an infectious disease such as SARS. Hospitals should explore new ways to interact with the public, to provide relevant health information, and to ensure continuity of care when they are forced to restrict their services.
PMCID: PMC1550678  PMID: 16236698
Severe acute respiratory syndrome; communicable diseases, emerging; information services; Internet; public health; questionnaires
25.  Two-dimensional Co-Seismic Surface Displacements Field of the Chi-Chi Earthquake Inferred from SAR Image Matching 
Sensors (Basel, Switzerland)  2008;8(10):6484-6495.
The Mw=7.6 Chi-Chi earthquake in Taiwan occurred in 1999 over the Chelungpu fault and caused a great surface rupture and severe damage. Differential Synthetic Aperture Radar Interferometry (DInSAR) has been applied previously to study the co-seismic ground displacements. There have however been significant limitations in the studies. First, only one-dimensional displacements along the Line-of-Sight (LOS) direction have been measured. The large horizontal displacements along the Chelungpu fault are largely missing from the measurements as the fault is nearly perpendicular to the LOS direction. Second, due to severe signal decorrelation on the hangling wall of the fault, the displacements in that area are un-measurable by differential InSAR method. We estimate the co-seismic displacements in both the azimuth and range directions with the method of SAR amplitude image matching. GPS observations at the 10 GPS stations are used to correct for the orbital ramp in the amplitude matching and to create the two-dimensional (2D) co-seismic surface displacements field using the descending ERS-2 SAR image pair. The results show that the co-seismic displacements range from about -2.0 m to 0.7 m in the azimuth direction (with the positive direction pointing to the flight direction), with the footwall side of the fault moving mainly southwards and the hanging wall side northwards. The displacements in the LOS direction range from about -0.5 m to 1.0 m, with the largest displacement occuring in the northeastern part of the hanging wall (the positive direction points to the satellite from ground). Comparing the results from amplitude matching with those from DInSAR, we can see that while only a very small fraction of the LOS displacement has been recovered by the DInSAR mehtod, the azimuth displacements cannot be well detected with the DInSAR measurements as they are almost perpendicular to the LOS. Therefore, the amplitude matching method is obviously more advantageous than the DInSAR in studying the Chi-Chi earthquake. Another advantage of the method is that the displacement in the hanging wall of the fault that is un-measurable with DInSAR due to severe signal decorrelation can almost completely retrieved in this research. This makes the whole co-seismic displacements field clearly visible and the location of the rupture identifiable. Using displacements measured at 15 independent GPS stations for validation, we found that the RMS values of the differences between the two types of results were 6.9 cm and 5.7 cm respectively in the azimuth and the range directions.
PMCID: PMC3707463
Chi-Chi earthquake; Differential Synthetic Aperture Radar (DInSAR); amplitude image match; GPS; Two dimensional (2D) displacements

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