MCHRI member leads coronavirus response, drawing on lessons from Taiwan

October 7, 2020

By Laura Hedli

Associate Professor of Pediatrics C. Jason Wang, MD, PhD, thinks the messaging around mask wearing could use a makeover. He cites a recent study from researchers at Temple University and the University of Pennsylvania that found faces with masks were rated as more attractive than those unobstructed by fabric. 

“Hey, if you wear a mask, people think you're more attractive,” says Dr. Wang, suggesting that this new announcement amplified with the right advertising could work well, particularly on teenagers.

Appealing to people’s vanity is one of the more playful ideas Dr. Wang has about how to reduce the spread of the coronavirus. As the former project manager of Taiwan’s National Health Insurance Reform Task-force, he in fact spends much of his time studying global responses to the coronavirus in order to make recommendations about what to do here in the United States. He is forthcoming with his knowledge and advice, which is grounded in his expertise as a pediatrician, policy analyst, and health services researcher.

Dr. Wang is a member of Stanford Maternal and Child Health Research Institute (MCHRI) and has several administrative appointments; he serves as the Director of the Center for Policy, Outcomes and Prevention and Co-director of the PCHA-UHA (Packard Children’s Health Alliance-University Healthcare Alliance) Research and Learning Collaborative. The COVID-19 pandemic, he believes, is the most complex problem he’s ever worked to solve.

“Having MCHRI funding as a major source of what we do allowed me to build a team that could respond to crises like this,” says Dr. Wang. He and his colleagues have been extraordinarily busy, developing research projects related to reopening the U.S. economy, improving the safety of air travel during the pandemic, and getting kids back into classrooms. 

What can Taiwan teach us?

With a population of over 23 million, Taiwan has had a total of 518 COVID-19 cases and just seven deaths to date. These numbers are remarkable, especially given the country is less than 100 miles from China by way of the Taiwan Strait.

Dr. Wang credits Taiwan’s success to learning from its past experiences with SARS (severe acute respiratory syndrome), MERS (middle east respiratory syndrome), and avian flu. The Taiwanese government and citizens were better prepared when COVID-19 was first identified as a novel pathogen late last year. Activating its Central Epidemic Command Center, Taiwan was able to respond quickly thanks to laws that prioritized public health, and allowed for government intervention to increase production of masks and personal protective equipment and ensure their equitable distribution.

Early on in the pandemic, Dr. Wang led a Stanford Pediatric Grand Rounds entitled “How can a democracy effectively respond to COVID-19: Lessons from Taiwan.” He also published an article on Taiwan’s response in the Journal of the American Medical Association (JAMA). The article has since been viewed over one million times, and has been covered by over 250 media outlets, according to Dr. Wang. (For a full list of Dr. Wang’s publications related to COVID-19, see the accompanying graphic.)

How to reopen safely

Americans have been couped up for months and are struggling to make sense of a patchwork, politicized response to the virus where federal, state, and local guidance are often at odds.

At the end of August, California Governor Gavin Newsom released his Blueprint for a Safer Economy. The blueprint unveiled a new color-coded system for reopening businesses in the state with four different tiers based on two metrics: the number of cases per 100,000 residents and the percent positivity rate. Most Bay Area counties are now in the “red,” meaning COVID-19 spread is deemed substantial. Some businesses can operate indoors, yet rules vary. Indoor retail can operate at 50% capacity, for instance, while indoor gyms can operate at only 10% capacity.

Dr. Wang thinks the critical task of reopening America needs reframing. “The idea is that it's not what to open, it's how to open,” he says.

Schools in a given county are allowed to reopen for in-person instruction once the county has been in the red tier for two full weeks. For school districts aiming to send students back to class in the coming months, Dr. Wang is showing a way forward.

Again, he’s using Taiwan as an example. In July, he traveled to the country to see how schools were able to conduct in-person instruction for grades K-12 and at universities. What he found was a well-coordinated system where parents and/or students recorded their symptoms online each day, and teachers and staff took the temperatures of students before they entered the classroom.

“People here [in the U.S.] that I talk to say, ‘You'll never get parents to do that,’” says Dr. Wang. “Well, yes you can. Because I've seen it.”

The Ministry of Education in Taiwan requires the status of all university students to be reported by noon each day in order to make decisions on schools’ operational status the next day. If one student in a class tests positive, all students in the class quarantine for 14 days. If two students in a school test positive, the school is closed for 14 days. Using these cutoffs for containment and closure, Taiwan has effectively been able to keep classroom doors open and transmission rates to a minimum.

Dr. Wang believes the U.S. can adopt a similar approach, making daily health inventories and temperature checks a part of everyday life for students. These steps would bolster existing public health prevention measures including hand washing, social distancing, and mask wearing.

Rapid antigen testing, he says, will be another critical component to a successful reopening.

Antigen testing is a rapid diagnostic test designed to detect proteins on the surface of the virus. “These rapid tests are going to be more like pregnancy tests where you could quickly get results, in 15 minutes” says Dr. Wang.

...the U.S. can adopt a similar approach, making daily health inventories and temperature checks a part of everyday life for students.

The other way to diagnose an active COVID-19 infection is by using a polymerase chain reaction (PCR) test, which is designed to detect nucleic acid, or the RNA of the virus. Processing takes longer for PCR tests, with results coming back in 24 hours or sometimes days. 

Compared to PCR testing, antigen testing is about one tenth of the cost—around $5-10 per test. Still, U.S. would need to quickly devise a production system to create a robust supply chain and ramp up testing capabilities. 

There are more than 56 million K-12 students in the U.S. According to enrollment totals released by the California Department of Education for the 2019-2020 school year, California educates about 6.2 million of them. In order to test each student at least once a week, California alone would need to secure or generate about one million tests per day.

To coordinate testing and track transmission rates, Dr. Wang advises that school districts rely on collaboration. He suggests each district forms a non-partisan task force made up of a superintendent, members of the school board, teachers, parents, and health care professionals. The task force would develop policies and procedures and create and oversee a command center for the school district. The command center would draw on the expertise of data science and health professionals to implement what the task force proposes and liaise with local government, health department and hospitals to provide students, teachers, and parents with COVID-19 prevention education materials and testing.

Testing reentry in the Bay Area

Dr. Wang and Professor of Pediatric Infectious Disease Yvonne Maldonado, MD, are putting some of his recommendations into practice at a Bay Area school. Stanford and Synapse School, a small, private K-8 school in Menlo Park, are partnering to resume in-person instruction and testing to determine if it’s feasible and safe.

Drs. Wang and Maldonado have been consulting with Synapse School about reopening plans since June, and they led a team who worked throughout the summer to set up the study. Next month, the two researchers will speak at MCHRI’s Virtual Symposium during a special session on the COVID-19 pandemic and innovations in school-aged learning.

With MCHRI funding, Dr. Wang was able to hire Shilpa Jani, MPH, to serve as the project manager for the PCHA Research and Learning Collaborative, based at the Center for Policy, Outcomes and Prevention. During the COVID-19 crisis, Jani has been critical to the reopening project. Much of her work has involved managing protocol submission to Stanford’s Institutional Review Board, supporting logistics with the school, and ensuring the study doesn’t overburden already taxed families.

Jani stresses the distinction between school policy and the research. The school requires any student or faculty engaged in onsite learning to complete a daily health questionnaire regarding symptoms and potential exposures, and be tested once a week. Meanwhile, Stanford asks the school to voluntarily share the test results for research purposes. (Stanford is also processing and analyzing test samples at its Clinical Virology Laboratory.) Testing will occur from September through the end of January 2021.

The school has adopted several other preventative measures. It’s grouped students whose families opted for in-person leaning into cohorts of 8-12 students per instructor, and the cohorts do not intermingle while on campus. Masks and social distancing are required for all. Hygiene education and practice are a routine part of the day, just like math or English class.

“Our goal is to be able to see, when all of these policies are put into place, whether transmission is limited in the school environment,” says Jani. “With this study, what we learn from it can really be applied to other schools.”

For those who believe reopening schools may be too complicated or too dangerous at this time, Dr. Wang stresses the risks children face by staying home are substantial. Kids may be more likely to become infected with COVID-19 if they live in close quarters with family members who are essential workers. They may be malnourished without a school lunch, as many families rely on the National School Lunch Program to feed their child one nutritious meal a day at little or no cost. And limited or no accessibility to virtual learning is exacerbating already existing achievement gaps across income levels and between white students and students of black or Hispanic heritage.

“Nowadays, I'm spending most of my time trying to reopen America's schools. Because we need to send our kids back to school,” says Wang. “In my personal opinion, we have to open them reasonably safely by actively managing the process to mitigate the concerns of what we now know is a potential source of viral spread within the school.”

Laura Hedli is a writer for the Division of Neonatal and Developmental Medicine in the Department of Pediatrics and contributes stories to the Stanford Maternal and Child Health Research Institute.