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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Interrupting COVID-19 transmission by implementing enhanced traffic control bundling: Implications for global prevention and control efforts</title><author><name sortKey="Yen, Muh Yong" sort="Yen, Muh Yong" uniqKey="Yen M" first="Muh-Yong" last="Yen">Muh-Yong Yen</name><affiliation><nlm:aff id="aff1">Division of Infectious Diseases, Taipei City Hospital, School of Medicine, National Yang-Ming University, Taipei, Taiwan</nlm:aff></affiliation></author><author><name sortKey="Schwartz, Jonathan" sort="Schwartz, Jonathan" uniqKey="Schwartz J" first="Jonathan" last="Schwartz">Jonathan Schwartz</name><affiliation><nlm:aff id="aff2">Department of Political Science, State University of New York, New Paltz, NY, USA</nlm:aff></affiliation></author><author><name sortKey="Chen, Shey Ying" sort="Chen, Shey Ying" uniqKey="Chen S" first="Shey-Ying" last="Chen">Shey-Ying Chen</name><affiliation><nlm:aff id="aff3">Department of Emergency Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan</nlm:aff></affiliation></author><author><name sortKey="King, Chwan Chuen" sort="King, Chwan Chuen" uniqKey="King C" first="Chwan-Chuen" last="King">Chwan-Chuen King</name><affiliation><nlm:aff id="aff4">Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, 10055, Taiwan</nlm:aff></affiliation></author><author><name sortKey="Yang, Guang Yang" sort="Yang, Guang Yang" uniqKey="Yang G" first="Guang-Yang" last="Yang">Guang-Yang Yang</name><affiliation><nlm:aff id="aff5">Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, 11221 Taiwan</nlm:aff></affiliation></author><author><name sortKey="Hsueh, Po Ren" sort="Hsueh, Po Ren" uniqKey="Hsueh P" first="Po-Ren" last="Hsueh">Po-Ren Hsueh</name><affiliation><nlm:aff id="aff6">Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan</nlm:aff></affiliation><affiliation><nlm:aff id="aff7">Department of Laboratory Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">32205090</idno><idno type="pmc">7156133</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7156133</idno><idno type="RBID">PMC:7156133</idno><idno type="doi">10.1016/j.jmii.2020.03.011</idno><date when="2020">2020</date><idno type="wicri:Area/Pmc/Corpus">000902</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000902</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Interrupting COVID-19 transmission by implementing enhanced traffic control bundling: Implications for global prevention and control efforts</title><author><name sortKey="Yen, Muh Yong" sort="Yen, Muh Yong" uniqKey="Yen M" first="Muh-Yong" last="Yen">Muh-Yong Yen</name><affiliation><nlm:aff id="aff1">Division of Infectious Diseases, Taipei City Hospital, School of Medicine, National Yang-Ming University, Taipei, Taiwan</nlm:aff></affiliation></author><author><name sortKey="Schwartz, Jonathan" sort="Schwartz, Jonathan" uniqKey="Schwartz J" first="Jonathan" last="Schwartz">Jonathan Schwartz</name><affiliation><nlm:aff id="aff2">Department of Political Science, State University of New York, New Paltz, NY, USA</nlm:aff></affiliation></author><author><name sortKey="Chen, Shey Ying" sort="Chen, Shey Ying" uniqKey="Chen S" first="Shey-Ying" last="Chen">Shey-Ying Chen</name><affiliation><nlm:aff id="aff3">Department of Emergency Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan</nlm:aff></affiliation></author><author><name sortKey="King, Chwan Chuen" sort="King, Chwan Chuen" uniqKey="King C" first="Chwan-Chuen" last="King">Chwan-Chuen King</name><affiliation><nlm:aff id="aff4">Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, 10055, Taiwan</nlm:aff></affiliation></author><author><name sortKey="Yang, Guang Yang" sort="Yang, Guang Yang" uniqKey="Yang G" first="Guang-Yang" last="Yang">Guang-Yang Yang</name><affiliation><nlm:aff id="aff5">Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, 11221 Taiwan</nlm:aff></affiliation></author><author><name sortKey="Hsueh, Po Ren" sort="Hsueh, Po Ren" uniqKey="Hsueh P" first="Po-Ren" last="Hsueh">Po-Ren Hsueh</name><affiliation><nlm:aff id="aff6">Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan</nlm:aff></affiliation><affiliation><nlm:aff id="aff7">Department of Laboratory Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan</nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Microbiology, Immunology, and Infection</title><idno type="ISSN">1684-1182</idno><idno type="eISSN">1995-9133</idno><imprint><date when="2020">2020</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>We argue that enhanced Traffic Control Bundling (eTCB) can interrupt the community-hospital-community transmission cycle, thereby limiting COVID-19’s impact. Enhanced TCB is an expansion of the traditional TCB that proved highly effective during Taiwan’s 2003 SARS outbreak. TCB’s success derived from ensuring that Health Care Workers (HCWs) and patients were protected from fomite, contact and droplet transmission within hospitals.</p><p>Although TCB proved successful during SARS, achieving a similar level of success with the COVID-19 outbreak requires adapting TCB to the unique manifestations of this new disease. These manifestations include asymptomatic infection, a hyper-affinity to ACE2 receptors resulting in high transmissibility, false negatives, and an incubation period of up to 22 days. Enhanced TCB incorporates the necessary adaptations. In particular, eTCB includes expanding the TCB transition zone to incorporate a new sector – the quarantine ward. This ward houses patients exhibiting atypical manifestations or awaiting definitive diagnosis. A second adaptation involves enhancing the checkpoint hand disinfection and gowning up with Personal Protective Equipment deployed in traditional TCB. Under eTCB, checkpoint hand disinfection and donning of face masks are now required of all visitors who seek to enter hospitals.</p><p>These enhancements ensure that transmissions by droplets, fomites and contact are disrupted both within hospitals and between hospitals and the broader community. Evidencing eTCB effectiveness is Taiwan’s success to date in containing and controlling the community-hospital-community transmission cycle.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Morens, D M" uniqKey="Morens D">D.M. Morens</name></author><author><name sortKey="Daszak, P" uniqKey="Daszak P">P. Daszak</name></author><author><name sortKey="Taubenberger, J K" uniqKey="Taubenberger J">J.K. 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<front><journal-meta><journal-id journal-id-type="nlm-ta">J Microbiol Immunol Infect</journal-id><journal-id journal-id-type="iso-abbrev">J Microbiol Immunol Infect</journal-id><journal-title-group><journal-title>Journal of Microbiology, Immunology, and Infection</journal-title></journal-title-group><issn pub-type="ppub">1684-1182</issn><issn pub-type="epub">1995-9133</issn><publisher><publisher-name>Taiwan Society of Microbiology. Published by Elsevier Taiwan LLC.</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">32205090</article-id><article-id pub-id-type="pmc">7156133</article-id><article-id pub-id-type="publisher-id">S1684-1182(20)30071-2</article-id><article-id pub-id-type="doi">10.1016/j.jmii.2020.03.011</article-id><article-categories><subj-group subj-group-type="heading"><subject>Article</subject></subj-group></article-categories><title-group><article-title>Interrupting COVID-19 transmission by implementing enhanced traffic control bundling: Implications for global prevention and control efforts</article-title></title-group><contrib-group><contrib contrib-type="author" id="au1"><name><surname>Yen</surname><given-names>Muh-Yong</given-names></name><email>myyen1121@gmail.com</email><xref rid="aff1" ref-type="aff">a</xref><xref rid="cor1" ref-type="corresp">∗</xref></contrib><contrib contrib-type="author" id="au2"><name><surname>Schwartz</surname><given-names>Jonathan</given-names></name><xref rid="aff2" ref-type="aff">b</xref></contrib><contrib contrib-type="author" id="au3"><name><surname>Chen</surname><given-names>Shey-Ying</given-names></name><xref rid="aff3" ref-type="aff">c</xref></contrib><contrib contrib-type="author" id="au4"><name><surname>King</surname><given-names>Chwan-Chuen</given-names></name><xref rid="aff4" ref-type="aff">d</xref></contrib><contrib contrib-type="author" id="au5"><name><surname>Yang</surname><given-names>Guang-Yang</given-names></name><xref rid="aff5" ref-type="aff">e</xref></contrib><contrib contrib-type="author" id="au6"><name><surname>Hsueh</surname><given-names>Po-Ren</given-names></name><xref rid="aff6" ref-type="aff">f</xref><xref rid="aff7" ref-type="aff">g</xref></contrib></contrib-group><aff id="aff1"><label>a</label>Division of Infectious Diseases, Taipei City Hospital, School of Medicine, National Yang-Ming University, Taipei, Taiwan</aff><aff id="aff2"><label>b</label>Department of Political Science, State University of New York, New Paltz, NY, USA</aff><aff id="aff3"><label>c</label>Department of Emergency Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan</aff><aff id="aff4"><label>d</label>Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, 10055, Taiwan</aff><aff id="aff5"><label>e</label>Institute of Environmental and Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, 11221 Taiwan</aff><aff id="aff6"><label>f</label>Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan</aff><aff id="aff7"><label>g</label>Department of Laboratory Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan</aff><author-notes><corresp id="cor1"><label>∗</label>Corresponding author. Division of Infectious Disease, Taipei City Hospital, Taipei, Taiwan. No. 100, Kunming St, Taipei, 10844, Taiwan. <email>myyen1121@gmail.com</email></corresp></author-notes><pub-date pub-type="pmc-release"><day>14</day><month>3</month><year>2020</year></pub-date><pmc-comment> PMC Release delay is 0 months and 0 days and was based on .</pmc-comment>
<pub-date pub-type="epub"><day>14</day><month>3</month><year>2020</year></pub-date><history><date date-type="received"><day>10</day><month>3</month><year>2020</year></date><date date-type="accepted"><day>11</day><month>3</month><year>2020</year></date></history><permissions><copyright-statement>© 2020 Taiwan Society of Microbiology. Published by Elsevier Taiwan LLC.</copyright-statement><copyright-year>2020</copyright-year><copyright-holder></copyright-holder><license><license-p>Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.</license-p></license></permissions><abstract id="abs0010"><p>We argue that enhanced Traffic Control Bundling (eTCB) can interrupt the community-hospital-community transmission cycle, thereby limiting COVID-19’s impact. Enhanced TCB is an expansion of the traditional TCB that proved highly effective during Taiwan’s 2003 SARS outbreak. TCB’s success derived from ensuring that Health Care Workers (HCWs) and patients were protected from fomite, contact and droplet transmission within hospitals.</p><p>Although TCB proved successful during SARS, achieving a similar level of success with the COVID-19 outbreak requires adapting TCB to the unique manifestations of this new disease. These manifestations include asymptomatic infection, a hyper-affinity to ACE2 receptors resulting in high transmissibility, false negatives, and an incubation period of up to 22 days. Enhanced TCB incorporates the necessary adaptations. In particular, eTCB includes expanding the TCB transition zone to incorporate a new sector – the quarantine ward. This ward houses patients exhibiting atypical manifestations or awaiting definitive diagnosis. A second adaptation involves enhancing the checkpoint hand disinfection and gowning up with Personal Protective Equipment deployed in traditional TCB. Under eTCB, checkpoint hand disinfection and donning of face masks are now required of all visitors who seek to enter hospitals.</p><p>These enhancements ensure that transmissions by droplets, fomites and contact are disrupted both within hospitals and between hospitals and the broader community. Evidencing eTCB effectiveness is Taiwan’s success to date in containing and controlling the community-hospital-community transmission cycle.</p></abstract><kwd-group id="kwrds0010"><title>Keywords</title><kwd>COVID-19</kwd><kwd>SARS-CoV</kwd><kwd>Traffic control bundling</kwd><kwd>eTCB</kwd><kwd>Community-hospital-community transmission</kwd><kwd>Fomite transmission</kwd></kwd-group></article-meta></front><body><sec id="sec1"><title>Perspective</title><p id="p0010">Repeated recent outbreaks of novel infectious diseases (e.g. H1N1 pdm09, SARS, MERS, avian influenza H5N1, Ebola) that have failed to develop into globe-spanning pandemics have given the international community a sense of security. Coronavirus disease (COVID-19) is undermining this sense of security because it is proving both highly transmissible (like H1N1) and not too deadly (unlike Ebola). The result is a relatively easily transmitted virus with a case fatality rate currently estimated as well above that of the seasonal influenza. With its high transmissibility and rapid global circulation, COVID-19 is being compared with the deadly Spanish flu outbreak of 1918.<xref rid="bib1" ref-type="bibr"><sup>1</sup></xref></p><p id="p0015">On 30 January, 2020, the World Health Organization (WHO) declared COVID-19 a public health emergency of international concern. Since erupting in China, it has claimed thousands of lives there, and has now spread globally, causing infections, death and growing alarm. The WHO's initial focus was on managing droplet and contact transmission, but it has since recognized the role fomites play as well.<xref rid="bib2" ref-type="bibr"><sup>2</sup></xref> Fomites are important because while populations generally protect themselves from clearly observable droplet transmissions (coughing, sneezing), being invisible, fomite transmission is regularly overlooked both in hospitals and communities.<xref rid="bib3" ref-type="bibr">3</xref>, <xref rid="bib4" ref-type="bibr">4</xref>, <xref rid="bib5" ref-type="bibr">5</xref> Consequently, during the community saturation phase, fomite transmission may play a larger role than droplet transmission as a mechanism in emergent infectious diseases.<xref rid="bib3" ref-type="bibr">3</xref>, <xref rid="bib4" ref-type="bibr">4</xref>, <xref rid="bib5" ref-type="bibr">5</xref>, <xref rid="bib6" ref-type="bibr">6</xref></p><p id="p0020">In this paper we argue that by implementing enhanced Traffic Control Bundling (eTCB),<xref rid="bib6" ref-type="bibr"><sup>6</sup></xref> an extension of the TCB deployed by Taiwan during the 2003 SARS outbreak, countries can interrupt the community-hospital-community transmission cycle, thereby limiting COVID-19's impact.</p><p id="p0025">During SARS 2003, Taiwan implemented a nationwide version of TCB that proved effective at minimizing nosocomial infection of healthcare workers (HCWs), patients, and visitors to hospitals.<xref rid="bib3" ref-type="bibr"><sup>3</sup></xref><sup>,</sup><xref rid="bib4" ref-type="bibr"><sup>4</sup></xref> Traffic Control Bundling is a version of multi-modal care that Taiwan has successfully implemented in the past.<xref rid="bib7" ref-type="bibr"><sup>7</sup></xref><sup>,</sup><xref rid="bib8" ref-type="bibr"><sup>8</sup></xref> TCB is an integrated infection control strategy that include triage prior to entering hospitals; strict separation among zones of risk, and; strict requirements and protocols for personal protective equipment (PPE) use coupled with checkpoint hand disinfection.<xref rid="bib3" ref-type="bibr"><sup>3</sup></xref></p><p id="p0030">TCB protocols include initial “triage outside of hospitals” - patients found to be infected with SARS-CoV during triage at outdoor fever screening stations are sent directly through a guarded control route to a designated contamination zone; “zones of risk” - clearly distinguished contamination, transition and clean zones. HCWs moving from contamination to clean zones must undertake decontamination and degowning in the transition zone, and hand disinfection at every checkpoint between the zones.</p><p id="p0035">During the Taiwan SARS outbreak, this strategy achieved 100% hand hygiene compliance among HCWs. When coupled with strict PPE use and standard infection control procedures, hospital fomite, contact and droplet transmissions were efficiently controlled. As a result, community SARS infection rates declined as well. Success was evidenced by no new diagnosed cases over two one-week incubation periods following TCB implementation.<xref rid="bib3" ref-type="bibr"><sup>3</sup></xref><sup>,</sup><xref rid="bib4" ref-type="bibr"><sup>4</sup></xref></p><p id="p0040">TCB is particularly effective as regards to the role of fomites. As noted, fomite transmission played a central role in SARS 2003. However, fomites have also proven important during other outbreaks. As with SARS, during MERS 2015 there were numerous examples of HCWs contracting the virus even when fully gowned and often despite having had no direct contact with carriers.<xref rid="bib6" ref-type="bibr"><sup>6</sup></xref> For example, during the Korean MERS outbreak, one super-spreader infected 82 people in a medical center. Initial analyses pointed to transmission by the index case via droplets and contact with exposed people in the same care zone. However, later analysis found that those without contact history with the index case were likely infected by fomites on bed curtains and/or public restroom fixtures touched by the index case who had been suffering from walking pneumonia and diarrhea.<xref rid="bib9" ref-type="bibr"><sup>9</sup></xref> Similar findings were identified regarding interactions of fomite-related nosocomial and community transmissions during H1N1 2009 and Ebola 2014.<xref rid="bib4" ref-type="bibr">4</xref>, <xref rid="bib5" ref-type="bibr">5</xref>, <xref rid="bib6" ref-type="bibr">6</xref></p><p id="p0045">In the COVID-19 case, after a long incubation period, family clusters related to Huanan market developed (<xref rid="fig1" ref-type="fig">Fig. 1</xref>, arrow 1). Early in the outbreak, much as with SARS, transmission via droplets and fomites began cycling between the local community and clinics and hospitals via waiting rooms crowded by both ill and healthy people (<xref rid="fig1" ref-type="fig">Fig. 1</xref>, arrow 2). In this case, nosocomial spread began among both HCWs and visitors to the hospitals, who when returning home, re-infected their communities (<xref rid="fig1" ref-type="fig">Fig. 1</xref>, arrow 3). This process extended the transmission cycle in a positive feedback loop, amplifying the outbreak (<xref rid="fig1" ref-type="fig">Fig. 1</xref>, arrows 4 &5) and cascading to the point of community saturation (<xref rid="fig1" ref-type="fig">Fig. 1</xref>).<xref rid="bib4" ref-type="bibr"><sup>4</sup></xref><fig id="fig1"><label>Figure 1</label><caption><p>Proposed mechanism of community-hospital-community chain of amplification in COVID-19.</p></caption><alt-text id="alttext0010">Figure 1</alt-text><graphic xlink:href="gr1_lrg"></graphic></fig></p><p id="p0050">In short, following a dynamic similar to earlier coronavirus outbreaks, COVID-19 spread from the Wuhan epicenter to nearby communities and outward within China and internationally. However, COVID-19 has some unique characteristics. These include asymptomatic infection; a hyper-affinity to ACE2 receptors resulting in high transmissibility; false negatives, and; an incubation period of up to 22 days.<xref rid="bib10" ref-type="bibr"><sup>10</sup></xref><sup>,</sup><xref rid="bib11" ref-type="bibr"><sup>11</sup></xref> These characteristics necessitate enhancement to the TCB protocols to ensure effective transmission control.<xref rid="bib6" ref-type="bibr"><sup>6</sup></xref></p><p id="p0055">Enhanced TCB (eTCB) includes two enhancements to traditional TCB. First, where TCB has a contamination zone (Isolation ward) and a transition zone, eTCB expands the transition zone to incorporate a quarantine ward as well. The quarantine ward houses patients with atypical manifestations and patients awaiting final diagnosis. These patients are transferred to the quarantine ward directly from outdoor triage and are held there for the full incubation period.<xref rid="bib6" ref-type="bibr"><sup>6</sup></xref> (<xref rid="fig2" ref-type="fig">Fig. 2</xref>).<fig id="fig2"><label>Figure 2</label><caption><p>Enhanced traffic control bundling.</p></caption><alt-text id="alttext0015">Figure 2</alt-text><graphic xlink:href="gr2_lrg"></graphic></fig></p><p id="p0060">As with traditional TCB, the zones are separated by a transition zone with checkpoints for hand disinfection. HCWs moving from the clean zone to quarantine ward must first dress in PPE. When transitioning from the quarantine to the isolation ward, HCWs must engage in comprehensive checkpoint disinfection, a process repeated as they move from the isolation ward to the clean zone (again, via a transition zone).</p><p id="p0065">Second, to address community to hospital infection threats, checkpoint hand disinfection and face masks are required of all visitors entering the hospital. This is supplemented with heightened environmental cleaning and disinfection.</p><p id="p0070">COVID-19 droplet and fomite transmission has been observed both inside and outside of hospitals. By containing nosocomial transmissions, eTCB contributes to breaking the cycle of community-hospital-community infection. Recently, Taiwan's COVID-19 response was praised in public health circles.<xref rid="bib12" ref-type="bibr"><sup>12</sup></xref> Taiwan's success can be at least partially attributed to its success in breaking the community-hospital-community transmission cycle by implementing TCB with the enhancements identified here. We therefore strongly recommend implementing eTCB as an important tool for containing COVID-19.</p></sec><sec id="sec2"><title>Author contributions</title><p id="p0075">Initiated this study and structure of this paper: MY Yen, J Schwartz.</p><p id="p0080">Conceived and designed this study: MY Yen, J Schwartz, SY Chen.</p><p id="p0085">Wrote the paper: MY Yen, J Schwartz, CC King.</p><p id="p0090">Setting up the Traffic Control Bundle: MY Yen, SY Chen.</p><p id="p0095">Literature search: MY Yen, CC King, GY Yang, PR Hsueh.</p><p id="p0100">Data collection: MY Yen, GY Yang.</p><p id="p0105">Analyzed the data: MY Yen, CC King, GC Yang.</p><p id="p0110">Data interpretation: MY Yen, CC King, GC Yang.</p><p id="p0115">Figure: MY Yen, J Schwartz, SY Chen, PR Hsueh.</p></sec><sec sec-type="COI-statement"><title>Declaration of Competing Interest</title><p id="p0075a">We declare no competing interests.</p></sec></body><back><ref-list id="cebib0010"><title>References</title><ref 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Yen MY, et al. Taiwan's traffic control bundle and the elimination of nosocomial severe acute respiratory syndrome among health care workers. J Hosp Infect 2011;<bold>77</bold>:332–7) was financially supported by <funding-source id="gs1">Taiwan CDC</funding-source> grant (DOH 92-DC-SA01) in 2003.</p></ack></back></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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