South Korea - a best practice

SOUTH KOREA - A COVID BEST PRACTICE

Distanced testing booths in Korea

Almost all the countries surrounding China fairly easily controlled the early COVID-19 epidemic by following procedures they had laid in place several decades earlier and which had been endorsed by WHO.  Because of SARS-1 – most of the countries surrounding China were sensitised to the possibilities of pandemic and took immediate action when Beijing announced the presence of a novel pneumonia. Many had some sort of system already in place and activated it immediately.

By 22 April, some of the success stories were

      Vietnam                268 cases, 0 deaths
      Mongolia                34 cases, 0 deaths
      Taiwan                  425 cases, 6 deaths
      Hong Kong         1025 cases, 4 deaths

These countries  barely had an epidemic at all. However, because so many others have had such severe epidemics, there has been considerable interest in the few that have suppressed a fully-fledged epidemic, particularly if they managed to do it without recourse to heavy lockdowns and quarantines costing many billions of dollars.

One country in the region stands out in the worldwide fight against COVID-19. South Korea was slow to start its response and had a significant outbreak, but it stopped COVID in its tracks by using relatively affordable test-and-trace technology.

Officials and experts worldwide, including France's President and Sweden's Prime Minister, have been commending South Korea for good practice. Their strategy appears relatively straightforward and affordable: swift action, widespread testing and contact tracing, and support from the public.

Korea had a reason to be ready. From May to July 2015 the country had an outbreak of the most dangerous coronavirus, Middle East Respiratory Syndrome (MERS). MERS infections mostly occur in a healthcare setting, and general community transfer is not known. But during this period, Korea set up a test-and-track system using modern technology.

The head of the World Health Organisation has hailed South Korea which in the face of an expanding epidemic "did not surrender" but 

educated, empowered and engaged communities. It developed an innovative testing strategy and expanded lab capacity. It rationed the use of masks. It did exhaustive contact tracing and testing in selected areas and it isolated suspected cases in designated facilities rather than hospitals or at home.

Beginnings of the epidemic in Korea

As with half-a-dozen other countries, Korea had its first confirmed case around 20 January. A trickle of cases from Wuhan continued during January. On 4 February, entry was denied to foreigners travelling from Hubei. However, on 1-5 February, several inbound travellers from Japan, Thailand and Singapore were found to have the disease. 

On 19 February, a substantial outbreak was recognised in Daegu, a major manufacturing centre in the south with 2.5 million population, connected to the Messianic Shincheonji Church. Services in this church involve very close proximity and touching. Most cases were attributed to a single superspreader, but there were half a dozen Chinese members from Wuhan were in the congregation, some of whom  might have been carrying the virus. By 21 February there were 544 suspected cases in the church, and the first death had been recorded. 

Seoul City sought to have the sect leaders charged with murder. Interviews were conducted with all 230,000 members of the sect and about 9,000 were said to be showing symptoms. Overall, about 50% of cases in Korea have stemmed from this cluster.

Response

The country was in a very good position to respond. South Koreans have universal health care, and they have double the number of hospital beds compared to the OECD average. Also, unlike Western countries, they were primed to treat the coronavirus as a national emergency. 

From the MERS control effort in 2015, Korea had learned that infections among medical staff turned hospitals into hotbeds of infection and sapped the ability of staff to do their job. At the onset of COVID-19 infection, the Korean government ensured that proper personal protective equipment was provided to medical staff. It also created physically separated testing and treatment sites for health care workers.

Testing

Much of South Korea’s success can be attributed to the rapid development and production of testing kits, and their accelerated deployment. Soon after the first case was found, several medical companies were licensed to begin production, and within two weeks, thousands of test kits were shipping daily.

The country now produces 100,000 kits per day. Diagnostics company Seegene Inc. exports test kits to many other countries. 

To deliver the kits, about 600 testing centres were opened designed to screen as many people as possible, and to keep health workers safe by minimising contact. Unlike in Europe, hundreds of thousands of asymptomatic people were tested. 

There are about 50 drive-thru stations. a novelty inspired by the drive-through counters at Starbucks, and these were rapidly copied by other countries. Drivers pull in to a parking lot where they are met by health workers dressed in hazmat suits.  Motorists then drive to several stations where nurses in protective plastic suits, masks and face shields register drivers, check their temperatures, and use swabs to take samples from their throats and nasal passages. Patients are tested without leaving their cars. The process takes about 10 minutes. Test results are usually back within hours.

Each centre tests about 400 people a day. Workers work five hour shifts during which they cannot take breaks.

There are also walk-in centres, where patients enter a chamber resembling a transparent phone booth (see picture). Health workers administer throat swabs using thick rubber gloves built into the chamber's walls. 

From the beginning, numbers of tests conducted considerably exceeded cases found – mostly by 30 to 1 or better. The inflection point or peak of the epidemic was reached about 1 March, when the hit rate of tests reached a maximum of 3.35%. This may indicate the average infection rate in the affected cities. A total of 571,000 tests have been administered, about 11 per thousand population. 

Tracing 

The contact-tracing system was developed during the MERS outbreak. Health officials retraced patients' movements using security camera footage, credit card records, and GPS data from their cars and cellphones. Later, laws were revised to prioritise social security over individual privacy at times of infectious disease.

Once the outbreak became too big to track, officials relied more on mass messaging. Whenever new cases are discovered, websites and smartphone apps deliver timelines and details of infected people's travel: their itineraries and even whether they were wearing masks. A central tracking app, Corona 100m, informs citizens of known cases within 100 metres of where they are. People who believe they may have crossed paths with a patient are urged to report to testing centres.

The contact tracing system uses data from 28 organizations including the National Police Agency, the Credit Finance Association, three smartphone companies, and 22 credit card companies to trace the movement of individuals with COVID-19. This system takes 10 minutes to analyse the movement of an infected individual, saving the days of laborious work and phone calls for each new patient made by trace workers elsewhere.  

For people who come in contact with an infected person, the Center for Disease Control and Prevention (KCDC) informs the local public health centre near the infected citizen’s residence. If they test positive, they are hospitalised at a COVID-19 special facility. Those without symptoms are asked to remain self-quarantined for 14 days.  Only epidemic investigators at KCDC can access the location information, and once the COVID-19 outbreak is over, all the personal information used for contact tracing will be purged.

People ordered into self-quarantine must download another app, which alerts officials if a patient ventures out of isolation. Fines for violations can reach US$2,500.

Visitors from abroad are also required to download a smartphone app that guides them through self-checks.

Public cooperation

A culture that has often rebelliously rejected authoritarianism has embraced intrusive measures when lives are at stake. Health authorities have aggressively promoted hygiene and social distancing. 

Throughout the epidemic, the full co-operation of citizens has been sought. Television broadcasts, subway station announcements and smartphone alerts provide endless reminders to wear face masks, pointers on social distancing and the day's transmission data – instilling a near-wartime sense of common purpose.  

Because the public have been so well informed, confidence has remained high, panic has been low and there has been little hoarding or rushes on supermarkets.

In an act of solidarity, government workers offered to donate 30% of their salaries to the COVID effort. 

Death rate

The case mortality rate is fairly low at 2.2%. Oddly it has continued to rise throughout the epidemic. It is actually not as low as found on cruise ships or in Australia, probably indicating that a pool of symptomless infected are present that are preventing the virus becoming extinct. 

Compared with Europe however the case death rate is low. Reasons given are that treatment has been focused on the severely ill, rather than those ‘likely to survive’ in overwhelmed facilities. By identifying and treating infections early, and segregating mild cases to special centres, South Korea has kept hospitals clear for the most serious patients. 

About 2000 cases are still isolated, and there have been 240 deaths. About 95% of cases have been from Daegu, from Seoul or repatriated from abroad.   

Continuing epidemic and lockdown

Korea belatedly issued a Level 2 lockdown or social distancing policy from March 21, after the epidemic had been suppressed but cases remained stubbornly around 100 per day. High-risk facilities were urged to close and religious, sports and entertainment gatherings were banned. To prevent a second-round resurgence, a set of guidelines have been issued for a new-normal “everyday life quarantine” covering outings of all kinds. Citizens wear masks and exercise social distancing at all times.

A modest payment is made to those in quarantine, allowing them to purchase simple necessities.

No cities are quarantined or under 'stay at home' orders, the restaurants, churches, bars, gyms and learning institutes are allowed to open, grocery stores are fully stocked, and the country just successfully held parliamentary elections in mid-April. Korea is open for business - and for sport.

Korea will be the second country in the world, after Taiwan, to hold baseball games this year -  without an audience and under a rigid testing and distancing regimen. Each player’s temperature will be taken twice before a game. Players will be highly encouraged to wear masks in the clubhouse and in other places, except for in the dugout and on the field. Barehand high fives and handshakes will be prohibited. Umpires will wear masks. If a player tests positive, that ballpark will not be used for two days. 

Commentary

The countries that were really successful in avoiding an epidemic closed their borders immediately. Korea did not want to do this, which is not surprising given its heavy integration into the global economy. The country did therefore suffer a fairly significant epidemic through its open borders and the presence of very large religious cults - ending up with 10,700 confirmed cases and probably quite a few more asymptomatic ones. 

Yet because of its general preparedness, its testing and tracing programme, its high grade medical facilities, its protection of medical staff and its engagement with the public, Korea managed to suppress the epidemic better than the 'advanced' countries of Europe and North America, and it has a fair chance of eliminating the disease.   

Korea brought its pandemic under control while barely engaging in the kinds of stringent control necessary elsewhere. It saved itself a vast fortune by being prepared and by encouraging trust among the populace. It  may even come out of the pandemic financially ahead through its exports of equipment, and because outside of Daegu it never closed down.

It is surprising that given this system is so much more efficient than the 'mediaeval' lockdown alternative, no other country has tried it. Repeated statements are made by other countries that this system could not work there because their own populations would never countenance that level of scrutiny. 

Yet police in all these countries have engaged since 9-11 and before in widespread public surveillance through mobile phones, credit cards, traffic cameras and CCTV without ever having consulted the public at all, and without any public protest. 'Persons of interest' and some not so interesting are under permanent scrutiny for no good reason except the existential fear of terrorism and quite often, for revenue generation through fines.

It is hard to understand why any populace would not tolerate temporary surveillance by medical workers wanting to save their lives. The difference appears to be that the public would have to consent and be kept informed, something foreign to existing surveillance agencies.