OPINION: Lessons from South Korea on COVID-19 pandemic response
By Ondari D. Mogeni
As COVID-19 spreads across the world, South Korea is one of the countries that was not spared from exposure in the early stages bearing in mind its proximity to China where the outbreak began.
In fact, some of the initial cases were from citizens who had travelled to Wuhan and linked to the Sincheonji church in Daegu, a city that now accounts for more than 50% of all the confirmed COVID-19 cases in South Korea that stand at 10,062 as of Friday April 3, 2020.
Globally, everyone seems to agree that South Korea has done well in its response to the pandemic. What is it that they did right?
It is important to state from the onset that they did face challenges as it would be the case in any ongoing and rapidly evolving process. However, they approached the response objectively and proactively using the available data and evidence.
Learning from history
South Korea learnt a lot of lessons from the Middle East Respiratory Syndrome (MERS) outbreak of 2015 in which there were 186 confirmed cases including 38 deaths.
Since then structures have been put in place to ensure the country is prepared for the next outbreak.
Thus, when it recorded its first COVID-19 case on 19th January, one could say, the country was ready and approached the pandemic with a unified voice and a clear structure.
After the 1st case was announced, what followed was single digit case notifications with none on some days.
The first double digit notification, 34 cases, was on 19th February. This found me in Nigeria where I was at the tail end of an official trip.
Friends and family members who were aware of my impending return to South Korea, urged me to travel to Kenya instead of South Korea, notwithstanding that Seoul, where I reside and, is about 237 kms away from Daegu city; the South Korea epicentre, had not recorded any positive case yet.
Kenya had not recorded any case at the time. Certainly, one would understand their sincere concern and while acknowledging their fears, I kept assuring them that I will exercise all the necessary precautions and emphasised that a soldier does not leave the battle field until the war is won and as such, South Korea, my current country of residence, is where I needed to be.
Adapting the case definition to the prevailing circumstances.
The COVID-19 situation is daily evolving and as such, what was applied to make decisions yesterday may need to be modified today based on available data, emerging concerns and credible information.
One was suspected to be infected with SARS-CoV-2 if they had a fever of (37.5 C) or respiratory symptoms (cough, sore throat, etc.) within 14 days after having close contact with a confirmed case while that patient was symptomatic.
On the other hand, one was considered to be under investigation if they had fever or above-mentioned respiratory symptoms within 14 days after traveling to affected countries/areas of local transmission of COVID-19 with confirmed cases or have epidemiologic link to the ongoing outbreak.
This meant if one did not fit into the above criteria when they called the designated call numbers, they were advised that they did warrant to get tested.
Case definitions are important as they ensure the focus is directed towards the target population that may have been exposed.
It is a key step in the process of identifying those with the disease. Where available, a lab confirmation is important which in the case of COVID-19 currently is through a molecular test that detects the gene material that is specific to SARS-CoV-2.
As the numbers of confirmed cases increased, an indication of local transmission, the case definition was expanded to include recommendation by physicians if they determine the patient has pneumonia of unknown cause even in the absence of exposure or travel history.
As the case definition was made sensitive, testing was decentralised to various centres, creative ways such as drive through stations and of booths were established for sample collection.
This not only ensured efficiency in sample collection but also guaranteed usage of few personal protective equipment’s (PPEs) in line with the World Health Organisation recommendations.
Consequently, there rest were utilised where they were needed most such as in clinical setups. Establishing and diversifying diagnostic capability across the country resulted in wider reach, faster sample collection and subsequent testing, provided a head start in the race to flatten the curve.
This is ongoing and as new COVID-19 clusters are identified so is the establishment of a testing centres in every region to enable easy access for everyone who requires testing.
Screening is an integral process of identifying suspect cases, though South Korea has not closed her borders, increasingly enhanced inbound screening efforts at all points entry for everyone have been established.
When I returned in to the country on February 22, other than the arrivals from China, it was expected of us to fill a health screening form at the arrival gate and temperature was taken as the health officials reviewed the filled details that included, among other things, countries where one has visited-other than the point of origin, any symptoms and where they will be staying.
There is a second thermal temperature check as one proceeds to the immigration desk.
At the beginning of the outbreak in South Korea there were calls from the public to close the borders but the government refrained from doing so though later it did, as a protest and retaliation to countries such as Japan which had revoked entry privileges for South Koreans during the peak of the outbreak.
As many know, South Korea is acclaimed as one of the most technologically advanced countries and this is evident during the ongoing pandemic.
Anyone exposed or currently arriving into the country downloads an app that records their movements. This information is accordingly relayed to the public via text/emergency alerts with a link to an attachment to the said person’s movements, should they test positive.
This helps with contact tracing as people are made aware of the places and time that the COVID-19 confirmed person frequented. The information relayed to the public includes details of the location of the case, and granular details such as street, sub-way station.
One of the greatest takeaways from the way South Korea has responded to the pandemic is through highlighting the value of investing in research and development (R and D).
They can manufacture their own testing kits and PPEs. South Korea has underscored the fact that self-sufficiency is possible but is a product of hard work, is resource intensive and includes investing in R and D.
Due to South Korea`s capacity to manufacture its own test kits, it became possible to ramp up its diagnostic capacity and currently i is the country that has tested the highest number of samples – 424,365.
No lockdown was implemented in South Korea. Instead the government provided guidelines encouraging people to voluntarily adopt social distancing, work from home and avoid large gatherings be they religious, conferences, weddings etc.
Unfortunately, other COVID-19 clusters emerged due to groups that still met despite these guidelines.
When the COVID-19 dust settles down, it will be interesting to find out what people think about working from home and the use of technology for telecommuting given that Korea is known for their culture of long hours of hard work.
Overall, people were supportive of the government guidelines to minimise activities and practise social distancing which I call physical distancing.
For instance, some restaurants changed the sitting arrangements to ensure people did not sit facing each other, varied working schedules, and cancellation large gatherings and events.
In the last 3 weeks, there has been an increase of imported COVID-19 cases from Europe and the Americas, 318 and 218 respectively from the total 597 confirmed imported cases during the period.
Consequently, the government instituted further measures over and above those that are already in existence.
They included screening and testing for COVID-19 of passengers from these two continents regardless of whether they are citizens, residents or visitors.
Those with a negative result are subjected to mandatory self-quarantine for 14 days while those with a positive result are moved to an isolation facility.
A senior colleague, who arrived during this period, described the process.
On arrival from one of the countries in Europe, they were asked to download two apps, to monitor movement and daily self-diagnosis.
After which and upon going through the necessary immigration procedures, underwent the test at a facility by the airport and then transferred to a quarantine facility.
The results were provided the following day and thankfully they tested negative for SARS-CoV-2 thus allowed to continue with self-quarantine at home.
Health officials will call to check on those on self-quarantine at home, make impromptu visits, just in case one may have deliberately left the phone at home, and if one leaves the defined area, information is relayed to the relevant health officials.
If one violates the self-quarantine measures a fine is imposed and further subjected to mandatory quarantine at their cost.
It is worth noting that since the pandemic spread to South Korea, of the 645 COVID-19 imported cases recorded as of April 3rd, only 3 are from the African continent while those from Europe account for the bulk of cases; 337.
Additionally, a further guideline has been provided to countries with flights to South Korea to bar any passenger who has a temperature of 37.5℃ and above from boarding a South Korean bound flight.
This is a measure the South Korean government implemented, for outbound flights, during the peak of cases notification by instituting comprehensive departure screening measures in 3-tier fashion from the check in desk to the departure gate and if one was found to exhibit symptoms/signs or history of COVID-19 exposure, they were advised to alter their travel plans.
Airlines were requested to facilitate that and subsequently, the passenger was subjected to the relevant COVID-19 surveillance investigations.
Diplomatic representatives in South Korea were invited to witness these departure screening procedures in order to assure their government of the reduced risk of exporting cases to other countries due to those rigorous measures.
At the peak of the outbreak in South Korea, the highest daily tally of confirmed COVID-19 cases was 909 on February 29.
To disinfect surfaces the security forces were enlisted to supplement regular service staff as was use of drones which have a broader reach potential. Sanitizers are placed at entry and exit points of building, subways and lifts.
Use of masks
Though there is an ongoing debate on the use of face masks to prevent infection, it is difficult here in South Korea to spot a person without one.
It is a norm for most countries in Far East to don masks either during Spring because of pollen, when one as cold/flu or instances of pollution. One day I forgot my mask in the house while heading to work and, a stranger who had an extra one on the subway kindly offered it to me.
The government came up with guidelines to ensure every person had access to a given number of masks per week when there was a limited supply. These guidelines included one`s identification card coupled with the national insurance documentation.
The two had to be presented before one could purchase masks at the selling outlets. Everyone could not buy on the same day but rather depending on their year of birth.
Foreigners who rely on other insurance schemes other than the National insurance, were consequently left out of this arrangement.
This was rectified following complaints and this group of people were supplied masks per family. Production was ramped up and currently the supply is enough thus, the guidelines have been voided.
Despite the initial surge in COVID-19 cases counts, Korea Centers for Disease Control and Prevention maintained and still does, regular updates initially at 9am and 4pm daily but this was later changed to once a day covering the period up to midnight of the previous day.
South Korean data has generated a lot of interest globally, WHO included, in the attempt to understand, among other things, transmission dynamics and the magnitude of work done to respond to the outbreak including lab diagnostics which leads to my next point.
South Korea on average tested no less than an average of 10, 000 using locally produced test kits by various manufactures. Provision of information by the South Korea government has been a key learning lesson.
No matter how tough the situation presented itself, and angry citizens demanding border closures, the government still provided regular updates with respect to policy guidelines, epidemiology, care updates, travel information be they partial or blanket bans, quarantine measures or revoking visas.
More than 100 countries have put in place travel restrictions against South Korea.
Daily, this information from the Ministry of Foreign affairs is shared with the Transport team as the office that is monitoring the situation and has been at the fore front of supporting staff who were on travel at the initial stages of the outbreak and continue to do so though office travel is currently halted unless it is business essential.
At our workplace, a team was put in place where I have the honour and privilege to leading. We were mandated to develop guidelines for staff to mitigate exposure, what to do if a member of staff is infected, and during that period what and how to handle essential services as well develop a business continuity plan.
This article has dwelt more on the health aspects of the pandemic. However, other things the government did is for senior government officials included taking pay-cuts, evacuation of its citizens from countries around the world, offering a stimulus package, provision wage pay for low income families etc.
It is evident, that South Korea has employed a comprehensive strategy to respond to the pandemic.
However, each country needs to tailor its outbreak management to their existing capacity with outbreak response principles as a guide. Kenya has in the past successfully managed various outbreaks thus, has a head start in the current pandemic.
However, for successful containment of the pandemic locally, we must comprehensively screen and test everyone who meets the case definition.
Contact tracing needs to be rigorous, those who must be quarantined; must be and, appropriate facilities that do not perpetuate potential cross infection with SARS-CoV-2 virus must be designated.
We must enhance our intensive clinical care capacity in anticipation of a surge of patients who will require critical care and ensure all the health care workers and support staff have the relevant PPEs to effectively undertake their work and have the relevant training on COVID-19.
The National Emergency Response Committee for Corona virus must ensure they have in place a multi-disciplinary professional team to manage operations.
Failure to do so is akin to setting out for a journey without the right mode of transport, in which case the night will be a long one before dawn arrives and the consequential impact will be huge and irreversible.
It pains me to see the Cabinet Secretary of Health surrounded more by cabinet colleagues and fewer or no medical or scientific professionals such as virologists, epidemiologists, anthropologists, sociologists, pulmonologists etc., during his press briefings who should be present to clarify technical concerns that are raised.
Science must take centre stage in the decisions that are being made based on the available data and evidence.
Mutahi must make the deliberate move to surround himself with relevant professionals so that he can lead with science and scientists. His team has done a commendable job and he has public goodwill but could do more to avoid eroding the head start their decisions have enabled thus far.
Finally, accurate, truthful, and consistent communication is one of the principles of outbreak response and a cornerstone to its success. That is how the government will build public trust and ensure support.
It is the priceless currency needed to galvanise the cooperation of the masses to collectively move in the direction of containing the current outbreak. To disrupt transmission and contain the pandemic; there will be no shortcuts.
The writer is an Associate Research Scientist (Epidemiologist) at the International Vaccine Institute, Seoul, Korea.
The writer is an Associate Research Scientist (Epidemiologist) at the International Vaccine Institute, Seoul, Korea.
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