At the end of February, the number of new coronavirus infections in South Korea exploded as a result of a major cluster of cases in Daegu, a city of 2.5 million people. This has been blamed on a so-called “super-spreader” – or patient-31 – who had recently visited Wuhan and come into contact with 1,100 people at a gathering of the Shincheonji Church of Jesus upon her return. Another major cluster occurred in the municipality of Cheongdo. At the peak of the epidemic on 29th February, there were 909 new cases. But by 5th March, the number of new cases was half the peak figure, and by 10th March this figure had fallen to 131.
Although South Korea isn’t out of danger yet, it reported only 47 new cases on 6th April. To date, there have been 10,284 confirmed cases and 186 deaths. It has therefore been able to avoid the death and devastation seen elsewhere. For comparison, 5,373 have died in the UK and 51,608 hospitalised patients have tested positive for COVID-19.
Unlike China, the other example of a country that has successfully brought a major COVID-19 outbreak under control, South Korea did so without large-scale confinement or travel restrictions. Although the People’s Health Movement has raised some justified concerns about the Korean response, the policy of testing and tracing offers valuable lessons on how to execute an effective response without the massive economic, political and social impact of a lockdown. This policy brief is based partly on insights provided by a friend living in Seoul, South Korea – plus information from the official sources, grey literature and academic articles.
The strategy of testing and tracing is led by the Korean Centers for Disease Control and Prevention (KCDC). The KCDC reports the number of antigen tests undertaken each day in press releases that appear on its website. At the peak of the outbreak about 20,000 tests were carried out each day. Since the beginning of the outbreak, there has been a total of 466,804 tests. This accounts for 0.9% of the total population. In the UK, 208,837 people have been tested (0.3% of the population) and 13,069 tests were carried out on 5 April – these figures do not include Northern Ireland.
There are 635 screening centers, according to KCDC. A list of these facilities and their location is available on the KCDC website, as well as a telephone helpline. The screening centres are designed to test as many as people as quickly as possible, while minimizing patient-health worker and patient-patient contact. There are about 50 drive-through testing facilities across the country, where throat swabs are taken as the patient sits in their car. Some walk-in centres have chambers that look like a transparent phone box, where health workers take throat swabs using gloves built into the wall.
Antigen testing is free and it is only a few hours before the results are returned by text message. The state covers the cost of hospitalisation and treatment of COVID-19 patients, as well as providing compensation for people who have to self-isolate. This provides an incentive for people to get tested even when they are asymptomatic.
In addition to the screening, many large buildings such as offices and hotels use thermal imaging cameras to identify people with fevers, and some restaurants check customers’ temperatures before allowing them to sit down.
A whole infrastructure has been set up to support the testing process – which often involves collaboration between the public and private sector. Crucially, the KCDC created a system of fast-track approval for testing kits in a virus outbreak. This allowed KCDC to bypass a lengthy authorization process. As a result, a local company called Kogene Biotec developed the Powercheck PCR Kit, which was approved by KCDC two weeks after China released the genetic sequence for COVID-19 and available in 50 clinics three days later.
The system of testing is only as good as the process that responds to test results. South Korea developed its tools and practices for contact tracing in response to the 2015 MERS outbreak. This includes the use of location data from mobiles phones and cars, CCTV footage, and credit card records to identify anyone who has come within 2 metres of a confirmed case in the 24 hours before the person began to display symptoms.
Across the country, people suspected of being exposed to the virus are then contacted, tested and, if necessary, isolated. This process is carried out by the KCDC in cooperation with local governments. People ordered into isolation must download a mobile phone app that allows the patient to communicate with health authorities and report their symptoms. It also alerts the authorities if someone breaks their isolation. The fine for violating mandatory self-isolation is between £1,900 and £6,500, or up to 1 year in jail.
In addition, KCDC provides a list of confirmed cases on its website. Names are not revealed but age, sex, and the area where the infection occurred are publicised. Local governments use local media, social media and, in some areas, text messaging to communicate details of infected people such as the occupation, employer, and travel history. Websites and apps allow the public to track the routes taken by infected people.
The KCDC would usually only be able to access this data with the consent of the individual or a court order, but after 2015 the law was changed so that these safeguards can be bypassed during infectious disease crises. The National Human Rights Commission raised concerns that the disclosure of personal information was overly intrusive. In response, the KCDC released new guidelines instructing local governments not to release information that could result in the identification of an individual.
It is interesting to note that KCDC used different strategies in different parts of the country. In the “special management regions” of Daegu and Cheongdo, resources were focused on isolating and treating potential cases rather than tracing. In regions where there were fewer cases, tracing continued.
Lessons to be learned
South Korea’s apparent success in containing the COVID-19 outbreak is widely seen as a consequence of learning lessons from mistakes made during previous infectious disease outbreaks, including SARS in 2003 and MERS in 2015.
In the same vein, it is important for the UK to learn from the mistakes it has made during the past couple of months and, in the words of Dr Tedros Adhanom Ghebreyesus, the Director General of the World Health Organization, “apply the lessons learned in Korea”.
So what exactly are these lessons?
First, that the Korean testing and tracing strategy appears to have been effective without being prohibitively complex or expensive. Even when it was not possible to continue intense testing and tracing in particularly badly hit localities due to the sheer number of cases, it was maintained elsewhere. This contained localised outbreaks and prevented them from becoming a national outbreak. In contrast, the UK abandoned testing and tracing in mid-March when it moved from its containment phase to mitigation.
Second, the testing and tracing strategy was supported by a well-funded health system and an active local government. Although the Korean hospital system is highly privatized, the government has asserted control over the sector. In the UK, the NHS and local government have been weakened by a decade of austerity. What is more, whereas there seems to be broad political and popular support for the Korean government’s approach, it is not clear that would be the case in the UK.
Finally, it is important to note that South Korea did not put a system of testing and tracing in place overnight. The response to the current outbreak is part of a well-resourced plan developed over years in response to failures in previous epidemics. The UK is now in the midst of the COVID-19 outbreak, so does not have much time or capacity to develop a strategy. It seems likely, however, that once the first wave of the outbreak is under control, any loosening of lockdown measures will precipitate a second wave of infections. There is a clear need to invest more in strategic planning for that scenario.