Report in May 2020 ②

Choe Seongjun
National Chungbuk University, Korea

Today (20 May 2020) is the day, 4 months after the detection of the first patient in Korea. Here, I would like to talk about the occurrence and response of COVID−19 in the Republic of Korea, which I watched as a citizen.

The calm before the storm

In January 2020, I was spending a normal daily life. I was planning to travel abroad with my wife and revising some data with a manuscript to be submitted in near future. I was only thinking that the mysterious disease I heard from foreign news was a just related to another country. Although I worried about my aunt and her husband, who were staying in China, I thought it would be finished after spreading to some local areas, like many other diseases. At least that was what I believed at that moment. Unlike with me who saw the situation in an optimistic light, it seems that the Korean government and experts were seriously looking at the situation and preparing for it. In fact, they have been prepared for this situation a long ago.

On December 17, 2019, the Korean Center for Disease Control and Prevention (KCDC) carried out training on countermeasures by assuming that a family exposed to an unknown pneumonia originating from China had entered to our country. KCDC have already tested the detection technique and epidemiological preparation [1]. And the preparations proved to be of a great help when the positive patient of COVID−19 was confirmed for the first time in Korea about a month later. The attitude of KCDC toward the newly emerged diseases is not a run up.

In 2015, we spent a hard time with the Middle East Respiratory Syndrome (MERS). Until when all the disease issues were over, 186 individuals were detected as positive, and among them, 39 people had died [2]. It was obviously a huge failure in the disease control, with the largest number of infected and dead case, with the exception of the number of cases in Saudi Arabia. In order not to repeat this mistake, the Korean government has been steadily preparing against the outbreak of similar diseases [3].

At the time when the number of positive patients in China increased, the KCDC had already established the measures based on information such as symptoms and the outbreak areas, and began to develop the detection kits based on the sequences of the virus provided by China. It was a very appropriate measure considering the COVID−19 pandemic, but it was pointed out that it was excessive at the moment [4]. In the early periods of the COVID−19 outbreak, there was a rumor that even the domestic production of mask in China could not satisfy the Chinese mask demand. People who are sneaky and unscrupulous have attempted to stock up or hoard the masks or try to get it by direct contact with the Chinese company. They even tried to re−export the masks to other countries, and it led to the lack of masks stocks at the early stages of COVID−19 outbreak in Korea. At the time, the word "mask coin" was frequently used between people, and it originated from the electronic money such as Bitcoin.

The beginning of spread

On January 20, 2020, the first positive case was confirmed in Korea. The patient was a 35 years old woman from Wuhan, China, and the second positive patient was confirmed four days later (January 24). Although both patients were imported cases from overseas and the infection in the local community was not confirmed, but it was enough to cause anxiety in Korean society. More and more people tried to get masks, and people who went out on the street with wearing masks increased. The number of positive cases increased one by one with the passage of time. All of the cases were imported cases from China, and some of them were walking through the streets with the symptoms. Flights between Korea and China have been on the decline, and many Korean in China have already returned. A lot of anxiety has been heightened by the contact with COVID−19 positive patient who are not detected, and also with the arrival of people from China. On January 30, the number of positive cases increased to six. Especially, one of them was the first case infected by contact with the third positive patient, and it means that secondary infection in Korea had occurred for the first time [5]. A stroke of good luck in the midst of misfortune was that the attempt to develop the inspection method was already successful, and it will soon be distributed through the emergency use authorization system. In addition, the KCDC provided information on the movement trails of positive patients, and through epidemiological investigations, almost all the people who had contacted the patients were self−isolated and inspected for COVID−19.

The initial responses to COVID−19 were aggressive and active measures. The KCDC tried not to miss a single positive patient through as many examinations as possible. They examined all the suspected cases and people who had contact with positive patients. It was a steady increase in the number of positive patients. In addition, policies to protect Korean nationals were continued. All the Koreans residing abroad, including KOICA (Korean Oversea International Cooperation Agency) members from each country, who were dispatched to support other countries, returned back home [6].

Through the launching of charter flights, they also made efforts to transport isolated Koreans from China. Some Koreans were concerned about the return of Koreans staying abroad, and some citizens in the vicinity of the facilities for isolation protested against the government. However, these movements quickly faded. Indeed, there were few positive cases confirmed among the returned Koreans who are isolated in the facilities, but they were all managed efficiently and there were no cases of transmission from them. In Korea, the COVID−19 seemed to be well managed.

The status of COVID−19 in Korea on 18 May 2020.
(Captured from http://ncov.mohw.go.kr/ )

Explosion

On February 18, 2020, a patient was added and the number of positive patients in Korea became 31 [7]. The problem was that the patient had no history of travel abroad and had no contact with other positive cases. And also, due to her vigorous activities, it was revealed that she had contact with a large numbers of unspecified persons. She had visited places of worship and was later revealed that she belongs to a religious group called "Shincheonji" as well. From this day, the pattern of COVID−19 transmission in Korea changed completely from those as before. The number of positive cases associated with patient 31 began to accelerate, and exceeded 800 in just a week [8].

The religious group, "Shincheonji" was considered as very special, especially in the situation of COVID−19. Shincheonji has been regarded as a heretical group by the mainstream Christian groups in Korea, and it had led to them to keep a low profile externally, but act mainly in the shades. They secretly recruited and educated the believers, and their meeting site provided conditions for close contact with people. Their clandestine activity has also been seen as a problem in epidemiological investigations, and it has been difficult to identify and trace the contacted people. Worship in the Shincheonji church in Daegu was pointed out as a hot spot of transmission, and as a result, the COVID−19 was finally spread into local communities in Daegu city. Infections related with Shincheonji were consistently detected, and on March 20, the number of patients who were directly associated to Shincheonji was counted as 5,028 [9]. At that time, it was occupying 58.7% of the total detected positive cases in Korea, and also on February 18, before the Shincheonji issue, only about 50 additional positive patients were newly confirmed in a month.

Prior to Shincheonji, the measures taken by the Korean government seemed quite successful. A small number of patients were isolated in negative pressure rooms and were being provided adequate treatment on time without a single death occurring. However, everything changed. On February 20, the first death occurred. The fatality was an elderly high−risk grouped patient who was infected while being hospitalized in hospital. As the number of patient and elderly patient increased, the medical staff began to be overloaded. Social distance was implemented, and the opening of the schools was delayed. The university began and continued with the online lectures.

The supply of the masks did not work out smoothly due to the seriousness of the situation. Many people wanted to get masks and other protective equipment but not all could lay a hand on them. The Korean government put mask production under the control of the government and distributed public masks to society. According to the date of their birthday, 5−shift mask distribution system was implemented to prevent too many people concentrating to buy the mask on the same day. Additionally, foreign exports of masks and other personal equipment were strictly prohibited. The KCDC made efforts to ensure efficient distribution of the mask to the public until the COVID−19 situation calms down [10].

People waiting in front of a restaurant. All the people are wearing face masks.

The fire burns low

Despite the explosive increase in the number of positive cases, the efforts of the Korean government and the KCDC were astonishing. They conducted the detection for all the suspected cases like trying to chase all the small pieces of COVID−19, and finally succeeded in catching the tail of transmission. Under the pressure of the government and public opinion, finally, the Shincheonji also agreed to cooperate by providing personal information of the related people. In early March 2020, it succeeded in conducting a total inspection of 99% of Shincheonji people [11]. The number of positive patients increased steadily and the COVID−19 was still transmitted between local communities. But the newly confirmed positive numbers were decreasing day by day. On April 20, two months after the Shincheonji issue began, the newly confirmed positive patient decreased to less than 10.

Various factors may have contributed to the successful COVID−19 management in Korea. The constant inspection to detect the positive cases was conducted steadily to prevent further transmission. During the period, it was conducted continuously from as few as a few thousand to as many as 10,000 daily. Additional diagnostic techniques have been developed to increase the testing efficiency. Typically, the drive−thru method was devised. This method was primarily introduced to the Daegu Chilgok hospital on February 23, and has the advantage of minimizing contact between medical staff and suspected patient, thereby reducing the risk of transmission and increasing the speed of examination [12][13].

In addition, a walk−through protective device was introduced to take care of the medical staff whose wear protective equipment all day or the need to change equipment periodically. This method, which was introduced from March 15, can be applied to people without cars, and it is possible to conduct tests more safely and efficiently by separating the medical staff from the suspected patients. A well−organized and systemized method could be carried out efficiently, thus reducing the inspection time [14].

Well−organized public health care was also one of the important factors. The inspection fee of COVID−19 was mostly supported by the Korean government. If the result was positive, the examination fee was free, and also for the situation that physicians recommended to get inspection or if the patient was classified as suspected COVID−19 patient, the examination fee is free as well. In addition, for the positive cases, the cost of treatment was very low through the utilization of the medical insurance system. For example, an invoice for a patient who had recovered from COVID−19 with 19 days of in−hospital treatment was open to the public. Among the billing costs of 9,709,900 won, the expense for the patient was just 44,150 won [15]. The people who were under the status of self−isolation were provided with many supplies, such as foods, drinks and stress relief books, coloring books and many others.

The cooperation of citizen was also very helpful for the control of COVID−19. Social distancing settled like a culture in people's minds, and it was difficult to find people without masks on the streets. Although there were some negative opinions in the area related to the disclosure of personal information, most of the citizens recognized that the society itself has greater priority to personal information, and many of them cooperated [16]. Based on the development of the Internet, the citizens communicated and exchanged disease information. Many people who did not wear masks or did not follow self−isolation guidelines even they have symptoms were criticized on the internet. People have managed themselves well and together with their neighbors, cooperated so as not to be a cause of transmission. In addition, due to the implementation of the 5−shift mask system, the enough medical materials were supplied sufficiently to the people, and by mid−April, the medical materials were even in excess of the actual need.

The war undone

At the beginning, the main measures of the Korean government to break through the situation with the standard tactics created a lot of concerns. All the suspected cases including contact with positive cases or its traces, suspected symptoms and all the related subjects were inspected, and sometimes it seems very aggressive. This attitude actually contributed to the increasing number of positive cases in Korea, and at some moment, the number of positive cases in Korea was higher than any other country except China. Due to these measures, some countries restrict entry from Korea. As a result, the measures were thought to lead to the diplomatic and economic damage to our nation. However, the decision was actually a choice to choose the future good rather than the benefits in front of the eyes. That choice was transformed and connected into positive results. It worked, and the COVID−19 in Korea seemed effectively controlled by the measures.

The basic policy of the Korean government was transparency and fairness. The government provided the accurate information related the COVID−19 issues, and they especially took care and paid more attention to the high−risk group such as elderly, childish, disabled person and low−income group. This policy created a situation in which people could trust the government and voluntarily participate in the measures against the disease. In particular, the support of government also reached to a lot of people, that is, including Koreans staying abroad, even adopted Koreans and also foreign veterans of the Korean War. It also contributed to improving the credibility of our nation and the national image. All the products related with quarantine and inspection kits obtained through effective COVID−19 management were also used as donation to countries that had a positive impact on Korean history in the past.

The situation seems to be better and better, but in fact the corona crisis has not been completely eradicated in Korea. At the end of April, optimism began to rise due to the steady decline of daily confirmed positive cases. Three months after the beginning of the COVID−19 issue, many Koreans felt tired on the unusual daily life, and the March to May is the season of flower in Korea. Many people missed the outdoor activities and the good weather in Korean spring. They missed the relaxed, peaceful normal life at the past days. Thus, when the COVID−19 seemed to fade, some people tried to do their usual activities again. The number of positive cases decreased, and there were some days when the confirmed positive case was zero, excluding the imported cases. People gradually loosen up the tension. Eventually, it exploded again during the long holiday season in Korea in early May. A person confirmed as positive for COVID−19 on May 7, was found to have visited several places in Itaewon, despite with symptoms. The disease was transmitted again from the Itaewon Club to the local community. And on May 20, there were around 200 additional confirmed infections. It wasn't over yet [17].

The COVID−19 in Korea and its control are still in progress. Although the second wave is expected, the KCDC is making preparation to face it. It is true that the transmission is still occurring in the local community in our society. One thing that is better than the Shincheonji incident is that the overload of medical staff due to the rapid increase of positive patients has been relieved, and the supplies of quarantine products are smooth, and all of these have been within the expected range. Most people have followed the notice of the government and tried to control the transmission of COVID−19. However, as like the Itaewon Club issue, some selfish people could reinvigorate the disease again at any time.

Perhaps the complete termination of COVID−19 could be achieved only through global corona management, not just by stopping the regional spread in Korea as achieved by blocking the foreign inflows. The supply of vaccines and treatments, or the possession of antibodies by most of the people, seems to be still far. The countermeasures against COVID−19 of Korean government are not only aimed at the prevention of transmission, but also the goal is to reduce the burden on medical staff and society, and to delay the major outbreak time until an effective treatment or prevention methods are available. Maybe, we will continue to overcome the COVID−19 with this attitude. I don't know when this tragic disease issues will be over, but I hope the day will come as soon as possible.