A new study has detailed how South Korea's carefully prepared and pre-planned combination of pandemic mitigation measures successfully curtailed the country's biggest outbreak of SARS-CoV-2 infection (also known as COVID-19) early in 2020, without resorting to formal lockdown.
"They had a set of infection control protocols that existed at the regional and national level, and at the hospital level," said Harvard University's June-Ho Kim, MD, MPH, from Ariadne Laboratories at Brigham and Women's Hospital, lead author of the study reported in the journal NEJM Catalyst (2020; doi: https://doi.org/10.1056/CAT.20.0159).
"In South Korea they were successful in being able to quickly mobilize," Kim told Oncology Times. "I think a lot of that success was due to national government coordinating the stakeholders-both private and public bodies. The government bought the majority of the supply of masks and distributed them [free] to hospitals and the general population," he said.
COVID-19 Coverage Success
Kim's group examined data from Daegu in southeast South Korea-a city with more than 2.4 million people. The first case of SARS-CoV-2 had been confirmed there on February 18, 2020, and by the end of the month the outbreak had already grown to a total of 2,000 infections. Such was the explosive growth of infections that by March 7 over 5,000 citizens of Daegu had been confirmed positive for COVID-19. The city's medical system was near to being overwhelmed-with a looming shortage of beds, supplies, and medical workers.
Under South Korea's pandemic preparedness program all high-risk facilities, including hospitals, nursing homes, and long-term care facilities conducted universal testing and intensive screening combined with systems for cohort isolation, infection control consultations, and transfer to COVID-19-designated hospitals. By March 15, infections in Daegu had reached a total of 6,000. But the pre-planned mitigation measures had kept this below 7,000 up to the publication of Kim's study when the outbreak was effectively over. However, teams in Daegu remained vigilant to prevent a second wave of infection.
Kim said there were a number of reasons to explain the success of South Korea's outbreak control measures. "One of the enabling factors was that they have a national insurance system. Because of that they are able to have a coordinated system in place and effect change across not just one hospital at a time but across the network."
He also gave credit to the Korean Centers for Disease Control and Prevention, which gave strong leadership and good communication to coordinate mitigation efforts and maintain public acceptance of measures-some of which included cell-phone technology and anonymously tracking card transactions to check for peoples' travel patterns.
He attributed the will for national preparedness and public cooperation to previous bad experience. Koreans had been motivated to comply with measures such as personal distancing, work closures, high-tech contact tracing, and the wearing of face masks by widespread knowledge and fear of disease transmission.
"Across a lot of the Asian countries-particularly after the SARS (severe acute respiratory syndrome) and MERS (Middle East respiratory syndrome) outbreaks-face covering was a lot more widespread," he said. "This was also helped by the fact that many Koreans choose to cover their faces to give some protection against pollution."
Informed by the Korean data, Kim was in favor of using face coverings widely to protect populations against COVID-19. "Masks and PPE are quite important. That's not been controversial [in Korea]. It's been accepted from the beginning," he said. In South Korea, citizens had been seeking out masks on the first news of the coronavirus pandemic, he said, and there had been mask shortages until the government stepped in to limit price and supply free ones.
"In hospitals there had been a big emphasis on stockpiling personal protective equipment (PPE) and N95-equivalent masks," said Kim. "This had been to ensure all PPE was appropriate, with high-grade masks."
The study found that the incidence of infection among hospital staff caring for patients with COVID-19 in Daegu had been only a fraction of the rate it had reached in some European countries-attesting to the efficacy of the high level PPE used Korea, where Kim said the highest protection N95-equivalent masks had been recommended in hospitals for all situations when dealing with infected patients-and not just for aerosolizing procedures.
Key Potential Lessons
Although no two countries or regions are the same, the data from South Korea clearly gave clues about effective mitigation elsewhere. Kim said there were key steps in South Korea that "really contributed to their ability to protect health care workers during the outbreak." But success had not been due to one "miracle" measure above all others. A combination of well-coordinated measures had been necessary.
One of the key individual planks of South Korea's strategy had been very large-scale testing through a network of nationally coordinated centers. Positive tests triggered diligent contact tracing. Added to this had been "supportive isolation." Early in the outbreak all patients with COVID-19 had been hospitalized. But the government had engaged big companies (such as Samsung) to make dormitories available that had normally been used for activities such as residential staff training. These facilities then became temporary isolation wards for mild cases of COVID-19. This practice not only provided good facilities for patient care, it also cut the chain of transmission by taking infected persons out of the community.
"They were not going home and spreading it to others," said Kim. At day 13, after their positive test, patients recovering from COVID-19 had been retested and, and if the result was negative, were discharged 2 days later.
Putting a system in place to stratify and triage patients according to their level of severity had been vital to balance the load of cases across the region so that bed and equipment shortages did not develop into major issues.
At the beginning of the outbreak, South Koreans already had more hospital beds per capita than most countries. By triaging less symptomatic patients to the new isolation wards, they were able to stay well ahead of the patient workload curve and, importantly, to continue most of the usual care for patients with other conditions. Other treatments were made safer by dedicating some hospitals to patients with COVID-19 only, leaving other centers for treating remaining morbidities.
"Having that regional system in place is quite important," said Kim. Also key to success had been the system (prepared in advance) for rapidly recruiting additional health care workers to limit working hours for all hospital staff and prevent staff fatigue, burnout, and psychological overload.
Among the factors for keeping nosocomial infection rates down within hospitals, Kim regarded universal masking as "a huge consideration."
"There's this outstanding issue of asymptomatic and pre-symptomatic spread. And the masks are a way of controlling that," he said.
When he was asked to comment on which of the measures his group's research article had identified as effective might guide action plans for other regions of the world where the pandemic had been more developed, he said that planners "should not let perfect be the enemy of the good."
"Even if contact tracing is not going to solve the entire issue, [the lesson is] to put that into place, and to put different measures into place in order to start chipping away at the problem even though there are an overwhelming number of cases," he said.
"It's really a combination of measures that does the trick, and not just one miracle treatment-[including] masking, symptom screening, social distancing. Even in places where the virus is more established (and almost endemic now), scaling effective measures in public health [does] work. It's not too late for that. And it's a combination of measures scaled and over time that will be able to bring the virus under control."
Kim also highlighted the importance of continuing other health care activities and routine hospital appointments, even in the midst of a COVID-19 pandemic crisis.
"What we're seeing around the world is that a lot of people are missing essential or routine care during the pandemic. So, having protocols in place, being able to triage effectively, being able to create spaces for both COVID and non-COVID patients at a regional level may really help serve both the COVID-19 patients and also patients without COVID-19," he said.
Peter M. Goodwin is a contributing writer.