Our Covid-19 response is a long way short of South Korea’s

The country is cited as the model for Ireland’s approach to the coronavirus but we are not conducting or processing nearly enough tests

2nd April, 2020
Our Covid-19 response is a long way short of South Korea’s
Disinfectant is sprayed in front of the Shincheonji Church in Daegu: a 61-year-old is believed to have infected many others crowded together during services. Picture: AFP via Getty Images

The Covid-19 response team at Imperial College London last month outlined two fundamental strategies for managing the coronavirus: suppression and mitigation.

With suppression, the aim is to reduce case numbers to low levels or eliminate them completely. The main challenge of this approach is that measures need to be maintained, at least intermittently, for as long as the virus is circulating in the human population, or until an effective vaccine becomes available.

In mitigation, the aim is to use interventions such as social distancing, not to interrupt transmission completely but to reduce the impact of an epidemic on health services.

In this scenario, herd immunity builds up through the epidemic. Once 70 to 80 per cent of the population have been infected and convalesced, the risk of further outbreaks becomes low. The risk with this strategy is that it may easily become uncontrollable, resulting in a hugely overloaded hospital system, mass suffering and loss of life.

Several Asian countries have so far successfully suppressed, or at least halted, the exponential growth of Covid-19. Broadly there have been two successful strategies: widespread testing with less stringent quarantine, as in South Korea, and draconian mass quarantine, as in the Chinese province of Hubei.

The Irish health authorities’ stated strategy is suppression, and Leo Varadkar has stated that we are following the South Korean model.

South Korea’s first case was confirmed on January 20. Though the government’s early response was criticised as “sluggish and naïve”, the country is now held as an exemplar in the management of a Covid-19 outbreak.

Its outbreak initially centred on Daegu, a city of 2.5 million people, and specifically on the Shincheonji Church, where a 61-year-old woman is believed to have infected many others crowded together during services. Over 50 per cent all confirmed cases in the country have been contact-traced to this church.

By late February, some 1,900 Shincheoji Church members had been tested; 1,300 had symptoms. Among them, 87.5 per cent were confirmed as having the coronavirus. Of the 600 without symptoms, 70 per cent were confirmed with coronavirus. The city rapidly set up drive-through testing, with results delivered by text message within 24 hours.

In addition, South Korea is using technology to track people in ways that those in our society may find intrusive under normal circumstances. Whenever a new case is identified, authorities publish detailed lists of their movements over the previous 48 to 72 hours. This information is gleaned from mobile phone location information, credit card usage and CCTV footage. It is extremely accurate, down to the shop or restaurant visited.

The information is shared with the public using phone apps. This helps people to avoid potentially contaminated areas, and reduces the time and effort that public health officials spend contact tracing.

Other Asian countries similarly use ‘“big data”. In Taiwan, citizens diagnosed with Covid-19 were tracked by apps to make sure they obeyed the strict self-isolation criteria.

In Singapore, those without symptoms but who had contact with a confirmed case are ordered into strict quarantine. They are required to confirm that they are doing so by sharing their location data.

The biggest difference between Asia and Europe is data access rules. Governments and companies in the EU have strong data privacy rights as part of GDPR, which make access to existing data difficult.

Along with most other European countries, Ireland is still not testing those without symptoms. Many do not seem to understand the simple fact that infected people without symptoms may be highly contagious, and so make the mistake of not practising social distancing. Indeed, our authorities have contributed to this by conveying mixed messages to the public.

As recently as March 21, Dr Tony Holohan, the chief medical officer at the Department of Health, clarified his position on not testing asymptomatic people: “It doesn’t relate to capacity…. our view is that even if asymptomatic transmission is something that is technically possible, it is not a significant or important part of the driving of continued growth.”

In fact, nothing could be further from the truth. The previous day, the journal Nature noted that “covert cases could represent some 60 per cent of all infections”, and that “people can be highly contagious when they have mild or no symptoms”.

The South Koreans understood this early on. Many, especially younger people, may show no symptoms or only mild symptoms, but can be at significant risk of transmitting the virus on to others.

Tedros Adhanom Ghebreyesus, the head of the World Health Organisation, said two weeks ago: “We have not seen an urgent enough escalation in testing, and contact tracing, which is the backbone of the response.”

Our health authorities have recently worked tirelessly in this regard. Initially processing a total of 60 samples a day, they are now sampling 4,000 daily and testing nearly 2,000 daily, more than many other countries.

Our magnificent National Ambulance Service has been working tirelessly 24 hours a day, seven days a week. Drive-through testing centres have been set up at various locations.

However, there is a backlog of seven to ten days from a test being requested to its result. This means we are working off figures that are a week or more out of date, and that we have lost valuable time for proper contact tracing - although that system is now changing to trace contacts of suspected cases.

By the time someone has been diagnosed, they will have interacted with their contacts and possibly spread the virus to many others. Also, despite the repeated pleas of our leaders, a minority of people have chosen to disregard the importance of self-isolation until they receive a result.

It was recently reported that tens of thousands of samples were yet to be processed. Then we were told that many people who were awaiting tests would not be tested at all. The criteria for testing had, once again, become too strict due to lack of capacity for testing.

Simply put, despite our Taoiseach’s best intentions and claim to be following the South Korean model, the reality is that we are some way off reaching their standards. We may have missed the boat in our quest to follow its lead in contact tracing and strict enforcement of self-isolation and quarantine.

China has excelled in many areas: its contact tracing, for example, and its monumental feat of building an entire hospital in ten days. However, draconian mass quarantine of the worst affected provinces was the keystone of its successful approach.

China’s social and political landscape is organised in ways to make it easier to impose a genuine lockdown. In China, most urban dwellers live in fully gated communities, often containing 30 high rise apartment blocks of 22 stories each. Each complex is home to thousands of people with security guards monitoring the entrance and exit while CCTV camera assesses all areas 24/7. This is replicated throughout the country.

It has the personnel to enforce it: apart from police and military, millions of ordinary citizens train every day in preparation to be deployed in crisis situations. Each citizen is given a colour code: green, yellow and red. Each person’s movements are restricted depending on the colour. China can enforce these graded restricted movements due to its technological ability to track and trace without consideration of personal privacy.

It is now enforcing a temporary suspension of entry by foreign nationals holding Chinese visas or residents’ permits.

In March, a visiting Chinese Red Cross team criticised the failure of Italians to properly quarantine themselves and take the national lock down seriously. Is Ireland making the same mistake?

The concern in South Korea is whether it can sustain focused mass testing and strict quarantine in the face of mounting social and economic consequences. The million-dollar question in China, meanwhile, is whether the virus will re-emerge as the country attempts to return to normality.

Here in Ireland, we have to ask ourselves the difficult question: if we continue to fall short of South Korean standards of testing and contact tracing and if we are unable enforce Chinese-style mass quarantine, are we facing many months valiantly trying to control Covid-19?

Dr Domhnall Heron is a pharmacist and GP registrar

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