On 27th February 2020, in Incheon Medical Centre, Songlim-dong, Incheon, Korea, the wards were silent like a night before the storm. As the confirmed positive cases of COVID-19 surged in the province of Daegu and Kyungsangbuk-do, the Ministry of Health instructed all the public health institutes to get the hospital beds ready. A few patients, who hadn’t found beds in hospitals treating COVID-19 patients, were walking the empty corridors accompanied by the distinctive sound of IV stands. A glass door, hastily set up in order to quarantine the wards when necessary, was standing in the middle of the corridor on each floor.

As of 27th February 2020, one COVID-19 patient was confirmed; a female aged 59 confirmed positive on 22nd February 2020 and was hospitalized in Incheon Metropolitan City Medical Centre. Dr Jinyong Kim of the Division of Infectious Diseases of infectious disease medicine at Incheon Metropolitan City Medical Centre had been preparing for the imminent storm while treating the patient. South Koreans saw a glimpse of hope when Dr Kim successfully treated the COVID-19 ‘Patient 1’ from Wuhan, China, who made a complete recovery. However, Dr Kim had a rather pessimistic view on the progression of coronavirus cases. He expected that this ward, which was then silent, would soon overflow with COVID-19 patients and the stockpile of medical and quarantine items, stacked up in the storage room in front of the negative pressure isolation ward, would run out quickly. I asked Dr Kim what should be done in order for his pessimism to be proved wrong.

How was the patient’s condition?

On Friday 21st February 2020, she was tested at a public health clinic and was admitted to the medical centre on Saturday morning. Her oxygen level dropped on Sunday. She reported a severe headache and pain in her flank. A CT showed pneumonia, which was not visible on the X-ray. She was provided with oxygen and her oxygen saturation rose, the headache disappeared but she still had a fever.

How would you compare her with ‘Patient 1’ who was discharged from hospital?

I was lucky to follow up the progression of the disease from the very beginning for both patients and they show similar progressions. Like the current inpatient, Patient 1 did not exhibit any abnormal signs on the X-ray, but on the CT her lung was white with pneumonia. She merely had a fever and didn’t cough and only the CT showed any sign of the disease. Another similarity is the progression of the virus emission. For MERS, the emission was at its peak during the second week after the onset of symptoms. In contrast, for COVID-19, the emission was already over 10 million copies/mL by the third day. This means that the patient released lots of virus even before she experienced shortness of breath or difficulty in breathing and was in need of oxygen. The patient would have already infected hospitals and communities by the time she developed pneumonia. By then she would’ve become less infectious because of the low level of virus emission. Thus, COVID-19 is a very difficult virus to quarantine. 

How can we stop the spread?

‘Community Mitigation Guidelines to Prevent Pandemic Influenza’ by Disease Control and Prevention (CDC) USA in 2017 (see Figure 1) is a good reference. One of the key mitigation strategies during the influenza A/H1N1 2009 pandemic (‘swine flu pandemic’) was ‘non-pharmaceutical interventions’. The basic principles are to stay at home when you have a fever, to follow the cough etiquette and to wash your hands. During a pandemic, we need to upgrade to ‘home quarantine’, which is much stricter than ‘home isolation’. The guideline advises that not only a sick person with a fever should stay at home for three days but also the family members. In case of COVID-19, unlike seasonal influenza, the highest amount of virus is emitted on the third to fifth days after the patient contracts the virus and then the emission drops slowly over two weeks, which indicates the guideline for COVID-19 should be much stricter. 

When the hospital beds and medical workers are in short supply, can all the confirmed positive cases be admitted to hospital?

In the end, medical resources are limited. When there is a surge of cases, the healthcare system cannot avoid collapse no matter how many resources have been put in place. It is crucial to flatten the curve. In all the known clinical cases, patients who get well showed early recovery and patients who develop into serious cases had abrupt issues with their lungs within 3 to 5 days, that is when treatment is most necessary. Until that point, patients need to stay in hospital. Then we need to devise measures to discharge patients from hospital soon. Like it was with MERS (Middle East Respiratory Syndrome), the criteria for discharge from quarantine (discharge from hospital) for now is to be 48 hours since being asymptomatic and to be tested negative twice with an interval of 24 hours after 48 hours of being asymptomatic. This criterion is a measure to contain the virus completely, which is possible only when there are a few positive cases. Now we need to adopt the mitigation strategy while partially maintaining the quarantine (containment) strategy. To prepare for a situation occurring here in Korea similar to Wuhan, I thought that patients should be hospitalized for the first 5 to 10 days, then go into home-quarantine and receive remote treatment for the remaining period of 2 to 3 weeks during which patients emit the coronavirus. As several COVID-19 patients died while waiting to be hospitalized in Daegu (where there was a surge of confirmed positive cases), on 1st March 2020 the government prepared a plan to admit patients with mild symptoms in the ‘Saeng-Whal Chi Ryo Centre’ (quarantined communal treatment centres specially designed to treat COVID-19) located in each region. 

Persuading the patients won’t be easy.

Citizens need to compromise. Even if a patient insists ‘I will leave hospital only after I have fully recovered’, ‘I only show mild symptoms but I feel very concerned so I will stay in hospital’, experts need to make decisions and we need to reach a social consensus to support such decisions. Doctors do not make correct decisions all the time and a patient might be fine until the fifth day and then deteriorate on the sixth day. In order to handle such cases, we need to have a new protocol such as 24 hour access to treatment via a call centre, etc. It is not sensible to respond to a new epidemic disease with the same old protocol. A new idea such as the “drive-through” testing stations that I proposed was put in to action in some areas. We need to implement new measures. We need to reflect on why in Wuhan new hospitals with 1000 beds were built with all the excavators that could be mustered. It is because it is crucial to have a space where patients can be appropriately provided with oxygen during this window of time when their condition can decline suddenly.

Isolating emergency rooms, self-quarantine of medical workers, picking up samples for tests, they all add up to overburden the healthcare system.

I absolutely oppose the idea of shutting down public facilities for a long time. The virus cannot survive on its own. It must live in a human cell. Even diluted bleach kills all viruses. If a confirmed patient has been to a supermarket or an outlet, the space can be disinfected, ventilated and reopened. Nevertheless, I will never say that COVID-19 will be considered as another influenza. I will never suggest lowering the level of protective equipment for medical workers. There is a notion of ‘attack rate’ when we discuss the transmission of infectious disease. It is the number of infected individuals out of one hundred who are exposed to the disease under identical conditions. We do not even need a devoted experiment to see this number because the Chung-do Daenam Hospital has been a test case already. The attack rate was 98%! There is no single person on earth who is immune to this virus. Slightly more terrifying than influenza? I do not think so. Excessive quarantine of medical facilities would be problematic because they would not be available for regular patients in need and they would die as a result. This did not happen in Guangdong/Beijing, but it did in Wuhan. We need to deploy the given resources wisely, which will decide whether we will land in Guangdong/Beijing or Wuhan. We are standing at the crossroads right now (as of February 2020).

How effective are non-pharmaceutical interventions? 

Researchers (in Korea) studying early-stage detection of infectious diseases comprising epidemiologists, preventive medicine experts, mathematicians and statisticians used mathematical models to simulate the coronavirus spread and compared the effect with non-pharmaceutical intervention with the scenario of limiting long-range public transport (high-speed trains, flights, intercity buses via highways). When transportation is limited, the propagation curve goes up more slowly but the peak does not get lower. In the non-pharmaceutical intervention scenario, as in ‘stop and isolate’ when you have a fever’, the curve rose more slowly and the peak was lower as well. Although the result is not publicly available yet, I believe that it was reported to the government. The same research group estimated (Figure 2) the effect of the isolation point between a COVID-19 patient and a person who the patient contacted (in person). The earlier the patients and their contacts are segregated the more significant is the decrease in the overall infected population. A notable finding is that if the contacts of the confirmed patients are quarantined ‘at the same time’ as the patient it is much more effective than an earlier isolation point (isolating them sooner).

In the best scenario, where a patient recognizes his symptoms after an average of one day after contracting the corona virus and all the contacts and the patient are quarantined, at most 5% of the population will be infected even if the attack rate is 60% (which gets higher in a confined and crowded space).

Not only Korea but the rest of the world is on alert due to COVID-19. 

Recently, a pharmaceutical scientist sent me an email from Italy after reading my paper on COVID-19 clinical cases and he seems to be developing drugs for therapy (there are over 450 confirmed positive cases in Italy as of 27th February 2020). As countries around the world want to know about COVID-19 and very little is known we must collaborate. In terms of the number of flights, Korea ranks as one of the top 5 countries most exposed to the coronavirus. Other countries will enter the phase later than us but will walk into it nevertheless. In the middle of the mayhem, Chinese doctors in Wuhan published a paper through the 〈American Medical Association〉 examining 72,314 cases. The title reads “Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China”. They want to share the lesson, saying that they have handled it well. Some people downplay China but we need to learn from them what’s worth learning. At the end of the day, they bent down the curve (of the spread of coronavirus), even in Wuhan. I received an email from ‘Patient 1’ who returned to Wuhan after being cured under my charge. She was concerned about my wellbeing as the news from Korea worried her.

Do we have hope?

Now is the crucial moment I believe. Non-pharmaceutical intervention can be carried out properly now. If the virus spreads further, it will be too late. If the policy makers and the people collaborate well, hopefully we can prevent and control the spread better than Beijing has done. 
We have to act now. If we wait until the incubation period, which can stretch out to two weeks, we will face the awful aftermath and it will be too late. We need to be prepared and act decisively for the worst scenario possible.  We cannot afford optimism. 

translated by Eunjung Kim
translation supervised by Lisa De Silva, Sumi Paik-Maier