At home 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?
A March 16th paper from the UK-based Imperial College COVID-19 Response Team describes two fundamental strategies for approaching COVID-19 management: 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 (herd immunity), the aim is to use interventions like social distancing, not to interrupt transmission completely, but to reduce the impact of an epidemic on the health services. In this scenario, ‘herd immunity’ builds up through the epidemic. Once 70-80% 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.
A number of Asian countries have so far successfully suppressed, or at least halted the exponential growth of COVID-19 . Broadly there have been two successful strategies:
1. Widespread testing with less stringent quarantine (e.g. South Korea, Taiwan, Singapore)
2. Draconian mass quarantine (e.g. Hubei province in China)
Our health authorities’ stated strategy is suppression and that we are following the South Korean model.
South Korean Model
South Korea’s first case was confirmed on January 20th. Though the government’s early response was criticised as “sluggish and naïve” South Korea is now held as an exemplar in the management of a Covid-19 outbreak. Theirs initially centred on Daegu, a city populated with 2.5 million, specifically the Shincheonji Church which worships there. A 61-year-old congregant is believed to have infected many other celebrants crowded amongst each other during services. Over 50% of all confirmed cases in the country have been contact-traced to this church. By late February, 1,900 Shincheoji Church members had been tested. 1,300 had symptoms while 600 did not. Among those 1,300 with symptoms, 87.5% were confirmed coronavirus. Of the 600 without symptoms, 70% were confirmed with coronavirus. They rapidly set up drive- thru testing, speedy ‘phone booth testing’ with results delivered by text message within 24 hours.
South Korea has used 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 48-72 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. This information is shared with the public using phone apps. This both facilitates people to avoid potentially contaminated areas and reduces the time and efforts that public health officials spend contact tracing, traditionally a cumbersome and time-consuming process
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 have had contact with a confirmed case are ordered into strict quarantine. They are required to confirm their presence at their stated quarantine 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 makes access to existing data difficult. A new ‘opt-in’ phone tracking app is to be introduced here by the HSE soon.
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 made the mistake of not practicing social distancing. Indeed, our authorities have contributed to this by conveying mixed messages to the public.
As recently as Saturday , March 21st, the Department of Health, clarified its 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, ‘Nature’ noted that “covert cases could represent some 60% of all infections” and that “people can be highly contagious when they have mild or no symptoms”. The South Koreans had understood this from early on. Many, especially younger people, may show no symptoms or only mild symptoms yet be a significant risk of transmitting the virus on to others.
The head of the World Health Organisation, Dr. Tedros Adhanom Ghebreyesus said: “You can’t fight a virus if you don’t know where it is” and urged countries to “find, isolate, test and treat every case to break the chains of transmission.” Our health authorities have recently worked tirelessly in this regard. Initially processing a total of 60 samples per day, they are now taking several thousand swabs per day. Our magnificent National Ambulance Service has been working tirelessly 24 hours a day, seven days per week calling to homes throughout the country. Drive- thru testing centres have been set up at various locations including Croke Park. However, due to a lack of testing equipment, our labs can process around 1,500 swabs per day, not the several thousand swabs that are collected per day. Now there is a backlog of 7-10 days from a test being requested to its result, even for some healthcare workers. Once a swab is greater than 14 days old, there is little need to test it as the person has finished their self-isolation. The criteria are now quite narrow and strict. Due to a lack of capacity we are unable to test many people who display symptoms, never mind those who do not show symptoms.
This means we are working off inaccurate figures and that we have lost valuable time for proper contact tracing. By the time someone had been diagnosed, their contacts had interacted with and possibly spread the virus on to many others. Also, despite repeated pleas of our leaders, a minority of people had chosen to disregard the importance of self-isolation until they receive a result.
Simply put, despite our health authority’s best intentions and claim to be following the South Korean model, the reality is that we are some way off reaching their standards and we may have missed the boat in our quest to follow their lead in contact tracing or strict enforcement of self-isolation and quarantine.
China has excelled in many areas: their contact tracing, ability to monitor citizens through technology and succeeding in the monumental feat of building an entire hospital in 10 days. Draconian mass quarantine of the worst affected provinces coupled with advanced tracking of their citizens was the keystone of their successful approach. China’s social and political landscape is organised in ways to make it more amenable to genuine ‘lockdown’. 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. With the click of the finger, China can put a province, a city, or a building on lockdown. It also 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.
On Friday March 20th, a visiting Chinese Red Cross team criticised Italians’ failure to properly quarantine themselves and take the national lockdown seriously. “Public transportation is still working, people are still moving around. I saw many people not wearing masks. We need to stop all economic activities. We need to stop the social interactions we normally like. All people should be staying at home for quarantine”. Clearly lockdown in Europe is different to lockdown in China. Though our government has recently acted decisively and deserving of great credit, we still may be unable to act in the way China found necessary to control Covid-19.
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 is whether the virus will re-emerge as they attempt to return to normality. At home 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?