A South Korean soldier on disinfection duty enters an infected apartment early in the pandemic. Photo: AFP

South Korea has the dubious distinction of suffering the second-highest number of  Covid-19 infections after China – but can also boast the lowest death ratio among countries with significant numbers of cases.

According to the WHO on March 6, the crude mortality ratio for Covid-19 – that is, the number of reported deaths divided by the number of reported cases – is between 3-4%. In Korea, as of March 9, that figure was a mere 0.7%.

While, 7,478 cases were confirmed in South Korea by the Korea Center for Disease Control and Prevention (KCDC) on Monday, only 51 have died. Meanwhile, according to data from John Hopkins University, Italy has 7,375 cases and 366 deaths, while Iran has 7161 cases and 237 deaths.

Amid the outbreak, neighboring China has used a “Great Wall” strategy to cordon off entire cities. South Korea has stuck to a liberal playbook: even its most affected city, Daegu, has not been isolated. This makes Seoul’s apparent success in the struggle against Covid-19 a potential benchmark for other affected democracies.

What is behind Korea’s low fatality rate from a virus that has spooked the world? Government briefers speaking to foreign reporters in Seoul on Monday offered some pointers.

Key factors include a robust national health service; prior experience of virus outbreaks and related preparations; aggressive execution of testing, isolation and treatment protocols, fully backed by the law – and two incidences of good fortune.

Systems activated

South Korea reacted to the crisis with vigor, deploying a range of legal, medical, technological and public communication efforts.

The country could act so effectively due to a piece of rare good luck. Buttressing prior experience with SARS and MERS, the KCDC – by coincidence – conducted a table-top exercise on a coronavirus outbreak in December 2019.

As a result, officials were fully prepared when the novel coronavirus hit the nation the following month. Testing started on January 11, Kwon said; the first infection was confirmed on January 19.

Telephone consulting services, drive-through test centers and thermal cameras – which, set up in buildings and public places to detect fever, swiftly came online. South Korea has undertaken approximately 190,000 tests thus far, according to KCDC Deputy Director General Kwon Jun-wook, and has the capacity to undertake 20,000 per day. Turnaround times are six-24 hours.

Tests are highly affordable. “The test kit is about $130, and about half is covered by insurance the other half by individual,” Kwon said. Those who test positive get the test free, “So there is no reason for suspected cases to hide their symptoms,” he said.

Overseas experts approve.

“There is no such thing as too much testing during an outbreak,” Dan Strickland, a retired American epidemiologist told Asia Times. “All the testing is catching false positives” – ie those who test positive but do not actually have the disease – “but is also catching mild cases.”

Dedicated centers and hospitals centralize specialized equipment and personnel, while keeping the virus out of regular hospitals. A triage system ensures only those with severe symptoms are admitted to oxygenated, low-pressure wards. Home quarantine with access to medical consulting is widely employed.

Widespread tests….

South Korea’s cases of infection had been minimal until the third week of February when cases suddenly exploded in the country’s southeast – a result of chain infections in crowded services held by the secretive Christian sect, Shincheonji.

Some 63% of Korea’s cases hail from the sect, according to government data.

While Shincheonji members are scattered nationwide, the government demanded – and received – its membership list. Contrary to widespread rumors and accusations, a senior government official said the church has cooperated.

A lot of research has been conducted based on the information delivered by their HQ, it was very comprehensive info: the number of members, their personal information and the location of their church facilities,” said Vice Minister of Health and Welfare Kim Gang-lip, who is also overall coordinator 1 of the Central Safety Countermeasures Headquarters.

“The reliability of the information was verified through an administrative investigation,” Kim said. “We went into their information systems to verify and double check; from the overall organizational perspective, they are cooperating.”

The government implemented widespread testing of the church’s 211,000 followers. Those with symptoms were triaged as priority testees; once they were cleared, tests were conducted on those who showed no symptoms to ensure they were not latent carriers.

“From the containment phase, we tried to implement case isolation and case tracking, and this was done in a very aggressive manner,” Kim Dong-hyun of the Korean Society of Epidemiology said.  

“We have legal grounds for cohort isolation,” said Kwon. “Rather than being an infringement of human rights, this was for the prevention of epidemic.” Related laws on the books date back to the MERS outbreak and further legal changes take effect in April.

Case tracking was done via CCTV data mining and credit use patterns.

…early treatment

Quarantines removed the infected from the general populace, but perhaps even more critical to the low death rate was the activation of early treatment.

“Even on followers who did not show symptoms, we conducted screening and confirmed early cases early on,” Kim said. “I think that was effective.”

The large dataset created a knowledge bank on effective measures and treatments.

“Mild and asymptomatic cases were denominated and this brings down the fatality rate,” Kim said. “I think we were able to identify almost all of the mild cases…. on that side, Korea was quite exceptional, and that allowed us to collect extensive data.”

Despite panicky headlines about a lack of specific medication for Covid-19,  advanced medical treatment offers hope even in severe cases.

“Viral pneumonia, even when complicated by bacterial pneumonia and end-organ failure, is potentially surmountable,” Ogan Gurel, a non-practicing doctor currently working as a professor in South Korea, told Asia Times. “You just need advanced medical care – and some oxygen.”

Age matters

Along with its December coronavirus drill, Korea was lucky in another respect: Its core cluster infected an age range with strong resistance to Covid-19, for Shincheonji concentrated its recruitment efforts on students and the young.

“When you look at the age and the distribution of confirmed cases in Shincheonji you see high portion of those in the 20s and 30s,” said Kim. “Therefore, the fatality rate in this cohort is low.”

“If you look at the population distribution compared to China, we have a higher portion of younger age groups,” agreed Kim Yeon-jae, an infectious disease specialist at Korea’s National Medical Center. “This has impact on the fatality rate.”

According to data supplied to journalists on Monday, there have been no fatalities in Korea among persons aged under 29.

Still, even for the aged, Korea is doing better than other affected countries, said epidemiologist Kim: the percentage of fatalities in the 70-80 age group are lower than in Japan or Italy. “I think this is thanks to early detection and early treatment,” he said.

Unanswered questions

Yet Korea is just three months into the virus. While the day-to-day increase rate appears to be slowing (see chart at bottom) it is presumptuous to declare victory.

“It too early to assess if we have been successful or not,” said Kim Dong-hyun. “We are still in a learning process….”

With Korea’s numbers having shot up just within the last three weeks, the risk of a sudden death surge, as the disease works its course through the biologies of thousands of infected, remains a possibility.

On the other hand, the low ratio of death-to-infection could continue. If so, Korea’s extensive dataset could prove Covid-19 far less lethal than many fear.

One expert believes Korea’s numbers are superior to the WHO’s.

“Death rates are almost always overestimates as they miss tons of people who don’t have [symptoms],” said a US-based statistical geneticist who requested anonymity. “False positive are less of an issue than untested masses.”

He added: “It is consistently in the interest of medical pros to overstate risks in order to win more funding from governments: ‘Fund me and you might not die,’ is a compelling argument!”

Culture-specific factors could be at work. In previous epidemics, some postulated that the Korean diet – heavy on such supposedly immune-boosting ingredients as garlic – might offer the populace superior in-body defenses.

Professionals are skeptical. “There is no evidence that Koreans, or other populations, have specifically strong adaptive immune systems” to the virus, said Gurel.

And big picture, Korea’s high testing/high numbers/low mortality ratios are not the only way forward: Neighbor Japan has lower overall numbers, but a higher percentage of fatalities.

“We were very strong in the early spread,” Kim said. “In Japan, there is a shortage of testing kits and they only focus on patients which show symptoms. You could say that is a strategy.”

South Korean confirmed Covid-19 cases

Jan. 20: First case

Tues Feb 18: Woman connected to Shincheonji Church tests positive

Wed Feb. 19: Total 51 cases.

Thurs Feb. 20: New cases: 53. Total 104

Friday Feb. 21: New cases: 100. Total 204

Saturday Feb. 22: New cases: 229. Total 433

Sunday Feb. 23: New cases: 169. Total 602

Monday Feb. 24:  New cases: 231. Total 833

Tuesday Feb. 25: New cases: 144. Total: 977

Wednesday Feb. 26: New cases: 284. Total: 1261

Thursday Feb 27: New cases: 505. Total: 1,766

Friday: Feb 28: New cases: 571.Total: 2,337

Saturday Feb 29:  New cases: 813. Total: 3,150

Sunday March 1: New cases: 586. Total: 3,736

Monday March 2: New cases: 549. Total: 4,335

Tuesday March 3: New cases: 851. Total: 5,186

Wednesday March 4: New cases: 435. Total: 5,621

Thursday March 5: New cases: 467. Total: 6,088

Friday March 6: New cases:  505. Total 6,593

Saturday March 7: New cases: 448. Total, 7041.

Sunday March 8: New cases: 273. Total 7,314

Monday March 9:  New cases: 164. Total: 7,478

Data: Korea Center for Disease Control and Prevention. Note: The KCDC releases figures at various times of the day. The above chart is collated from figures released at close of business, daily.