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South Korea managed to avoid a nationwide lockdown and extensive travel restrictions by devising a comprehensive public health strategy early in the COVID-19 outbreak, as well as voluntary social distancing measures, an expert said here.

Youngmee Jee, MD, PhD, of the Center for Immunology and Pathology at the Korea Centers for Disease Control and Prevention in Cheongju, described the country's COVID-19 strategy at a clinical symposium focused on COVID-19 at the American Association for the Study of Liver Diseases (AASLD) virtual meeting.

In her talk, Jee used terms also employed by the Trump administration, such as a "whole of government approach," and emphasized the role of "public and private partnerships." Data as of November 15 shows South Korea with a case fatality rate of 1.7% versus the U.S. with a 2.3% case fatality rate.

"All important actions were taken before the World Health Organization [WHO] declared" the COVID-19 outbreak a public health emergency of international concern on January 30, she said, noting emergency use authorization of diagnostic kits in early February after a meeting with pharmaceutical companies on January 27 when there were only four cases in the country.

Jee explained how South Korea was able to keep society open through 4Ts: test, trace, treat, and transparency.

By early February, there was a rapid expansion of testing labs, with turnaround time in 24 hours, as well as "need-based free testing of asymptomatic people" in the large city of Seoul. A smart tracking system significantly reduced time for epidemiological investigation. They even overhauled hospitals, with designated infectious disease hospitals for COVID-19 and community treatment centers for mild cases. The "transparency" consisted of twice daily press briefings.

However, Jee added there is easy access to medical services for everyone in South Korea, with 95% of private hospitals operating within National Health Insurance, and with a high number of hospital beds (12.27 per 1,000 people in 2017).

She noted how South Korea learned from the lessons of the MERS outbreak, and the government "changed their testing and tracing services" after that.

Key to the country's success was buy-in from the public to these public health strategies. The public was expected to abide by a code of conduct, including staying away from "enclosed, crowded spaces with poor ventilation." They were advised to avoid the three Cs: crowded places, close-contact settings, and confined and enclosed spaces.

Mask wearing was advised not only for indoor settings, but outdoor settings where it was impossible to keep a 2-m (about 6 ft.) distance. The country also recommended avoiding activities in public that cannot be done with a mask on, such as eating, singing, and cheering out loud.

There were no widespread travel restrictions, but the country tested all incoming travelers, including asymptomatic people, and even if the results were negative, all travelers were required to quarantine for 14 days, as of April 1.

Jee described how social distancing measures were dictated by numbers of cases, which included detailed recommendations for gatherings, sporting events, schools, and companies. The country also implemented enhanced infection prevention measures, including a ban on gatherings of 50 people or more indoors and 100 or more outside.

Twelve types of high-risk facilities were subject to this ban on gatherings, including bars, clubs, gyms, performance halls, and buffet restaurants. Distribution and logistics centers were exempt, because they were "essential industrial facilities," she said.

Jee said South Korea's next steps include how to adjust phased social distancing in various situations to "balance public health and economic/societal impact" until herd immunity can be achieved through vaccination. The country also plans to invest further in medical resources, infrastructure, and training.

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