key: cord-356348-e7hefkd3 authors: Kim, Inho; Lee, Jia; Lee, Jihee; Shin, Eensuk; Chu, Chaeshin; Lee, Seon Kui title: KCDC Risk Assessments on the Initial Phase of the COVID-19 Outbreak in Korea date: 2020-04-17 journal: Osong Public Health Res Perspect DOI: 10.24171/j.phrp.2020.11.2.02 sha: doc_id: 356348 cord_uid: e7hefkd3 OBJECTIVES: This study aims to evaluate the risk assessments of coronavirus 2019 (COVID-19) in the Korea Centers for Disease Control and Prevention (KCDC), from the point of detection to the provision of basic information to the relevant public health authorities. METHODS: To estimate the overall risk of specific public health events, probability, and impact at the country-level were evaluated using available information. To determine the probability of particular public health events, the risk of importation and risk of transmission were taken into consideration. KCDC used 5 levels (“very low,” “low,” “moderate,” “high,” and “very high”) for each category and overall risk was eventually decided. RESULTS: A total of 8 risk assessments were performed on 8 separate occasions between January 8(th) to February 28(th), 2020, depending on the detection and report of COVID-19 cases in other countries. The overall risk of the situation in each assessment increased in severity over this period: “low” (first), “moderate” (second), “high” (third), “high” (fourth), “high” (fifth), “high” (sixth), “high” (seventh), and “very high” (eighth). CONCLUSION: The KCDC’s 8 risk assessments were utilized to activate national emergency response mechanisms and eventually prepare for the pandemic to ensure the containment and mitigation of COVID-19 with non-pharmaceutical public health measures. On December 31 st 2019, a cluster of pneumonia cases with unknown etiology was reported in Wuhan City, China [1] . On January 11 th , 2020, the Chinese authority identified a new type of coronavirus from 41 cases and isolated the nucleic acid of the pathogen [2] . The South China Seafood Market in Wuhan city was thought to be the source of the outbreak, which remains under investigation. Since then, the number of confirmed cases in China has rapidly increased, with the outbreak spreading to other countries. As of 5 th March 2020, a total of 89,253 confirmed cases of coronavirus-19 (COVID-19), including 3,246 deaths, have been reported in 79 countries [3] . KCDC has officially established a risk assessment system since 2016 due to lessons learned from the 2015 Middle East Respiratory Syndrome coronavirus (MERS-CoV) outbreak in Korea. The initial format of the system was established using the overall structure of the European Centre for Disease Prevention and Control (ECDC) rapid risk assessment procedures, and updated and modified this based on the requirements of the institution. To estimate the overall risk of specific public health events, probability, and impact at the country-level were evaluated using the available information. For the probability of certain public health events, risk of importation and risk of transmission were taken into consideration. KCDC risk assessment was categorized into 5 levels ("very low," "low," "moderate," "high," and "very high"), and overall risk was determined [4] . The emergence of COVID-19, which started as clusters of pneumonia with unknown etiology in China at the end of 2019, was unique and thus, a good example for KCDC to conduct a series of risk assessments to evaluate the potential risk of importation, transmission, and the impact at the country-level. The risk of importation and transmission were evaluated separately as COVID-19 was a newly identified pathogen where information about the coronavirus was limited. Predefined criteria triggered the KCDC risk assessment and enabled each risk assessment to be described in detail. Since the beginning of the current COVID-19 outbreak, 8 risk assessments have been conducted from January 8 th to February 19 th, 2020 ( Figure 1 ; Table 1 ). The first risk assessment was conducted on January 8 th , which was 8 days after the official Date report of the outbreak in Wuhan city. The overall risk of the situation was considered "low" in the first risk assessment. The risk of importation was estimated "very low" due to the immediate closure of the South China Seafood Market in Wuhan on January 1 st . The risk of importation to Korea was "low," but could not be excluded given the unknown nature of the respiratory pathogens and unknown human to human transmissibility. The impact of the outbreak was "low," as no fatal cases had been reported in China. The Wuhan pneumonia task force was established on January 3 rd , and entry fever screening of flights from Wuhan was initiated. A pancoronavirus laboratory diagnosis method was established on January 7 th . The second risk assessment was conducted on January 16 th , 9 days after the first assessment. The main triggers of this risk assessment were official reports of imported cases in Thailand on January 13 th , and in Japan on January 16 th . There was no evidence of human to human transmission until this time and no additional case had been officially reported in China since January 3 rd . The overall risk was escalated to "moderate" due to the increased risk of importation ("low" to "high") and transmission ("low" to "moderate"). The risk of importation was estimated as "high" because of the imported cases identified in Thailand and Japan, indicating a possibility of under-reporting of cases due to the unknown nature of the virus. The risk of transmission was also escalated due to the report of 1 potential family cluster in Wuhan, and contact history with an unidentified pneumonia patient from Japan. The impact was "low" as there had been only 1 fatal case who had underlying chronic conditions and the rest of the patients were in stable conditions. Additionally, evidence of recovery of patients in Japan and Thailand also influenced the estimation. On January 11 th , the WHO confirmed that the pathogen was a novel coronavirus and a validated primer was distributed and diagnostic probe was made available from January 11 th . The third risk assessment was conducted on January 20 th , 4 days after the second risk assessment. Beijing and Shenzhen also reported confirmed cases. The risk of spread was not changed ("moderate") as no secondary transmission was officially confirmed. The impact was escalated to "moderate" as there was growing concern over the risk of additional cases, and human to human transmission. Overall, the risk was escalated to "high" accordingly. Meanwhile, updated case definitions were shared with provincial government and healthcare facilities on January 17 th . cluster of cases, the risk of infection in this specific province was evaluated and it was estimated as "very high" and also the risk of transmission to other provinces was "high." All other nationwide risk assessment results remained the same (Risk of importation: "very high," Risk of spread: "very high," Impact: "high," overall risk: "high"). The last risk assessment was conducted on February 23 rd because of an exponential number of confirmed cases. As of This led to an increased impact on the risk estimation, and the overall risk was also increased to "very high" accordingly (Risk of importation: "very high," Risk of spread: "very high," Impact: "very high," overall risk: "very high)." After this risk assessment, the national crisis management level was escalated to the highest level, Level 4. Risk assessment is one of the core functions of a national public health agency, and it has been conducted by many The elderly and those with underlying chronic illnesses are most susceptible to severe symptoms of the disease [5] . The risk of COVID-19 ranged from "low" to "very high" in the risk assessments, based on the likelihood of transmission and the impact on society. Given the available epidemiological and clinical characteristics, the Korean population was deemed to be susceptible, and as more information became available, it was evident that virus transmission was rapid, and had the potential to be a major public health issue in Korea. The ROK risk assessment covered each phase of the outbreak, formats including social media, homepages, and press-releases. The ECDC evaluated the situation based on the Chinese report, initially indicating a "low" likelihood of importation to Europe [6] . The WHO indicated that the imported case in Thailand did not prove human-to-human transmission as further information was required [7] . The key messages to the general public include prevention of infection and transmission, and preparation status of public health authorities. It also addresses multi-sectoral messages to relevant ministries/agencies and healthcare workers. Communication can use all available formats including social media, homepages, and press-releases. ECDC evaluations are escalated when the likelihood of importation to Europe is "low" to "moderate," and likelihood of importation to neighboring Asian countries is "high," and human-to-human transmission cannot be excluded [8, 9] . The WHO's risk assessment showed that China's risk is "very high," while the risk of the Asia region is "high," and human-to-human transmission is occurring [10] . to "moderate," and likelihood of importation to neighboring Asian countries as "high." Infection contracted in hospital was considered a "low" risk when appropriate infection prevention and control measures were in place [9] . The WHO evaluates risk in China as "very high" and the Asia region's risk as "high." The WHO proposed that super-spread events may occur with human-to-human transmission among family members, and healthcare workers [10] . Risk Assessment 7 described a situation with distinct local outbreaks. There was sustained local transmission in Korea. The objective was to mitigate the impact of the outbreak by decreasing general admissions to the hospitals and clinics to protect the general population from contracting the disease. In this situation, communication should be conducted daily. Messages should be balanced and focused on prevention and treatment. It also provides detailed routes of confirmed cases ECDC evaluations are escalated from likelihood of importation to Europe as "moderate" to "high," and the impact of the disease as "high," and human-to-human transmission may lead to widespread community transmission [11] . The WHO assesses the situation that several countries show local humanto-human transmission [10] . Risk Assessment 8 dealt with a situation with widespread sustained transmission in a Korean province (Daegu-Gyeongbuk Province) and distinct local outbreaks in other regions of Korea. The healthcare system was overburdened. ICU capacity was strained. The workers suffered from exhaustion, and staff numbers, PPE, and diagnostic testing capacity became insufficient. The objective was the same as Risk Assessment 7. At this stage, the communication of risk was to ensure close collaboration of the general public with public health authorities, and healthcare providers is essential. Individual, religious, and societal concerns about death need to be considered. There are several limitations in this study. Firstly, the information in the early phase of the COVID-19 outbreak was preliminary and very limited, mainly since COVID-19 was a new emerging disease, and data from the Chinese government was the main source of information of this novel coronavirus. Thus, we conducted several risk assessments with the ongoing available evidence, in a very short period of time as the situation evolved rapidly. Therefore, the estimation was very likely to be subjective in nature. Secondly, the risk assessment tool was not strictly applied to this novel pathogen as critical information was missing and had to be estimated with limited confirmed evidence. Thus, initial evaluation of this virus pathogenesis was likely to be subjective, and was the one of major factors that needed to be considered when conducting the risk assessment. Once more scientific evidence and knowledge becomes available after the end of this pandemic, overall review procedures and evaluation mechanisms need to be developed to improve and to minimize the limitations of the existing risk assessments by the Korea CDC. There was no conflicts of interest to declare. Notice of situation on pneumonia of unknown etiology Novel coronavirus (nCoV-2019) situation report-1 Coronavirus disease (COVID-19) situation report-45 Risk assessment tool Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) European Centre for Disease Prevention and Control Novel Coronavirus-Thailand (ex-China) Rapid Risk Assessment: Cluster of pneumonia cases caused by a novel coronavirus Risk assessment: Outbreak of acute respiratory syndrome associated with a novel coronavirus Novel coronavirus (2019-nCoV) situation report-3 Risk assessment: Outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2): Increased transmission beyond China -fourth update We acknowledge all the efforts and hard work of staff in the KCDC in responding to COVID-19.