Analyzing the Coronavirus Disease 2019 Pandemic Response Governance and Policy (January 2020–December 2021)

Abstract

The severe acute respiratory syndrome coronavirus-2 virus caused the the coronavirus disease 2019 (COVID-19) pandemic, which was a first for the twenty-first century and an infectious disease that spotlighted the importance of the Korea Disease Control and Prevention Agency to public health. In response to the COVID-19 pandemic, the Korea Disease Control and Prevention Agency promptly implemented testing, treatment, and social distancing measures. Only a thorough analysis can evaluate the efficacy of the agency’s COVID-19 response policies. It would be challenging to characterize the lessons and preventative actions learned from the findings as accurate insights. This paper analyzes the COVID-19 pandemic response strategy and governance from January 2020 to December 2021 by placing actions taken within the conceptual framework of infectious disease management policy. This strategy establishes a valuable policy evaluation framework that can integrate limitations of policy decisions in response to pandemic infectious diseases with imbalancing ripple effects. Infectious disease control countermeasures provoke an unexpected secondary outcome, like reduced economic growth or social isolation. It is very difficult to balance these negative consequences with the effectiveness of preventing infectious diseases. In other words, infectious disease prevention strategies can be specific obligations in specific contexts that are derived from ex post accountability. Therefore, infectious disease response policy assessment requires a step-by-step framework to evaluate potential negative impacts, and it is important to set parameters in advance to resolve competing interests arising in particular contexts.

Key messages

① What is known previously?

The Republic of Korea’s experience in responding to significant infectious diseases, including SARS, Influenza A (H1N1), and MERS, has fostered expansion and improvement of the country’s infectious disease response capability.

② What new information is presented?

The prominence of the Korea Disease Control and Prevention Agency was elevated on September 12, 2020. In response to COVID-19, the agency implemented control strategies based on national public health and securitization, technification of non-pharmaceutical interventions, and social solidarity.

③ What are implications?

Evaluations of process change drivers, policy measure efficiency, and response personnel’s capabilities must serve as the foundation for effective assessment of infectious disease control policies.

Introduction

On February 11, 2020, the World Health Organization (WHO) officially designated the novel coronavirus disease, which emerged in Wuhan, China, in 2019, as coronavirus disease 2019 (COVID-19). The Republic of Korea (ROK) followed suit on February 12, 2020, adopting the name COVID-19 on February 12, 2020 [1]. By the time the WHO formally declared COVID-19 a pandemic on March 11, 2020, over 120,000 cases had been reported in 114 countries, resulting in approximately 4,300 deaths. The COVID-19 pandemic was an infectious disease that spread across the globe with unprecedented scale, speed, and impact, surpassing any previous epidemic or pandemic [2].

According to policy theory, policymakers may sometimes make decisions that appear irrational by overly focusing on a limited aspect of the problem and related information [3]. When the complexity of tasks exceeds the capabilities of centralized management, the central government often delegates authority to local governments [4]. The distribution of responsibilities across various levels and types of government organizations, each with unique rules and diverse approaches to understanding policy issues, can pose challenges [5]. Addressing the COVID-19 pandemic presented a daunting challenge that no single country or government department could effectively manage at any outbreak stage. To highlight the importance of policies mitigating the 21st-century pandemic’s threat to public health, this study investigates the governance transformations required to fulfill the response and management objectives for COVID-19 and identifies the key elements of strategies to reduce policy ambiguities.

Methods

This study primarily utilized policy briefings and press releases with accompanying reference materials issued by the Central Epidemic Prevention and Control Headquarters (CEPHC) and briefing messages from the Central Disaster and Safety Countermeasure Headquarters. Employing the WHO’s Strategic Preparedness and Response Plan as a conceptual framework for strategy analysis and categorization [6], we analyzed these raw materials to identify the governance changes implemented in response to the evolving outbreak situations during the different phases of the COVID-19 pandemic. This analysis enabled the extraction of critical themes for each strategy.

Results

1. Changes in COVID-19 Response Governance

Severe acute respiratory syndrome coronavirus-2 virus spreads unpredictably, sometimes following anticipated routes and other times deviating from expected patterns, influenced by prevailing conditions. Like typical novel infectious diseases, it propagates by targeting susceptible populations, infecting them, or forming clusters within infected groups.

The ROK’s official response to COVID-19 commenced on January 3, 2020, entering a “concern” phase. Following the confirmation of the first COVID-19 case on January 20, 2020, the then Korea Centers for Disease Control and Prevention (KCDC) elevated the infectious disease crisis warning level to “caution” and expanded its response structure from the Novel Coronavirus Response Task Force to the CEPHC. With the emergence of four confirmed domestic cases on January 27, the infectious disease crisis warning level was raised to “alert,” prompting the establishment of the COVID-19 Central Disaster and Safety Countermeasures Headquarters within the Ministry of Health and Welfare. The joint Central Disaster and Safety Countermeasures Headquarters, chaired by the Prime Minister, convened for its first expanded meeting on February 2, 2020. Anticipating the possibility of rapid changes in the outbreak situation, the COVID-19 Central Disaster and Safety Countermeasures Headquarters, headed by the Prime Minister, prepared for a government-wide response equivalent to the “severe crisis” level, ensuring prompt decision-making across multiple departments [7]. In its briefing on September 8, the Central Disaster and Safety Countermeasures Headquarters announced that the then KCDC would be upgraded to the Korea Disease Control and Prevention Agency (KDCA) on September 12 [8].

The CEPHC’s initial response strategy for COVID-19 infection prevention was built upon four key pillars: blocking domestic entry, preventing community transmission, establishing medical infection prevention measures to curb nationwide spread, and implementing social responses. Through proactive and preemptive strategies based on non-pharmaceutical interventions (NPIs), these preventive measures aim to significantly reduce the infectious agent's effective reproduction number (R) and bring it below one. These strategies include limiting the hours of operation for large stores and gathering places, restricting the number of people in gatherings, encouraging remote work, and discouraging non-essential travel [9]. Social responses combined these various strategies appropriately, tailoring them to the specific conditions of each epidemic phase while supporting the maintenance of essential social functions and the healthcare system. The most substantial medical response, the COVID-19 vaccination program, commenced on February 26, 2021, prioritizing nursing homes and long-term care facilities.

Over two years, spanning from late January 2020 to the end of December 2021, the ROK experienced four distinct phases of COVID-19 outbreak cycles. The cumulative number of community infections, seasonal risk factors, different NPIs for infection prevention, personal hygiene habits, social distancing measures, and vaccination status were among the factors that affected the incidence rates over the course of outbreak cycles. The alpha variant of the virus caused outbreaks in the initial phase. Subsequently, in August 2021, the highly transmissible delta variant surfaced as a new dominant variant, explaining more than 90% of cases up until December. Immediately after implementing the policy of a phased return to normalcy, the rapidly spreading Omicron variant BA.1 emerged and spread (Figure 1).

Figure 1. The Republic of Korea’s COVID-19 outbreak trend and response (2020. 1–2021. 12).

KDCA=the Korea Disease Control and Prevention Agency; COVID-19=coronavirus disease 2019.

The Omicron variant spread unprecedentedly, infecting half of the European population within 6–8 weeks, surpassing the global incidence rates over the past 2 years. Even though the same variant was circulating, outbreak severity varied markedly across countries, with some experiencing relatively mild outbreaks while others faced severe surges. The ROK confirmed its first Omicron case on December 1, 2021. From late January to late April 2022, a new confirmed cases and the death rate skyrocketed [10]. Infection rates increased into the hundreds of thousands even though 85% of those who could have been vaccinated had done so by March 2022. This outbreak pattern contrasted sharply with those seen in countries like the United States of America and France, which recorded high incidence rates and death rates before the Omicron outbreak (Figure 2).

Figure 2. Seven-day average trends in the number of confirmed cases and mortality rates in the Republic of Korea, the United States, and France (per million population, 2020. 3–2022. 2).

Variations in incidence rates across countries can be attributed to differences in “immunity walls.” For instance, the BA.5 subvariant of the Omicron lineage exhibited enhanced transmissibility, severity, survivability, and rapid mutation. These biological traits of BA.5 eroded the immunity walls established by prior infections. The impact of variant mutations is responsible for significant differences in incidence rates across countries, even with similar vaccination rates. Immunity walls, which include factors like prior infections, vaccination, coinfections, and waning immunity over time, are crucial in explaining these differences [11].

2. Key Themes of COVID-19 Response Strategies

An examination of briefing messages, press releases, and accompanying reference materials issued by the CEPHC and the Central Disaster and Safety Countermeasure Headquarters between January 2020 and December 2021 revealed that the risk of COVID-19 was not static over time and that the intensity of response measures varied with each epidemic phase. Despite overlapping themes across the phases, the strategies are presented as a comprehensive list rather than being categorized by epidemic phase (Table 1).

Table 1. Topics of the COVID-19 response strategy.

Strategy	Topics
Suppress transmission	- Explanation of major COVID-19 statistics and supplementary measures - Measures to improve information system related to COVID-19 - Plan to expand diagnostic testing and strengthen testing capabilities - Diagnostic test priority adjustment plan - Plan to expand implementation of COVID-19 RT-PCR diagnostic test - COVID-19 diagnostic test for military enlisted personnel - Support for diagnostic testing costs for new residents of residential facilities for the disabled - Screening clinic response plan and operation efficiency plan - Adjustment of temporary living facilities for overseas entrants - Preemptive testing measures to block asymptomatic transmission in the metropolitan area - Preemptive coronavirus testing plan for high-risk facilities in the metropolitan area - Establishment of medical use system for respiratory and fever patients - Measures to improve diagnostic testing efficiency for preemptive patient detection in group facilities - Evaluation of the operation of temporary screening centers in the metropolitan area and future operation plans - Measures to strengthen quarantine and inspection of overseas entrants - Plan to simplify quarantine and entry procedures for US military (A3) soldiers - Measures to strengthen quarantine due to the increase in confirmed cases entering countries with strengthened quarantine - Measures to strengthen crew quarantine management - Measures to strengthen quarantine of overseas entrants in response to mutant virus - Measures to implement preemptive diagnostic tests for social welfare facility workers - Analysis of the status of periodic preemptive inspections of facilities vulnerable to infection - Preemptive PCR testing for workers in facilities vulnerable to infection compared to Omicron - Promotion plan for national quarantine guidelines - Promotion plan for conversion of daily quarantine system - Collection of public suggestions and opinions on COVID-19 ‘daily quarantine’ - Check the status of measures to implement social distancing in daily life - Plan to strengthen church quarantine management - Quarantine manager training program implementation plan - Evaluation of daily quarantine period and future quarantine strategy - Summer vacation/vacation rules and future plans - Plan to upgrade national social distancing to level 2 - Step-by-step strengthening plan for social distancing in the metropolitan area - Review of social distancing adjustment for stage 2 in non-metropolitan areas - Measures to strengthen social distancing during the Chuseok special quarantine period - Quarantine rules for living in holiday destinations - Plan to impose fines due to mandatory wearing of masks - Quarantine rules for hiking and outdoor activities - Establishment of standards and procedures for adjusting social distancing levels by local government - Additional composition and operation plan for the daily life quarantine committee - Analysis of weekend travel volume after phase adjustment in the metropolitan area - Analysis of step-by-step implementation of social distancing and measures to improve practice - Request regarding care measures for vulnerable groups when upgraded to level 3 - Ripple effects when the quarantine situation and social distancing level are raised - Intensive quarantine strengthening measures for the year-end and New Year holidays - Interim evaluation of the characteristics of the 3rd wave of COVID-19 and social distancing - Open discussion to reorganize social distancing levels - Measures to improve the classification system for multi-use facilities based on risk - Temporary living facility operation rate status analysis and countermeasures - Pilot project for social distancing system reform plan - Measures to improve the limit on the number of people at private gatherings in non-metropolitan areas - City, county and district distancing level adjustment procedures - Phased recovery of daily life Social distancing reform plan
Reduce exposure	- Special management plan for workers in high-risk occupations - Delegation of local government head authority to disclose confirmed patient information - Plan to build a patient management information system - ICT-based digital quarantine system establishment and operation plan - Status of collection and disclosure of clinical epidemiological information on COVID-19 patients - Check the implementation status of local governments in disclosing confirmed patient information - Problems with issuing voice certificates for self-quarantined people - Survey of re-positive cases after release from quarantine - Expansion of requirements for conversion to self-quarantine for facility quarantined persons - Risk assessment plan for each country related to quarantine exemption for short-term overseas business travelers - Pilot project implementation plan to establish appropriate facility quarantine period for inbound travelers - Discussion on ways to improve the self-quarantine system and quarantine period - Expansion of self-treatment targets and measures to lift quarantine - Measures to strengthen management of overseas entrants in response to mutant viruses - Plan for taking the test for confirmed cases and self-quarantine - Status and joint inspection of the same group quarantine facility - Plan to change the criteria for lifting mutant virus quarantine - Expected to occur after COVID-19 vaccination - Plan to activate vacation for adverse reactions to vaccines
Counter misinformation	- COVID-19 major cluster outbreaks and transmission patterns card news - Promotional plan to ensure implementation of social distancing and quarantine rules - Communication strategy related to COVID-19 vaccine - Public communication plan for one year after COVID-19 outbreak - Public awareness survey regarding COVID-19 quarantine policy - Public communication plan regarding the implementation of the 4th stage of social distancing in the metropolitan area - Public communication plan related to phased recovery of daily life - Promotion of youth quarantine pass to the public - Report trends and public opinion response to vaccine security and vaccination announcements - Responding to false facts about the existence of microorganisms in the coronavirus vaccine
Protect the vulnerable	- Analysis of risk factors and response plans for facilities vulnerable to infection, such as nursing hospitals - Plan to expand preemptive testing of facilities vulnerable to infection, such as nursing hospitals - Admission to nursing hospitals, psychiatric hospitals, and nursing facilities - diagnostic testing for all residents - Issues regarding quarantine measures for vulnerable facilities such as nursing hospitals - Preemptive PCR testing for workers in facilities vulnerable to infection compared to Omicron - Adjustment of preemptive testing cycle for nursing hospital workers - Plan to expand preemptive testing of facilities vulnerable to infection, such as nursing hospitals - Implementation of rapid antigen test for nursing hospitals - Quarantine guidelines related to vaccination-related culture, welfare, and participation in religious facilities for the elderly - Measures to revitalize senior culture and welfare programs related to vaccination
Reduce mortality and morbidity from all causes	- Emergency medical response plan - Plan to secure hospital beds in the metropolitan area - Designation and expansion plan for living treatment center - Measures to secure medical and testing personnel related to the occurrence of critically ill patients - Current status of expansion of beds for treatment of confirmed COVID-19 patients - Plan to rebuild the treatment system for severe COVID-19 patients - Role in joint response to quarantine and treatment in the metropolitan area - Plan to secure plasma for development of COVID-19 plasma treatment - Cost analysis report by COVID-19 treatment institution - Self-payment of quarantine hospitalization treatment costs for confirmed foreigners imported from abroad - Support for medical personnel for COVID-19 treatment - Plan to secure nationally designated inpatient treatment beds for seriously ill patients - Treatment application plan such as national clinical trials for COVID-19 treatment - Support for influenza vaccination for workers at living treatment centers - Living treatment center operation plan according to phased recovery of daily life - Response strategies for each patient occurrence scenario - Self-treatment operation plan for COVID-19 confirmed patients - Expansion of self-treatment targets and measures to lift quarantine - Compensation plan for losses in hospitals operating treatment medical institutions or screening clinics - Plan to expand the supply of health care sets for patients diagnosed with home treatment - Progress in expanding COVID-19 treatment beds and measures for efficiency - Implementation plan and activation plan for stable operation of home treatment - Supply and utilization plan for COVID-19 oral treatments, etc. - Funeral management plan for COVID-19 deaths outside of medical institutions - 2021 COVID-19 response strategy based on vaccination - Public health operation plan to secure vaccination workforce - Expected to occur after COVID-19 vaccination - COVID-19 vaccine inventory management status - Prediction of future outbreaks due to COVID-19 vaccination
Accelerate equitable access to new COVID-19 tools	- COVID-19 treatment and vaccine development trends and government-wide support measures - Plan to support private use of bio safety research facilities - Survey status of COVID-19 antibody possession rate - Current status of COVID-19 plasma treatment and antibody treatment development - Treatment application plan such as national clinical trials for COVID-19 treatment - Current status of domestic mRNA vaccine development - Government-wide support system for COVID-19 treatment and vaccine development - 2020~2021 influenza vaccine supply plan - Measures to support local production and export of diagnostic tests - Adjustment of oral treatment pre-purchase contract

ICT=information and communications technology; COVID-19=coronavirus disease 2019; RT-PCR=reverse transcription polymerase chain reaction.

Countermeasures were addressed in 6 overarching strategies: curbing transmission, reducing risk exposure, countering misinformation, protecting vulnerable populations, reducing severe morbidities and mortality from all causes, and accelerating equitable access to new tools. Specific themes for implementing these strategies included establishing COVID-19 response guidelines, developing infection control guidelines for high-risk workplaces, formulating public health guidelines for daily life, creating detailed social distancing guidelines, crafting self-treatment guidelines, and devising management guidelines for individuals fully vaccinated against COVID-19.

Diagnostic testing methods and procedures were refined to further understand the characteristics and status of viruses entering from abroad. Themes covered included risk assessment processes regarding the specific character, origin countries, and outbreak indicators of each viral variant in order to lay the groundwork for strategies to suppress transmission.

Protective measures for vulnerable populations were enhanced, focusing on infection-prone facilities such as long-term care hospitals, nursing homes, correctional facilities, and unauthorized alternative educational facilities. Strategies were developed for diagnostics, isolation, and treatment under specific vulnerable conditions. Concrete measures were developed to support diagnostic testing plans for proactive patient detection in group facilities, infection control in childcare centers, and participation in cultural, welfare, and religious programs for older adults. The shared vulnerabilities of infection-prone facilities and high-risk groups formed the COVID-19 transmission chain of density, enclosure, and proximity [12]. Self-treatment guidelines for confirmed patients were established in October 2020, encompassing isolation, treatment, and operational plans.

Social distancing measures were periodically adjusted every 2 to 4 weeks, even after achieving higher vaccination rates, to ensure effective implementation and minimize ambiguity. These measures complemented the effects of vaccines and therapeutics, continuing alongside mask-wearing until normalcy was restored. The findings of epidemiological investigations using electronic entry logs and information and communication technology guided changes in social distancing.

Despite the rapid and widespread rollout of vaccination, crisis communication remained crucial to address reinfection after vaccination, vaccination refusal, vaccine hesitancy, and misinformation. A vaccination campaign targeting adolescents, including promoting the vaccine pass, was also developed.

Discussion

Navigating the unprecedented challenges posed by the COVID-19 pandemic, the KDCA employed an adaptive approach, frequently adjusting strategies and leaving a trail of confrontational and cooperative strategies. Recognizing the inherent unpredictability of novel infectious disease agents, the KDCA prioritized virus transmission suppression as the cornerstone of its response, a strategy that necessitated national-level intervention. The implications of this study can be summarized with the following three critical takeaways for crafting future infectious disease response policies:

1. Adaptable and transformative national health security strategy: The COVID-19 pandemic response underscored the need for an adaptable and transformative national-level health security strategy capable of swiftly adapting to the characteristics of emerging pathogens and their far-reaching societal impacts. Infectious disease pandemics profoundly disrupt social infrastructure and individual citizens, sending ripples across industries, national security, and political interests [13]. The KDCA adopted a pan-governmental approach to COVID-19 from the outset, leveraging technological advancements in data analysis and introducing various response tools.

2. Transparent and evidence-based communication: The CEPHC consistently provided comprehensive explanations of policy decisions and disseminated new infectious disease knowledge and insights through press releases and reference materials. While incorporating external expert theories and empirical studies proved beneficial in explaining policy choices, the inevitable gap between past experiences and current realities risked perpetuating inefficient circular arguments [14]. As pathogen mutations outpaced meticulously crafted response plans, citizens could only understand the value and significance of policy rationale when presented in the context of situation-specific, professional infectious disease management strategies. Moreover, the public’s trust in health authorities’ ability to overcome infectious disease challenges hinges on how efficiently and sincerely crisis communication occurs, along with the details of the messages communicated. The driving force behind overcoming the pandemic originated from a sense of solidarity and adherence to policies for the collective good [15].

3. Balanced assessment framework: The KDCA’s COVID-19 response must be evaluated based on a balanced assessment framework. Due to the limited or incomplete understanding of novel infectious disease agents, indirectly measured average values are often utilized. These values, primarily derived from limited scenarios and varying demographic compositions, inherently contain uncertainty and variability. Consequently, the criteria for evaluating policy effectiveness can be ambiguous, potentially leading to overestimating their effects at overlapping points or underestimation when solely focused on biomedical solutions. Pathogen’s epidemiological and clinical characteristics can vary across different outbreak phases, and the severity of the public health crisis tends to vary due to diverse social factors. This precludes the adoption of any fixed framework for interpreting strategy effectiveness. As the causes and cycles of outbreaks dynamically evolve, the conceptual clarity of problems and response strategies can diverge over time, and the effectiveness of each measure may be assessed differently depending on the urgency of the problem [16].

This study proposes three crucial assessment elements for evaluating infectious disease response policies, as follows:

1. Evaluation of drivers for policy implementation changes: While countermeasures should adhere to a defined command system, newly discovered facts and on-site developments may necessitate adjustments to the response process. To effectively evaluate these drivers periodically, it is essential to acknowledge and reflect the differences in policy priorities across various sectors. Additionally, given that the framing of a problem can significantly impact its priority level and resource allocation, a consensus must be reached regarding the relative value of the problem definition and the intended policy effects.

2. Effectiveness evaluation of policy tools: The emergence and spread of novel infectious diseases are not limited to one or two factors but stem from a complex interplay of biological, environmental, sociopolitical, and economic factors. Consequently, the effectiveness of infectious disease response tools is multifaceted and manifests through interactions with other socioeconomic conditions. The same policy tool may exhibit varying levels of effectiveness over time, necessitating a tool to measure consistency among policy tools.

3. Capacity evaluation of response personnel: The capacity set of response staff should include analysis of epidemiological characteristics, such as pathogen features, outbreak incidence and distribution, transmission pathways and processes, and the intensity of transmission and spread, in addition to clinical traits, such as the severity of morbidity and mortality rate, which may vary throughout the epidemic phases. Additionally, the responsibility and efficient resource allocation reflecting the impact of the infectious disease should be evaluated in a position-specific manner. Crisis communication ability and organizational resilience for implementing specific and consistent measures should also be assessed as crucial competencies in responding to public health crises.