In Korea, COVID-19 killed fewer people than elsewhere. How? And when will we have a treatment for the disease. Go inside the fight against coronavirus with an expert virologist

Dr. Marc Windisch is head of the Applied Molecular Virology Laboratory and director at the Institut Pasteur, in South Korea,  which is a leading global translational research institute, active in the eradication of infectious diseases, and research for drug discovery (http://www.ip-korea.org/). We asked him about the challenges posted by COVID-19 around the world and how South Korea had recorded such a low mortality rate.

First, there was Severe Acute Respiratory Syndrome (Sars) in 2003, then swine flu (H1N1) in 2009, now Covid-19 in 2020. Why so many pandemics in the last fifteen years? Is there no way to predict them and protect ourselves?

Globalisation and the increased mobility of people and goods seem to be among the major causes of the frequent appearance of virus outbreaks. These days, in approximately 24 hours, anybody can go anywhere, and, of course, this is an opportunity for pathogens to accompany travelers without the patient being aware. The high population density in some parts of the world also helps diseases spread quickly.

Local virus outbreaks cannot be predicted. But the outbreak of a potential pandemic can be inferred by several factors. Besides population density and mobility of the population by plane, train, and so on, one of the most important factors to consider is the virus transmission rate—that is how many people can be infected by a single infected individual. At the moment, COVID-19 spreads statistically to 2.5 individuals (based on preliminary data). To put this in perspective, one Ebola patient transmits the virus to 2 other individuals, in case of mumps to 4.5, and measles to 16 individuals. Every virus with a transmission rate greater than one can potentially lead to a pandemic.

Preparedness will play a key role in protecting our lives and economies in the future. Governments will have to learn the hard way how to react quickly and with adequate measures (stockpiling of personal protective equipments, training for medical staff, strengthened healthcare systems). Financial investments targeting infectious diseases are needed to develop new drugs, vaccines, and diagnostics to prepare us for the next, potential pandemic.

Let’s talk about financing. What role do you see in the fight against pandemics for multilateral development banks like the European Investment Bank?

The EIB is focusing, among other things, on innovation and skills and small businesses. In these areas, a lot can be done and has to be done. For example, supporting fundamental and applied research will generate new opportunities and new businesses. New ways of education are needed, such as eLearning, which requires fast internet access anywhere. That means 5G. The digital economy does not exist in Europe as compared to the USA and China. And of course, life sciences need a significant boost to develop novel and innovative drugs, vaccines, diagnostics, etc. Healthcare, surveillance, and information technologies. Also, the production of “basic” personal protective equipment. What can we do to reduce dependencies? What can we do to increase competitiveness? How can we reduce production costs?

I have been living in Asia for more than 10 years, and I am amazed by the entrepreneurial mind-set of people here. Asians are risk-takers, and the risks are mitigated by governmental banks and funds and by venture capital. We have to ask the general question, how can we foster innovative start-ups, and what can the EIB do to encourage entrepreneurship? And how to reduce the risks for start-ups, SMEs, etc.?

However, even during this devastating crisis, there are opportunities to make significant changes for a better future by holistically addressing climate changes, globalization, pandemics, etc.

Do you think that national health systems should cooperate more to fight future pandemics?
National health systems have to be prepared and financially supported to handle outbreaks of pathogens in the future. What happened with COVID-19 must be a “lesson learned” for all governments... Especially inside the European Union, cooperation and solidarity among the member states is more than necessary, and not only during a pandemic. The World Health Organization (WHO) is another crucial instrument for orchestrating a global response. If a country develops and validates useful diagnostic tools, other countries should be able to adopt these technologies quickly, to avoid any waste of time, which costs lives. Common measures should be taken as soon as possible to reduce dramatic effects on the economy.  

Sars and Covid-19 are genetically related. Is there a relationship between the outbreaks of the two pandemics?       
There is a relationship between the two viruses (SARS-CoV-1 and SARS-CoV-2); both belong to the family of Coronaviridae, which are enveloped, positive-sense, single-stranded RNA viruses. Both are zoonotic viruses that originated from an as yet uncertain animal reservoir. And both viruses are transmitted from human-to-human via aerosol droplets and cause respiratory diseases. However, there are differences in transmission and mortality rates.                          

Is the nature of the Covid-19 virus fully known? Why are there people who become infected a second time? Why can even young people, apparently in good health, become infected and die in a very short time? Are there different forms of Covid 19, some more aggressive than others?
Currently, the nature or origin of COVID-19 is not known. There are a few reports that the virus may have been originated from bats or pangolins, but it is still unclear. There are even rumors that the virus might have been “escaped” accidentally from a laboratory in Wuhan, which seems to be unlikely.

Whether patients can be re-infected by the same virus is not certain yet, but it cannot be excluded. The causes behind the so-called re-activation, the detection of viral genomes that were undetectable, is not fully understood. Scientists are investigating. However, in both cases, the clinical symptoms are expected to be mild because the patient’s adaptive immune response, as a rule, generates antibodies that neutralize the pathogen. Unfortunately, in biology, it is not always black or white. Therefore, an exemption from the rule might be possible.

Unfortunately, there are cases where “healthy” patients without underlying health conditions died quickly after contracting the disease. For sure, this is alarming. It seems that the virus disclosed a health precondition that was not recognizable before.

There are different variants of COVID-19, especially RNA viruses which generate random mutations during the multiplication of their genomes. It can’t be excluded that this leads to a higher virulence, however, was not shown for COVID-19 yet.

>@DR
Marc Windisch ©DR

South Korea registered more than 10 000 cases of Covid 19, but only 200 deaths. How was this possible?
South Korea experienced a MERS-CoV outbreak in 2015, in which the government and hospitals learned how to quickly respond to a fast spreading disease. With the beginning of the COVID-19 outbreak, the Korean government almost immediately started testing and isolating infected patients. In parallel, state-of-the-art surveillance technologies for data tracking, including credit card usage, mobile phone tracking, closed-circuit tv, face recognition, artificial intelligence, were used to trace individuals who had contact with an infected patient. This surveillance strategy seems to be very successful.

In addition, South Korea has excellently equipped hospitals and well trained medical personnel. The government is educating citizens on how to prevent becoming infected and how to prevent spreading the disease: for example, cough etiquette, how and when to wear a face mask, keep your distance, stay at home. This information is given everywhere in four languages (Korean, English, Chinese, and Japanese). Kindergartens, schools, universities, cinemas, gyms were closed soon after the outbreak of the pandemic. It’s important to mention that there was, and there is no general lockdown of businesses in South Korea. Supermarkets, retailers, barbers, etc. are open. To cope with the situation, schools and universities have online classes. Everybody has access to extremely fast internet in South Korea, everywhere.

In Europe, Italy, Spain, France, and Germany all had more than 10 000 Covid 19 cases, but Germany has a very low mortality rate, less than 3%. What makes the difference?
Germany has a solid healthcare system, hospitals are well equipped, and medical staff is well-trained. Germany started early testing patients with no or mild symptoms, which statistically increases the survival rate. Nevertheless, a faster learning from Asian countries could have further reduced transmission and mortality rates. However, as in South Korea, the situation is fragile. A few measures to prevent the spread of the virus have to become the new normal, all over the world, at least for a while.              

To explain the outbreak and the quick spread of the virus in certain countries, several theories have been raised, i.e., that the virus may be linked to climate change and pollution, or population density and high industrialisation, even to 5G networks. Is there something true in all this?
At the moment, there are no data to support the assertion that the COVID-19 outbreak correlates with climate change; I do not see any correlation. There a few reports on pollution and the severity of the clinical outcome. Air pollution (fine dust) in China and South Korea can be severe, especially during this time of the year. However, the number of patients, the severity of the diseases is not higher compared to less polluted countries. For sure, we can rule out that 5G networks have anything to do with COVID-19. High industrialization means globalization because industries are interdependent, and, e.g., products produced in China end up in European products and vice versa. Increased interaction between continents will increase the probability of spreading diseases, especially easy transmittable respiratory diseases.

The most successful measures adopted so far are social distancing, facial masks, frequent hand cleaning, and lockdown. Is there anything else we can do?     
The measures of physical distancing, wearing facial masks, and appropriate hand hygiene are very important and easy to adopt and will be practiced for a long period of time (the new normal). As for a general lockdown, ideally, it would be better to avoid it, if possible.  

What else could we do? If we travel to “exotic” places, it would be better not to eat or touch “exotic” animals like bats, primates, pangolins, marmosets. And, if we are able to travel less, we would reduce the probability of being exposed to novel pathogens, and simultaneously we would reduce CO2 emissions.

There are currently many vaccines and therapies at different stages being tested. What will the response be to the virus in the near future: a single vaccine or several independent therapies? Or a single protocol? If so, when?           
Currently, there are many ongoing clinical trials with vaccines, drugs, convalescent plasma. In the near future, the third quarter of 2020, several drugs will hopefully be approved for the treatment of COVID-19. However, because none of the drugs was specifically developed for the virus, expectations should not be too high.

Still, I expect that the new drugs will reduce clinical symptoms and further lower mortality rates. Concerning vaccines, we might have to wait until the first quarter of 2021. Then a limited number of people (e.g., healthcare personnel) will get the vaccines first. Research and development is complex, time-consuming, and costly. Also, the approval of new drugs and vaccines takes time in order not to jeopardize the lives of patients.

What can we do to “flatten the curve” in the meantime?           
What all of us can do to flatten the curve and to keep the spread of the virus low is to wear a face mask and keep a distance (more than two metres). Stay away from crowds of people. Increase hygiene measures, wash your hands properly by using good old-fashioned soap, which is also much cheaper than hand disinfectants.