PHWR Public Health Weekly Report

Quarantine is an important measure to protect public health and minimize social and economic damage by preventing and managing the introduction and spread of foreign public health threats from travelers, transportation, and cargo at the forefront of national borders. In 2020, when the first case of coronavirus disease 2019 (COVID-19) was confirmed in the Republic of Korea (ROK), the country’s real gross domestic product growth rate decreased by 3.7%, the private consumption growth rate reduced by 7.41%, and the employment rate decreased by 457,000 people. ROK experienced this economic shock comparable to the first and second oil shocks or the global financial crisis triggered by the Lehman Brothers crisis 2009 (Table 1) [1]. Fortunately, ROK effectively implemented the 3T strategy—Test, Trace, Treat—relying on testing, meticulous infection route tracing, and tailored treatment for severe conditions. This approach led to ROK being recognized as a successful responder to COVID-19 by the international monetary fund [2]. Building upon the success of minimizing COVID-19-related damage, our aim was to continually refine quarantine policies through the formulation of a comprehensive master plan for quarantine management that encapsulates a forward-looking quarantine vision and mid- to long-term strategic initiatives.

Table 1 Comparison between economic shock from main crisis

	1st oil shock (1975)	2nd oil shock (1980)	Foreign exchange crisis (1998)	World financial crisis (2009)	COVID-19 crisis (2020)
Real GDP growth rate decline (%p)	–2.6	–12.3	–13.1	–3.9	–3.7
Private consumption growth rate decline (%p)	–2.7	–7.39	–19.7	–3.2	–7.41
Employment decline (thousand people)	–222	–316	–1,512	–311	–457

Data: Bank of Korea, Statistics Korea. The size of the shock is the change in the year of the low point (indicated year) compared to the trend of the previous 5 years (3 years for employment). COVID-19=coronavirus disease 2019; GDP=gross domestic product..

Under Article 4 (2) of the Quarantine Act, the commissioner of the Korea Disease Control and Prevention Agency (KDCA) is mandated to formulate a master plan for quarantine management every 5 years through reviews by the Quarantine Expert Committee. The first Master Plan for Quarantine Management represents a pioneering initiative in the field of quarantine in the ROK. We analyzed quarantine response cases for decades since the enactment of the Quarantine Act in 1954; examined the trends of international organizations considering the nature of quarantine that manages cross-border entry, ports, and import and export; and conducted an environmental analysis after COVID-19. Based on these considerations, the primary objectives are to establish a proactive preparedness system through the management of the introduction of foreign public health threats and to minimize public health, social, and economic damage through safe quarantine management.

To establish the first master plan for quarantine management, the STEEP technique was used to analyze the external environment and determine the course of the quarantine policy. The STEEP technique consists of social, technological, economic, environmental, and political/legal analyses, and it is an acronym for these elements. It was first published by James Kyler [3] in his paper “Assessing your External Environment: STEEP Analysis” and is one of the representative techniques for analyzing external environments.

As a result of applying the STEEP analysis, from the social perspective, the proportion of the population aged 65 years increased from 17.5% in 2022 to 46.4% in 2070 [4]. As the population of ROK ages, people are becoming more vulnerable to diseases and experiencing increased anxiety toward new virus outbreaks, highlighting the need to fortify preparedness for future pandemics. From a technological standpoint, advancements in diagnostic testing technologies, facilitated by the continuous evolution of rapid diagnostic kits, and the pervasive development of information and communication technology, particularly with the advent of artificial intelligence, underscore the escalating need for evidence-based quarantine techniques. In terms of economic perspective, in response to the growing concerns of economic recession after COVID-19 and the increase in non-tariff barriers by each country, the need to modernize cargo quarantine and adopt a scientific evidence-based approach in the ROK was recognized. In terms of environmental considerations, the risk of diseases is increasing due to climate crisis and fine dust, and the cycle of infectious diseases is shortening, necessitating the need to manage environments susceptible to disease introduction and mitigate human hazards contributing to disease transmission. From legal and political perspectives, the need to revitalize international cooperation on the front line through cargo quarantine in response to global protectionism and to strengthen international cooperation in overall quarantine policies was identified.

We analyzed trends of international organizations related to travelers, means of transport, and cargo subject to quarantine. The World Health Organization (WHO), an international organization that also focuses on the health of people entering and leaving countries, has initiated a process to prepare for “Disease X” that can cause a pandemic in the future. In April 2023, the WHO introduced the “Preparedness and Resilience for Emerging Treats (PRET)” program [5], which is an initiative that aims to enhance the global pandemic response system by modularizing pathogens with shared characteristics. The International Civil Aviation Organization (ICAO), responsible for the entry and departure of civil aircraft, has revised relevant addenda to ensure the resilience of the airline industry by establishing a preparedness system for public health crises in the wake of COVID-19. The World Trade Organization (WTO), which is related to the import and export of cargo, adopted the Ministerial Declaration on the Modernization of Sanitary and Phytosanitary Measures at the twelfth WTO Ministerial Meeting in 2022, declaring the principle of cargo hygiene quarantine based on scientific evidence and principles.

In the process of establishing a master plan for quarantine management, we analyzed not only the external environment but also the current status of ROK’s quarantine response since the enactment of the Quarantine Act in 1954 and particularly analyzed the measures to prevent the introduction of COVID-19 corresponding for the past 3 years in detail.

Based on the Seaports and Airports Quarantine Act promulgated in 1945, ROK established eight new quarantine stations by 1949 and enacted the Quarantine Act in 1954. Later, the Jeju Quarantine Station was established in 1958, and from 1969 to 1978, four additional quarantine stations were established, consisting of the current system of 13 quarantine stations. Quarantine has been carried out to block the introduction of smallpox, severe acute respiratory syndrome, and new influenza. In 2005, an integrated computer network was established by adding quarantine contents for travelers to the comprehensive information service for import and export logistics. From 2015 to 2017, national quarantine facilities were established at Incheon Airport, Busan, and Jeju to provide temporary facilities for use in the event of infectious diseases being introduced. In 2019, the electronic quarantine inspection desk was introduced. In 2021, the current quarantine information pre-entry system (Q-CODE) was introduced to establish an electronic quarantine system.

To prevent the introduction and spread of COVID-19 in the past 3 years, quarantine measures for arrivals were improved, integrating systems to enable local government management post-entry, and adopting a collaborative approach across relevant ministries to jointly address COVID-19 introductions. In addition, efforts were made to ensure travelers’ convenience by providing expedited passage for businessmen, issuing quarantine exemption certificates in case of emergency, and supporting the transfer of Koreans living abroad.

In the context of overcoming the COVID-19 crisis and returning to daily life over the last 5 years, the average number of daily arrivals decreased from 141,824 in 2019 to 9,486 in 2021. Then, it increased to 79,391, as of May 2023, and this number of arrivals subject to quarantine is expected to increase rapidly. Transportation subject to quarantine inspections is expected to increase sharply as the average number of vehicles, such as airplanes, ships, and cars, decreases from 920 in 2019 to 361 in 2021 and then rebounds to 646 in 2023. In addition, in the case of imported cargo, such as scrap metal, scrap ships, and other cargo, which are subject to quarantine, the yearly cargo peaked at 11.46 million tons in 2020 and has been declining (Table 2).

Table 2 Yearly entrants

	2018	2019	2020	2021	2022
Sum	49,439,394	51,765,788	9,408,738	3,462,451	10,412,630
Through aircraft	46,456,631	48,710,388	8,241,601	2,414,179	9,344,001
Through vessel	2,973,545	3,049,889	1,166,767	1,048,272	1,068,629
Through car	9,218	5,511	370	-	-

However, with return to daily life from COVID-19 and usual travel and transportation, the number of quarantine targets is predicted to increase, with the number of cargos also being expected to increase when the economy recovers. Further, quarantine policies that consider various aspects derived from analyzing the external environment will be required.

1. Basic Directions

The first Master Plan for Quarantine Management declared, for the first time, the ultimate objective of achieving a healthy society that is safe from overseas diseases as the conclusive mission of the quarantine policy. It outlines three overarching visions for each quarantine target: containment of infectious diseases through traveler quarantine, management of disease-prone environments via transportation quarantine, and blocking disease-inducing factors along with the supervision of their introduction through cargo quarantine. Underpinning this mission and vision, the plan sets forth four promotional strategies, associated goals, and 15 detailed strategies to be systematically implemented over a continuous five-year period, spanning from 2023 to 2027 (Figure 1).

Figure 1. The first master plan for quarantine management, mission, vision and strategy
COVID-19=coronavirus disease 2019; ICT=Information and Communication Technology; ICAO=International Civil Aviation Organization.

2. Establishment of the Next Pandemic Response System based on Participation and Communication

Regarding the first vision of the first Master Plan for Quarantine Management, we will establish a response system for the next pandemic based on the participation and communication of travelers. This is directly linked to the third Basic Plan for Prevention and Control of Infectious Diseases and the mid-to-long-term plan for pandemic preparedness and focuses on minimizing the recurrence of social and economic damage caused by the introduction of COVID-19. First, by expanding infectious diseases subject to quarantine, we will expand the number of infectious diseases that can be identified for symptomatic individuals at the airports and seaports. A wastewater-based infectious disease surveillance system will be established to monitor the outbreak of infectious diseases through wastewater testing in quarantine areas. In addition, experimental functions in quarantine centers will be established, the infrastructure of quarantine facilities in the airports and seaports will be expanded, and the workforce for this will be secured to be always prepared. Second, the effectiveness of the anti-epidemic policies used in the process of preventing the introduction of COVID-19 will be reviewed, and a consultative body participated by 14 related ministries will be institutionalized for the KDCA to oversee and coordinate infectious diseases coming from overseas. Third, we will strengthen the Overseas Infectious Disease Reporting Center and its functions by providing comprehensive information related to travelers’ health and information on infectious diseases within the Overseas Infectious Diseases NOW. An integrated national secretary chatbot consultation service using artificial intelligence technology and immigration-related agencies will be established to provide 24-hour consultation for civil complaints while strengthening communication with the public to prevent overseas infectious diseases online and offline. Fourth, Information and Communication Technology will be applied to streamline quarantine for arrivals. This includes expanding the infrastructure of the quarantine information pre-entry system in seaports, diversifying software (SW)-related functions to increase utilization, and implementing paperless quarantine through an automated quarantine inspection station to streamline the operation of quarantine personnel.

3. Supporting a Healthy Society from Diseases through Transportation and Cargo Quarantine

Regarding the second and third visions of the first Master Plan for Quarantine Management, we will support a healthy society that is safe from diseases through transportation and cargo quarantine. First, we will reflect on the revised ICAO Addendum to advance the aviation health and sanitation policy. We will establish an aircraft sanitary condition management system by combining reporting and management, institutionalize support for returning home in the event of a confirmed case overseas, and establish a reporting-emergency response system in the event of an infectious disease patient or symptomatic patient on board the aircraft. We will continue to improve our capabilities by institutionalizing the evaluation of ports’ public health crisis response levels. Second, we will complement the marine health and sanitation policy and lay the foundation for land quarantine. Reflecting the WHO’s international standards, the investigation items and methods will be improved to ensure effectiveness of ship sanitation investigation, and response procedures will be prepared in the event of an emergency patient on a ship, similar to that in an aircraft. Simultaneously, we will establish the foundation for a land quarantine system, enabling prompt and effective land-based quarantine operations. Third, we will establish a pollution control system such as disinfection of transportation. In the event of contamination through transportation, standards and procedures will be established from the order of disinfection to the performance of disinfection, and safety will be continuously ensured by registering and managing companies for disinfection in the means of transportation. Fourth, under the policy trend of the WTO, we will carry out sanitary inspections of import and export cargo based on scientific evidence. We will reorganize cargo quarantine requirements and procedures to protect public health, secure a system to evaluate and select health hazards contained in cargo and build infrastructure related to cargo quarantine. In response to the global trend of expanding sanitary quarantine, we will expand the types and items for export product certificates to improve effectiveness and begin providing domestic and foreign cargo quarantine information to companies.

4. Strengthening Quarantine Capabilities by Expanding the Implementation Framework

We will continue to expand the implementation framework to achieve the three visions of the first Master Plan for Quarantine Management to strengthen quarantine capabilities. First, we will improve the education and training of related personnel, such as quarantine officers, to secure their expertise. We will normalize quarantine officer training that was suspended during COVID-19 and strengthen expertise by subdividing the process. In addition, a training plan for foreign infectious diseases at airports and seaports will be prepared, and overseas infectious disease training in which relevant organizations will participate will be held regularly. Second, we will promote effective quarantine by managing the safety of quarantine officers and improving their rights. We will ensure the safety of quarantine officers by minimizing unnecessary marine boarding quarantines and protect quarantine officers from external and internal violence by preparing a manual for responding to complaints such as harsh complaints, verbal abuse, and sexual harassment. In addition, we will lay the groundwork under the Quarantine Act to protect the rights of quarantine officers and assistive personnel who support quarantine. Third, we will strengthen quarantine statistics and quarantine information management. In addition to establishing an integrated quarantine information system and strengthening the linkage with overseas infectious disease information, we will regularly diagnose the timeliness of quarantine statistics to reflect continuously changing situations and continuously discover, manage, and supplement new statistics to strengthen evidence-based administration. Fourth, we will strengthen the framework for promoting quarantine policies. To respond to domestic and international demands on quarantine institutions, the policy organization will be expanded from the Quarantine Policy Department, a departmental level, to the Quarantine Policy Bureau, a bureau level. The overall function of directly managing quarantine centers will be strengthened while specializing in each field. In addition, human and material improvement plans will be derived through periodic diagnosis of quarantine center organization. If necessary, the utilization of civilian assistive personnel for quarantine will be increased in the long term. Like other border management agencies, such as customs and immigration, quarantine-only transportation will be introduced to eliminate blind spots in quarantine work.

5. Laying the Foundation for Quarantine through Internal and External Cooperation

In addition to achieving the three visions outlines in the first Master Plan for Quarantine Management, we aim to lay the foundation for quarantine through internal and external cooperation, considering the characteristics of quarantine related to cross-border movement. First, we will strengthen international cooperation in the field of quarantine. The basis for international cooperation will be established within the Quarantine Act, and cooperation between countries will be strengthened in terms of quarantine of travelers, means of transportation, and cargo. In addition, we will strengthen cooperation for the quarantine of the US Forces Korea. Second, we will strengthen the solidarity of the quarantine network by region. We will also strengthen cooperation between quarantine and disease response centers and establish a cooperation system for arrivals among CIQ-related agencies, which manage borders. In addition, considering the COVID-19 situation, the response system will be strengthened at airports and seaports through cooperation with related ministries. Third, we will strengthen cooperation with the private sector by promoting R&D related to quarantine. We will support transportation inspection in the marine and aviation sectors and support testing and inspection by securing cargo quarantine inspection capabilities.

The KDCA is systematically upgrading its aviation health and hygiene policy to reflect the revised ICAO Addendum under the first Master Plan for Quarantine Management.

The aircraft commander uses the Flight Declaration of Health form to check changes in in-flight health conditions from the time of departure from overseas to the time of arrival in the ROK and to report it to the quarantine center, a public health agency for border management. The quarantine office checks the health status of the aircraft based on the Flight Declaration of Health form on board and, at the same time, checks some of the sanitation conditions. The KDCA is checking and revising the aircraft health status declaration system under the Master Plan for Quarantine Management. Simultaneously, in adherence to the revised annex, we are preparing a plan to systematically inspect the sanitary conditions in the aircraft, evaluate the risk, and implement disinfection or eradication measures through a research project for “Introduction of the Aircraft Health and Sanitation Management System.”

Before COVID-19, quarantine centers primarily dealt with infectious diseases imported from overseas, but after COVID-19, the first Master Plan for Quarantine Management aims to expand the scope of quarantine management by including not only infectious diseases but also public health threats coming from abroad following the development of technology. WHO, in its 2005 International Health Regulations, already suggested that the role of quarantine centers is to manage borders to prevent and manage public health threats that may come from abroad and affect people’s health. In the ROK, quarantine centers also want to move forward to protect health security at the forefront. The first Master Plan for Quarantine Management has established a mission, vision, and detailed strategy for the next 5 years in line with this direction. The KDCA intends to implement effective quarantine management policies to realize these objectives.

Ethics Statement: Not applicable.

Funding Source: None.

Acknowledgments: None.

Conflict of Interest: The authors have no conflicts of interest to declare.

Author Contributions: Conceptualization: JUP. Writing – original draft: JUP. Writing – review & editing: JHP, JWK.