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Fighting the Coronavirus Pandemic, East Asian Responses - Hong Kong: Border Management, Epidemiological Tracking and Social Responsibility

BLOG - 7 April 2020
Key Points
1

Immediate reaction as early as December 31 through the Center for Health Protection, created after the 2003 SARS crisis under the Department of Health for disease prevention and control.

2

Activation of the Serious Response Level on January 4, 18 days before the identification of the first confirmed case in Hong Kong

3

Gradual reduction of cross-border inflow and quarantine of incoming travelers instead of shutting down completely the border.

4

All Hubei residents from Hong Kong requested to leave the city or go in quarantine.

5

Social pressure for more stringent border controls and travel bans, with protests on February 3.

6

Tracing and investigation of each suspected and confirmed case with details of each shared on the dedicated government website.

7

Social responsibility among an experienced population strongly hit by SARS. Precautionary measures such as mask wearing and social distance are adopted independently.

8

A surge of infection cases starting mid-March leads to compulsory quarantine for all incoming passengers on March 19 and the closure of the border on March 25.

9

Electronic wristband to enforce quarantine.

10

Government regulations to enforce social distancing and limit gatherings, including closing bars and not allowing restaurants to supply foods or drinks for on-site consumption.

This article was updated on April 9.

An early response, tracking of each suspected and confirmed case, quarantine of incoming travelers, and, above all, self-discipline and solidarity : here is the recipe for Hong Kong’s relative success in managing the Covid-19 crisis - at least until recently. New challenges now emerge...

Timeline

  • December 31, 2019: Press release on pneumonia cases of unknown cause at Wuhan’s Huanan Seafood Market.
  • January 2, 2020: Government holds inter-departmental meeting on the cluster of pneumonia cases in Wuhan and reminds all relevant departments to heighten their vigilance and be well prepared.
  • January 3: Additional thermal imaging systems installed at the airport for body temperature check of travelers from Wuhan. For all boundary control points, fever patients with acute respiratory symptoms who had visited wet markets or seafood markets in Wuhan within 14 days prior to the onset of the illness will be immediately referred to public hospitals for isolation, treatment and follow-up.
  • January 4: Launches the Preparedness and Response Plan for Novel Infectious Disease of Public Health Significance and activates the Serious Response Level.
  • January 6: Government convenes the Steering Committee meeting to prevent novel infectious disease
  • January 8: "Severe Respiratory Disease associated with a Novel Infectious Agent" defined as a notifiable infectious disease. Medical practitioners required to report patients with fever, and acute respiratory illness, or pneumonia, and who had visited Wuhan within 14 days prior to the onset of symptoms to the Centre for Health Protection (CHP)
  • January 9: The Scientific Committee on Emerging and Zoonotic Diseases and the Scientific Committee on Infection Control under the CHP convened a joint meeting, during which members were updated on the latest progress relating to the Wuhan cases and provided with advice on various aspects of disease prevention and control, including surveillance, emergency preparedness, port health measures, risk communication and health promotion.
  • January 13: The HKSAR Government delegation departs for Wuhan on January 13 to participate in a two-day working visit under the arrangement of the National Health Commission (NHC).
  • January 21: Health Declaration is made a requirement for all passengers arriving from Wuhan by air. Later, on January 24, it is extended to travelers arriving at Hong Kong West Kowloon Station. On January 29, extended again to cover all travelers by air from the Mainland and finally to all travellers on March 8.
  • January 22: First highly suspected case of COVID-19, a patient detected with fever at the Hong Kong West Kowloon Station and sent to the hospital for isolation and treatment. Immediate contact tracing of the patient, quarantine for close contacts while medical surveillance for other contacts.
  • January 23: The Lady MacLehose Holiday Village converted as a quarantine center to host close contacts of confirmed cases.
  • January 25: Activation of Emergency Response Level in relation to novel coronavirus infection; suspension of flights and high-speed train services between Hongkong and Wuhan; advice against travel to Hubei province
  • January 27: Hubei Province residents and people who visited Hubei Province (except for Hong Kong residents) in the past 14 days are barred from entering Hong Kong
  • January 28: Hong Kong residents who have visited Hubei Province in the past 14 days should approach staff of DH's Port Health Division for relevant assessment upon their arrivals. If members of the public are found to be asymptomatic, they will be required to wear a surgical mask immediately and self isolate for 14 days as far as possible. They will also be placed under medical surveillance by the DH. Hong Kong residents returning from other parts of the Mainland are advised to stay home for 14 days upon their return as far as possible. Those who need to go out should wear a surgical mask.
  • January 30: Suspension of the Individual Visit Scheme. Number of mainland flights reduced to half
  • February 4: Confirmation of the first local infection case
  • February 8: a 14-day mandatory quarantine on all individuals entering Hong Kong from the Mainland and who have stayed in the Mainland for any period during the 14 days prior to the arrival in Hong Kong.
  • February 17: Non-emergency and non-essential medical services adjusted and/or postponed by Hospital Authority for four weeks to focus manpower and resources on COVID-19 cases
  • February 20: 106 Hong Kong residents from the Diamond Princess arrive on a 1st chartered flight arranged by HKSAR are sent to quarantine centers
  • February 28/29: several HK authorities (HA, LCSD, ICAC, etc) announce they will resume normal services with preventive measures. Other public services continue to reduce their activities.
  • March 2: Government gradually resume public services after implementing targeted measures (reduce social contact and infection control measures)
  • March 19: Compulsory quarantine for persons arriving at Hong Kong from abroad
  • March 25: Hong Kong bans entry of all nonresident travelers, for a tentative period of 14 days. On April 6, the entry ban period is extended until further notice.
  • March 28: Prohibits catering businesses from selling or supplying foods or drinks for on-site consumption, for a maximum period of 14 days
  • March 29: Prohibits group gatherings with more than four people in public places for 14 days (except transport, government, healthcare facilities, etc)
  • April 3: Closure of bars and premises selling liquor for 14 days
  • April 8: The government extends social distancing measures until April 23

Analysis

Hong Kong, China’s Special Administrative Region, has managed to keep its number of coronavirus infections low in January and February despite a land border and intense human interactions with Mainland China. Its government has taken the initial reports of the coronavirus outbreak at the end of December extremely seriously and communicated information to the Hong Kong population. Each suspected and confirmed case is tracked thoroughly. The Hong Kong government’s crisis management focuses on a gradual reduction of cross-border inflows and the quarantine of incoming travelers. It appears that the low number of local infections during this phase is in large part due to the community’s self-discipline and solidarity, and the emphasis on masks.

The low number of local infections during this phase is in large part due to the community’s self-discipline and solidarity, and the emphasis on masks.

However, since mid-March, the number of confirmed cases starts to surge, even if it remains at very low levels compared to the United States, Western Europe or China during the peak of the crisis. On March 20, a record high 48 new cases is reported, bringing the total number to 256. Stricter measures have been implemented since then, but the number of Hong Kong residents returning from overseas and the risk posed by asymptomatic cases are posing challenges to the containment. As of April 10, Hong Kong has 990 confirmed cases.

Early stage crisis management

In 2003, Hong Kong was strongly hit by SARS. The outbreak resulted in 298 deaths, second only to mainland China. The lessons of the crisis are compiled in a report published by Hong Kong’s SARS Expert Committee "SARS in Hong Kong: From Experience to Action". The report recommends short and long-term action to prepare the public health system for future crises, and leads to the establishment in June 2004 of the Center for Health Protection (CHP) under the Department of Health. The center is the main entity responsible for disease prevention and control. Its mission mirrors the recommendation of the report, with three focuses ("3Rs"): real-time surveillance, rapid intervention, and responsive risk communication.

This institutional arrangement facilitates immediate action after the Wuhan Municipal Health Commission acknowledges severe pneumonia cases of unknown cause linked to Wuhan’s Huanan Seafood Market, on December 31. The CHP issues a press release that provides an overview of the situation and informs the public that CHP is in contact with China’s National Health Commission for further information. An alert of the disease is sent to the Hospital Authority. The document lists personal and environmental hygiene advice to prevent pneumonia and respiratory infection, and health advice for travel outside Hong Kong. Cleaning and disinfection of public transportation and spaces are promoted. People with respiratory symptoms are advised to wear surgical masks and seek medical assistance.

The CHP has maintained regular updates on the diseases since then, and each government department has transferred information to their respective sector. In addition, a dedicated website is set up to disseminate coronavirus-related information and health advice, including daily case reports. Health-related information is promoted at all boundary control points through broadcast, leaflets and posters. On January 2, the first government meeting takes place to discuss the pneumonia cases detected in Wuhan. All departments are requested to heighten their vigilance and preparedness.

The government response is rapid, but also gradual and light. Thermal imaging was already in place at border checkpoints, but additional equipment is installed on January 3 specifically for body temperature checks of incoming passengers from Wuhan. The frequency of random temperature checks is later increased for other travelers. The Hong Kong West Kowloon Station, which connects Hongkong to Shenzhen, is equipped with more staff to operate and manage body temperature checks. All passengers with fever and severe respiratory symptoms are interrogated about their travel history, and are transferred to the hospital for isolation and treatment if they have visited Wuhan seafood markets within the past 14 days. Medical practitioners that encounter fever patients with and several respiratory symptoms and had visited Wuhan seafood markets within the past 14 days are requested to report to the CHP suspected cases for further investigation.

On January 4, the government launches the "Preparedness and Response Plan for Novel Infectious Disease of Public Health Significance" that provides guidance in case of a novel infectious disease outbreak. It presents a three-tier response level (alert, serious and emergency) with a corresponding command structure. On the same day, the Serious Response Level is activated. It corresponds to the assessment that the spread of the disease is limited, with a moderate risk to public health.

As numbers of confirmed coronavirus cases increase in the mainland and imported cases start to be reported in other countries, the government upscales its monitoring and revises its reporting criteria.

As numbers of confirmed coronavirus cases increase in the mainland and imported cases start to be reported in other countries, the government upscales its monitoring and revises its reporting criteria. On January 16, medical practitioners are required to report individuals with fever and severe respiratory symptoms fulfilling one of the following criteria within 14 days prior to demonstrating symptoms to CHR: a visit to Wuhan, and no longer only to the seafood market; the visit of a medical hospital in the mainland; or having been in close contact with a confirmed symptomatic patient. From January 21, all passengers traveling from Wuhan by air are required to fill a health declaration. However, the border remains open, and the government displays its trust in its well-developed public health system and hospital infrastructure, and in other words, in its capacity to contain the emergence of clusters linked to imported cases.

After two cases are confirmed on January 23, more measures and advice are issued. The health declaration form system is extended to travelers arriving at Hong Kong West Kowloon Station. Schools are asked to reconsider their exchange activities with Mainland China, and travel to Wuhan is advised against. But the Emergency Response Level is only activated on January 25, one day after the announcement of investigations of three additional imported cases, acknowledging the COVID-19 risk as high and imminent. A Steering Committee cum Command Centre is established to develop strategies and measures against coronavirus. Chaired by Carrie Lam, the Command Center is composed by 4 workgroups and an expert advisory group. Each workgroup is assigned specific tasks and led by a secretary-level official.

Contact Tracing and disclosure of information

On January 22, a highly suspected imported coronavirus case (from Wuhan) is reported, followed by a second case the day after. Suspected individuals are placed in isolation to receive medical care, and both individuals are confirmed positive on January 23. Contact tracing starts immediately. Travel history of patients, including travel date, train/flight number and seat number, with the results of the investigation published online. All their close contacts, such as passengers seated close by, taxi drivers etc, are subject to quarantine at the Lady MacLehose Holiday Village, converted as a quarantine center to host close contacts of confirmed cases. Regarded as "contacts", passengers in the same carriage or cabin are subject to medical surveillance. A hotline is set up to answer public enquiries linked to the cases, and the CHP urges passengers on the same train/flight to call the line.

Individuals are required to share any information considered relevant to the handling of the public health emergency. Refusal leads to a maximum penalty of a HK$10,000 (US$ 1,283) fine and six months imprisonment. The general public is provided with detailed information related to confirmed and suspected cases. The CHP publishes daily a list of flights, trains, ships, vehicles taken by confirmed or suspected patients. In addition, a list of buildings that have confirmed or suspected cases, and a list of buildings where people under quarantine reside made available to the public online. To better visualize information published by various government departments, the HKSAR government launches an "Interactive Map Dashboard" on February 3. The Dashboard presents all confirmed cases on the map and provides statistical updates on the number of cases, suspected, confirmed, discharged from hospital and deceased. It also provides information on the timeline and places visited by the infected person.

Travel Ban and Reducing cross-border travel with the Mainland

To reduce the risk of imported cases, three major changes occur. On January 25, flight and high-speed train services to and from Wuhan are indefinitely suspended. Exchanges, visits, cultural and sport activities organized by the HKSAR government are also put on hold. On January 27, Hubei Province residents and people who have visited the province (except Hong Kong residents) in the past 14 days are banned from entering Hong Kong. Hubei residents who already are in Hong Kong are tracked down and are either requested to leave or transferred to quarantine centers. On January 30, the Individual Visit Scheme, the travel permit granted to Mainland residents to visit Hong Kong, is suspended. Flights from the Mainland are reduced to half.

The HKSAR government launches an "Interactive Map Dashboard" on February 3. The Dashboard presents all confirmed cases on the map and provides statistical updates on the number of cases, suspected, confirmed, discharged from hospital and deceased.

The government statement celebrates the impact of the above measures on reducing inflow from the Mainland. On February 2, the number of incoming visitors has already diminished by 57% compared to January 29 (not including air travel). However, the border remains open to the Mainland and the rest of the world, a decision justified by Hong Kong’s Chief Executive Carrie Lam as necessary to sustain the economic activity in the city. She also makes reference to the WHO suggestion to not implement measures that may fuel discrimination.

Protesting against the soft border restrictions, 2500 medical workers go on a three-day strike on February 3, demanding a full ban on entry from the Mainland. The government announces on February 5 the implementation of compulsory quarantine for all incoming travelers from the Mainland, effective on February 8. Carrie Lam’s statement denies that this is a measure to appease the strikers and describes it as a response to expert advice. However, it is believed that public pressure and the confirmation of the first local infection on February 4 played a significant role. Overall, the focus of the government strategy remains on drastically reducing the cross-border flow rather than shutting down the border. A full border closure is only announced on March 23, effective from March 25 for all nonresident travelers for a tentative period of 14 days. The government later decides to extend the border closure period until further notice. This change reflects the concern about the surge in the imported case number. Hong Kong reports 10 new confirmed cases on March 17, and 8 of them had travel history.

Quarantine and Enforcement

To allow better monitoring of the situation, the Prevention and Control of Disease Ordinance is amended on January 8 to include coronavirus as a notifiable infectious disease. This amendment gives the Department of Health (DH) the legal power to enforce isolation or quarantine. Four quarantine centers are put into use, complemented with mobile units of modular housing.

On February 8, a 14 day compulsory quarantine on all travelers arriving from the Mainland and all individuals who have stayed in the Mainland for any period 14 days prior to the arrival in Hong Kong is implemented. They are transferred to a quarantine premise once they pass airport checks for symptoms and temperature. Travelers failing the check are referred to the Department of Health for further handling and testing. The quarantine arrangements on inbound travelers have been constantly updated, finally applying to all international arrivals since March 19, three days after Beijing implemented the same measure.

Initially, with the first few imported cases, only close contacts were subject to quarantine in quarantine centers. As the number of cases increases and the quarantine requirement expands to a larger public, available quarantine space becomes insufficient. People considered less at-risk start being placed into home or hotel quarantine. The latest published criteria states that travelers arriving from Daegu and Gyeongsangbuk-do in Korea, Emilia-Romagna, Lombardy and Veneto regions in Italy, and Iran have to stay in a quarantine center. Returning Hong Kong residents who request to stay at a quarantine center instead of their home, are charged a quarantine fee. Free testing is made available to asymptomatic inbound travelers from overseas on March 28, after having the covered group expanded a few times. Due to the limited resources available at the airport for testing, passengers to either visit the DH's Temporary Specimen Collection Centre after landing to undergo a throat swab or to have it deliver by a family member (the door-to-door collection service becomes available on April 3) while they stay in quarantine. However, starting from April 7, passengers are directly transferred to the testing center from the airport. Passengers landing from high risk places have to wait for the test result at the center which takes 8 hours on average. Other passengers have to go to their quarantine premise.  

If tested positive, the person is then transferred for medical treatment. If no notification is received, the person is only requested to continue quarantine until the end of the preset period.

The quarantine is enforced by disciplinary forces conducting spot checks, and electronic wristbands. Upon arrival at the Hong Kong International Airport, travelers are requested to put on an electronic wristband and install a mobile application (Stay Home Safe). The wristband has to be activated once at home and will be able to detect location change of the subject based on environmental communication signals (such as bluetooth and wifi). Changes in signals are recorded by the app, alerting the Department of Health and Police.

Amid privacy concerns, the government explains that the Privacy Commissioner was consulted: there shouldn't be any privacy concerns since the determination of location is not based on the monitoring of the precise location (thus not GPS) but signal changes of the surrounding environment.

The quarantined persons may also receive a surprise visit or video call from CHP staff to check whether they are staying at the quarantine premise. The government also encourages the public to report suspected violations via the online platform "e-Report Center". Quarantined individuals who leave the quarantine premise without permission are subject to criminal charges and a maximum penalty of HK$5,000 (US$641) and six months imprisonment.

Community awareness and self-restraint

Hong Kong’s success in containing contagion so far is often attributed to community awareness and self-restraint. The SARS outbreak has not only forced the government to take action to improve its capability of handling health emergencies, but also trained the Hong Kong population. Disappointed by the government’s poor management of SARS and distrusting the government, local communities decided to act on their own responsibility. "Every citizen did their part, including wearing masks and washing their hands and taking necessary precautions, such as avoiding crowded places and gatherings." according to Kwok Ka-ki, a former member of the Legislative Council’s Medical functional constituency. The importance of wearing masks, personal protection and hygiene, and avoiding crowded spaces has been on government press release documents since December 31, but in the form of advice. It is therefore for individuals to take the responsibility to wear masks and refrain from going out and using public transportation. This is only a few months after wearing masks in public assemblies was banned by the government to prevent pro-democracy protesters from hiding their identity.

Supplying masks to the public sector and private citizens is a challenge for the government, given its strong dependency on imports. The government ensures its mask supply mainly through the Government Logistics Department (GLD), which is in charge of procurement. However, the outbreak leads to an increase of the consumption rate by five to six times. On January 30, GLD’s available stockpile for relevant government departments is adequate for about one to two months only. The masks are distributed based on risk level assessment, meaning that front-line officers and essential services providers are prioritized. The Hospital Authority also has a stockpile that can sustain consumption by medical professionals for about three months. To meet the increasing demand, the GLD decides to remove unnecessary procedures related to the import of masks, and proactively contacts global suppliers. The government is also in touch with chambers of commerce, the retail industry and the Mainland authorities to ensure sufficient market supply.

In addition to imports, local production is boosted to meet government demand, but its production capacity remains limited compared to the estimated need of 200 million per month. The Correctional Services Department (CSD), increases its mask production volume and has them exclusively supplied to GLD since January 2020. Some Correctional Institutions switch to 24 hours operations and recruit off-duty and retired officers as volunteers. In 2019, the CSD produced around 1,1 million masks per month. By mid-March 2020, production has reached 2.5 million per month.

Yuen Kwok-yung, a leading microbiologist, warns the public on April 5 the possibility of a new wave of infections coming from the mainland as it resumes economic life.

As it becomes harder to acquire sufficient masks and other medical equipment from abroad, the government introduces a HK$ 1500 million (US$ 192 million) "Local Mask Production Subsidy Scheme" under the Anti-Epidemic Fund to tackle the mask shortage. The HK$30 billion (US$3.85 billion) commitment for the Anti-Epidemic Fund is approved on February 21 by the Finance Committee of the Legislative Council, with the goal to enhance Hong Kong’s capacity in combating coronavirus by supporting government sectors, and assisting enterprises and members of the public. The "Local Mask Production Subsidy Scheme" opens for application on March 2. Each successful applicant is entitled to receive a subsidy of up to HK$ 3 million (US$ 385,000) for the first mask production line, and up to HK$ 2 million (US$ 256,600) for the second. The government will purchase the first 2 million produced masks each month, while the remaining stock can be sold for local consumption. Export is prohibited by the scheme. The purchase price of masks is based on production cost and not uniformized. The government also encourages and facilitates relocation of production lines to Hong Kong.

Local Infections and Restrictions

These measures however are not sufficient to prevent an increase of local infection cases, e.g. cases with no travel history or no reported contact with confirmed cases. The government lacks the capacity and resources to test the general population without any epidemiological links, and urges better enforcement of social distancing. In order to reduce gatherings, the government issues on March 27 a regulation on requirements and direction for business and premises, effective the following day. Catering businesses are no longer allowed to sell or supply foods or drinks for on-site consumption. In accordance with the Regulation, the Secretary for Food and Health is empowered to issue directions to scheduled premises, for a maximum period of 14 days. The legal representative of the business may face a fine of up to HK$ 50,000 (US$ 6450) and six months imprisonment for non compliance.

Catering businesses are then issued new regulations. the number of customers in their premises should not exceed 50% of their normal seating capacity; a minimum 1,5 meters distance between tables; less than 4 persons seated at the same table; temperature checks of customers before entry; mask-wearing in the premise; and provision of hand sanitiser. A list of premises required to close is also published, and updated. Decisions on these temporary closures are based on risk assessment, taking in consideration the gathering opportunity and the intensity of confirmed cases in the area. For instance, with the emergence of 62 confirmed coronavirus cases related to bar visits, leading to 14 cases of contamination, all bars, pubs and other premises selling liquor for on site consumption are closed for 14 days, starting from April 3. Another prohibition on Group Gathering takes effect on March 29, banning group gathering of more than 4 people in public space for 14 days, imposing a maximum fine of HK$ 25,000 (US$ 3225)and six months imprisonment. Workplace and weddings are exempted. On April 8, the government decides to extend all regulations above that enforce social distancing to April 23.

Hong Kong’s measures have so far been effective in containing a major outbreak of COVID-19. However, many local experts and public figures discuss worst case scenarios. Bernard Chan, Convenor of Hong Kong’s Executive Council, stresses the need for tougher measures and does not exclude the possibility of strict lockdown. Yuen Kwok-yung, a leading microbiologist, warns the public on April 5 the possibility of a new wave of infections coming from the mainland as it resumes economic life. The Hong Kong population is told to stay alert. There is a strong possibility that the coronavirus crisis will not be fully contained in the short term and that more prevention and containment efforts will be required.

 

Copyright : ANTHONY WALLACE / AFP

 

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