By Jerri-Lynn Scofield, who has worked as a securities lawyer and a derivatives trader. She is currently writing a book about textile artisans.
I was chatting on Facebook the other day about the topic de jour – protecting friends, family, and myself from coronavirus – with Dr. Sarah Borwein, an old friend and travel buddy from my Oxford days. Sarah’s a Canadian- trained doctor who has practiced family medicine for more than 15 years in Hong Kong. She co-founded the Central Health Group.
I recently attended Sarah’s wedding in Hong Kong in early January – and got out just in time to avoid some of the more draconian travel restrictions that have since been imposed as a result of the outbreak of COVID-19. At least for now. And just before Hong Kong implemented drastic restrictions that have allowed it to weather the coronavirus crisis while recording only three deaths so far.
She has an extensive professional history of dealing with infectious diseases in Asia. Prior to commencing her practice in Hong Kong, she successfully ran the Infection Control program for the only expatriate hospital in Beijing during the SARS period, also serving as liaison with the World Health Organization. For a fuller account of her career and her thoughts on the current crisis, see this interview in AD MediLink, Exclusive Interview on COVID-19 with SARS Veteran Dr. Sarah Borwein.
I thought readers might be interested in some of the things Hong Kong is doing to combat the virus.
The city has been in partial lockdown from the middle of January, with schools and universities shut, employees encouraged to work from home, sports facilities and museums closed down, and people told to avoid crowds according to the Financial Times, Hong Kong’s coronavirus response leads to sharp drop in flu cases. Hong Kong residents have accepted these restrictions, since:
Hongkongers are particularly compliant with public health measures because the 2002-2003 Sars outbreak, which claimed almost 300 lives in the territory, is still fresh in many people’s minds.
The partial lockdown is neither easy nor cost-free, but it largely seems to have controlled incidence of the disease, without paralysing Hong Kong. The city is close to mainland China and has extensive economic and other ties. But so far, it has recorded only three deaths, according to the South China Morning Post, Coronavirus: Hong Kong records third death as five more cases confirmed, bringing total to 114. And this for a city with population of roughly 7.5 million people.
There has been extensive testing for the coronavirus in Hong Kong – which is free. This allows public health austhories to track the spread of the disease, and see that victims get treated properly and promptly.
This record stands in contrast to the US, which has not yet managed to distribute tests widely – let alone, as far as I can see, determine who will pay for testing.
The disease seems to have taken hold in In U.S., with cases exceeding 500 and deaths so far recorded of 22, with 19 in Washington state, according to the New York Times, Cases of Coronavirus Cross 500, and Deaths Rise to 22.
New York declared a state of emergency on Saturday. Governor Andrew Cuomo has complained about the lack of testing kits (see Coronavirus in N.Y.: Cuomo Attacks C.D.C. Over Delays in Testing).
The inability to test means that it’s not possible to track the progress of the disease properly, is as to determine from where a patient may have caught it. Nationwide in the US, a fraction of people who are symptomatic or who may have been exposed to the virus have been tested. Even India, which has so far managed to limit exposure of its population to foreign sources of infection, has tested many more people – and is doing comprehensive screening at its airports.
Which makes a lot of sense, as foreigners – tourists – are principal source of the infection, Others are Indians returning from foreign climes, carrying with them the disease. So far, India has reported 39 cases, a large cluster of which is an Italian tour group that visited Rajasthan. Five other recent cases are non-resident Indians (NRIs), who returned to India from Venice. We can only hope as the temperature slowly rises as we approach the Indian summer, that increase in temperature slows spread of the virus (see Coronavirus cases rise to 39 as 5 found infected in Kerala). Whether this will prove to be the case is as yet unknown, but as Sarah discussed in her MediLink interview:
It is true that some viruses that are spread by respiratory droplets, as COVID-19 is believed to, spread more easily when the air is cold and dry. In warm, humid conditions, they fall to the ground more easily and that makes transmission harder.
But there is still a lot we don’t know about exactly how COVID-19 is spread and the effects climate may have on it. We do see it spreading in Singapore, which is warm and humid, so who knows?
I should mention that there has been dark musing about the NRIs returning to the state of Kerala from Venice – as they concealed their travel history and exposure. Kerala Health Minister K.K. Shailaja has said these victims will be treated, but that this type of behavior — the deception – should be considered to be a crime.
Hong Kong has made it a criminal offence to lie to a health care provider about one’s travel or exposure history, according to Sarah; I wonder whether the US will attempt to do the same?
There have been numerous complaints about the lack screening at US airports, including JFK, for people coming from Italy, which has locked down 16 million people in Lombardy and the north (see ‘Absolutely Chilling’: Reports From Frontlines of Coronavirus Outbreak Reveal Roadblocks to Testing, Lack of Safety Protocols.)
How to Protect Yourself From Infection
Most of us have heard the advice for avoiding infection. I’m going to repeat this advice. Those who know it all already, feel free to skip ahead. Those who’ve not seen such advice, pay attention.
Wash your hands, with soap, properly and frequently. I posted this video last week, but some readers may not have seen it:
WHO handwashing technique. Notice the attention to between the fingers, back of fingers, and nails:
Hand sanitiser can be used as a stopgap until you can wash your hands, but the World Health Organization says that only those that are 60% alcohol killl the virus. And hand washing is an absolute must for hands that are visibly dirty.
Maintain social distance. Avoid crowds.
Cough or sneeze into a tissue, and dispose of it promptly and properly (I’m tossing mine into my toilet, and flushing them away.).
Pay attention to your overall health. Eat well. Including plenty of fruits and vegetables. Stay properly hydrated.
Get a ‘flu shot if you haven’t already. Although this won’t protect you from coronavirus, ‘flu can be a nasty disease in its own right, and catching it can land you in hospital or quarantine. Not to mention getting sick with the ‘flu overburdens health systems when resources are needed elsewhere.
The procedures Hong Kong has put in place to control coronavirus have also led to a drastic decline in ‘flu cases,. In fact, its winter influenza season has ended more than a month earlier than usual. ‘Flu cases also dropped during the ARS crisis, according to the FT:
Data provided by the government’s Centre for Health Protection show the incidence of infection with influenza had fallen to less than 1 per cent by the end of February, marking an end to the winter flu season, which normally extends to the end of March or into April.
“A similar pattern happened in 2003 during Sars. All respiratory infection diseases were down between March to September compared to 2002,” said David Hui, a respiratory disease expert from the Chinese University of Hong Kong.
“Influenza spread is one of the markers [of the coronavirus containment] as the same principles of avoiding droplets and social contacts apply.”
Ho Pak-leung, a leading microbiologist at the University of Hong Kong, said data showed the flu season had shortened from an average of 98.7 days to 34 days this year.
Use of Masks?
Masks are not very useful, and many places are out of stock anyway, but Sarah says these can prevent you from passing along any infection you might have to others. She says the advice to avoid masks outright is wrong. There is a place for them, they’re just not a panacea, and in any case, if used improperly, they may actually increase your risk.
From her Medilink interview:
The shortage of masks has many people feeling quite anxious and unprotected. But masks are NOT very effective at preventing transmission of viral infections, particularly when worn by healthy people. They are by no means the most important measure you can take to protect your health. In fact, if you wear a mask incorrectly, touch or adjust it frequently, re-use it, or fail to wash your hands before putting it on and after taking it off, you may actually increase your risk.
Who should wear a mask:
– People who are sick, to prevent them spreading their viral droplets when they cough or sneeze.
– People caring for sick people at close quarters.
– In a health-care setting.
– People whose occupation requires them to have close contact with clients.
As it has become socially unacceptable in Hong Kong to NOT wear a mask, there may be situations in which you might choose to wear a mask simply to make other people feel comfortable. But in general, healthy people do not need to wear masks, except when they need to be in crowded places, or with possibly sick people.
Infection Control Protocol?
This to me was the most striking thing I learned from our conversation. I don’t think anything like this infection control protocol is yet in place – certainly not throughout the US, nor even in high-risk areas. And it it should be.
From a text from Sarah:
We have triage at the door. People with high-risk travel history can’t be seen, have to go directly to government hospital if symptomatic; or if just for routine care, wait 14 days after return (all of which must be healthy). Low risk people with symptoms we isolate immediately; they never enter the main clinic. And we wear PPE [i.e., personal protective equipment] to see them.
In Hong Kong, people are being told to get tested if you think you have been exposed, and/or are symptomatic. Anyone with a fever or respiratory symptoms is tested as a matter of course, upon recommendation of a doctor.
To be fair, I should mention that Hong Kong did not initially test so extensively. Sarah texted me:
Testing has been ramped up gradually. Initially they just added testing of all pneumonia patients, regarless of epidemiological link. The testing of all mildly symptomatic patients with no epidemiologic link is relatively new. A few weeks ago they started offering it in the public hospital A&E’s and public outpatient clinics. Then last week they extended that to private sentinel clinics (of which we are one) and this week have extended it to all private clinics
But in the US, even if your doctor wants to test you, no testing kit may be available to conduct the test. This is simply insane, so many weeks after the disease has taken root in so many places, and after the World Health Organization made accurate tests available months ago.
Hong Kong has also made it easier for patients to test themselves, without involving a health care provider. From a message from Sarah:
They also pioneered a test that patients could do themselves – ie they self-collect a “deep throat saliva” sample at home. That reduces risk of exposure to healthcare workers, as taking nasopharyngeal swabs is “aerosol generating”
So there is considerable scope for United States to learn from Hong Kong’s experience and ramp up its testing – without appreciably increasing risk to its health care providers.
One thing chatting with Sarah has driven home to me is how poor the comparative US infrastructure for dealing with such a disease is – although she didn’t say so in so many words. These are my words, but I don’t think she would dispute the conclusion.
Contrast that to Hong Kong. From her MediLink interview:
The situation is much less serious in Hong Kong than in mainland China, especially Wuhan and Hubei. We are quite exposed here, because of our close ties with the mainland, but we have a very strong public health system, good resources, and deep experience in managing epidemics. After SARS, Hong Kong set up the Centre for Health Protection (CHP), which is our version of the CDC in the United States. When COVID-19 emerged, there was already an epidemic management plan in place that just had to be activated. The four best prepared places in Asia are probably Hong Kong, Singapore, Thailand and South Korea.
Her MediLink interview is upbeat in some ways. Perhaps a better description would be measured. She points out that COVID-19 is less lethal than SARS. But because of that fact, it’s much easier to spread:
COVID-19 and SARS do share some common features: they belong to the same family of viruses, they both seem to have jumped from animals to humans, they both originated in China and both can cause severe pneumonia.
But there are some important differences. SARS was more lethal than COVID-19, but less easily transmitted. It went straight for the lungs, and caused severe pneumonia which became transmissible only when patients were quite severely ill and usually by then in hospital. About 10% died.
COVID-19, on the other hand, seems to be more likely to replicate in the upper respiratory tract and it seems like individuals might produce a lot of virus when they are only mildly symptomatic. It’s not known how many people with COVID-19 develop pneumonia, but of the ones who do, about 20% get severely ill and fewer than 2% die. Overall death rates are still not known for sure, but are probably less than 1%.
So COVID-19 is a lot less lethal than SARS, but harder to control because it spreads more easily and by people with milder symptoms. That’s why, despite being considerably less likely to kill you than SARS was, COVID-19 has still in total killed more people in 6 weeks than SARS did in eight months.
We should recognise considerable advances in infection control have been made since that time. Alas, many countries seem not to have absorbed these lessons – including the United States. Or if they did, that knowledge has failed to translate into effective responses. From MediLink:
Another important difference is that medical science has advanced considerably in the 17 years since SARS. In 2003, it took months to identify the virus and develop a test. For COVID-19 that happened within a couple of weeks. That has made identifying patients a great deal easier. In addition, there are newer treatments and some vaccine prospects already in the works.
Epidemic control is something that has confounded the US political system. The relevant public health officials may know what needs to be done, they’re not doing it. That may simply be, at least in part, because resources are simply not available. It’s also due to the way we divide authority for such problems, with responsibility largely lodged at the state and local level. And the reflexive reliance on neoliberal, market-based solutions is also at fault. There are some things government is uniquely positioned to provide, but many are no longer capable of recognising that simple fact.
Over to Sarah’s MediLink interview again:
The most important thing we learned from SARS was that infectious diseases do not respect borders or government edicts, and cannot be hidden. It requires international cooperation, transparency and sharing of information to control an epidemic.
We also learned the importance of providing good, balanced, reliable information to the public. In any epidemic, there is the outbreak of disease and then there is the epidemic of panic. And nowadays, there is also what the WHO has termed the Infodemic, the explosion of information about the epidemic. Some of it is good information, but some of it is rumour, myth, speculation and conspiracy theory, and those things feed the anxiety. It can be hard to sort out which information to believe, so it is important to choose trustworthy sources. Panic and misinformation make controlling the outbreak more difficult.
On a day when markets are melting down, and people are succumbing to panic, I can only say, keep calm. And remind everyone: wash your hands!