Written By: Dr David Owens
In a previous article, I asked whether Omicron would trigger a shift in the Hong Kong public health strategy. In the interim, as anticipated, we have seen an increase in case numbers leading to the subtle acceptance of the challenges of zero Covid, as illustrated by the rebranding to ‘dynamic zero Covid’. Essentially we are seeing a shift to scenario two of the three scenarios described in this article.
- The fifth wave is controlled and we return to a Zero Covid strategy in Hong Kong.
- Cases continue but public health restrictions are able to mitigate such that existing policies can continue.
- The rise in cases forces a strategic change.
It makes sense to consider all potential scenarios including a transition to Plan B, whether planned or forced. This article addresses the apparent reluctance to accept evolving evidence and asks what Plan B may look like.
The Hong Kong and China strategies in context
The prevailing international analysis of the Hong Kong response relates almost exclusively to external political control. Undoubtedly this is confounded by both local and geopolitics. The political narrative is outside my expertise, but I do find much of the commentary to be reductionist. China has a very strong tradition of planned public health. The science tells us with certainty that Zero Covid was the right strategy, for both China and Hong Kong, until summer 2021. Regardless of the external rationalization of the Olympics, continuing suppression of Covid over the winter 2021-22 is probably still the best public health strategy for China. Giving time to wait for lower global viral load, boost high vaccine coverage and prepare medical infrastructure makes perfect sense. Structural issues in the political systems and populations mean that both the socioeconomic impact and the capacity to eliminate Covid are different in Hong Kong and China. Omicron may yet escape even the ability of China to eliminate. Regardless of the political and economic benefits of an open border, the science has for some time suggested that population health in Hong Kong would be best served by a different strategy. Why has this science not driven policy to a greater degree?
Epidemic response, a historical context
In an editorial I wrote the following critique of the epidemic response in Hong Kong. The summary of my analysis was:
- Poor communication and poor media reporting
- Too much focus on ‘disease experts’
- Experts in community and population health side-lined
‘In general the level of news reporting in Hong Kong has been very poor.’
‘Some of this opinion has been poorly informed, emotional and speculative.’
‘The prominence given both in the media and within the profession to the opinions of hospital specialists is in part a result of a medical structure in which the political power base rests almost exclusively with hospital specialists.’
‘Hospitals and hospital-based medical specialties contribute significantly to the health of individual patients but very little to the health of populations.’
‘In this context, 99.98% of our population have not suffered from the physical manifestations of this disease but the vast majority have suffered psychologically and socially. It is conceivable that the mortality in Hong Kong from the economic, social and psychological fallout will ultimately be greater than from the disease itself.’
~ Journal of the Hong Kong College of Family Physicians, May 2003
I wrote that editorial in the Journal of the Hong Kong College of Family Physicians in May 2003. The new disease I was referring to was SARS.
Many of the same issues persist today. Hong Kong has internationally renowned experts in epidemiology and public health. In August 2021 Jingxi Xiao, Ben Cowling and Gabriel Leung, from HKU, wrote an article in the British Medical Journal titled ‘transitioning from Covid-19 to sustainable endemnicity in East Asia’.
We would go so far as to say that accepting that Covid-19 will become endemic could ultimately be the only foreseeable exit for all countries.
Sustainable endemnicity is more commonly known as ‘Living with Covid’. This playbook has been adopted by all of the elimination countries apart from Hong Kong and China. Why has Hong Kong not followed the advice of our own public health experts?
As I have previously argued, Zero Covid without an exit policy produces unintended negative consequences for public health.
In the case of Covid the following are the public health priorities for Hong Kong, in order:
1. Increasing vaccine uptake in the old and vulnerable.
2. Increasing vaccine uptake in the old and vulnerable.
3. Increasing vaccine uptake in the old and vulnerable.
In the last three months vaccination rates in the most vulnerable have increased from 15% to 30%, yet this remains amongst the lowest in the developed world. Apart from negatively impacting vaccination rates, our focus on locking down borders to keep the disease out has been associated with negative messaging and blame. The current outbreak was entirely predictable, it was triggered by a non-evidence-based 21-day hotel quarantine policy. A narrative built around creating scapegoats, whether it be aircrew or hamsters, shifts the emphasis away from an evidence-based focus on policies supported by science.
In the article on vaccine mandates I touched upon the science of decision making.
‘The field of behavioural economics has changed our understanding of the way in which humans make decisions. One of the most important lessons is that human behaviour is irrational, but in a predictable way. We are all subject to cognitive or heuristic biases. In the pandemic such biases are widely visible. Herd behaviour, confirmation bias and numerous examples of status quo bias. How long will it now take to remove countries from the blacklist or change the length of quarantine despite evolving evidence? The active positive choice has now become to change back to normal and that carries risks to the decision makers. Much easier to just keep things the way they are.’
The evolving science of Omicron is likely to make the decision on our behalf. The reluctance to consider scenarios other than a return to zero Covid is the antithesis of prudence. We really need to start preparing Plan B. We also need to consider the input of experts in public health, community health, behavioural change and economics.
What could Plan B look like?
Answer: Mitigating the impact of Omicron on the health system and accepting a transition to ‘Living with Covid’.
Firstly, it is important to realise that opening up and letting Covid burn is not an option. Omicron does appear to be a milder disease but that is relative. If the epidemic burns through Hong Kong with the current vaccination rates, our health system would be overloaded within weeks. Even if we persist with the current zero Covid strategy, it is possible that the health system will be under stress within weeks regardless. Omicron is simply too infectious. I hope that I am wrong, but it at least makes sense to consider what an alternative strategy would look like if the current one fails.
1. Positive communication and education
The first transition, which should start immediately is an honest and open explanation of the options and plans for different scenarios. Public health communication should be positive, reliable, acknowledge uncertainty and be prepared to adapt to evolving evidence. Creating an illusion of certainty around zero Covid is disingenuous. People will die of Covid and this should be acknowledged and communicated. The challenge is to balance the damage from the disease and the damage from the public health measures. We cannot look at the public health impact without considering all of the alternative unintended consequences and costs. These consequences include impacts on mental health, delayed hospital appointments, postponed operations and on the social and educational development of children in addition to the economic impact. Poverty remains the single most important factor in population health.
Government communication must acknowledge that zero Covid is only a temporary state in order to boost vaccination rates. Vaccinations work and they are the only long-term solution. We can learn from other locations. Singapore has followed a transition plan which has been well communicated. A recent article described the importance of communication in managing the epidemic within Japan. A focus on avoiding the 3C’s, Closed spaces, Crowded places and Close contact has become a widely recognised national public health mantra.
2. Drive vaccination rates
The single most important drivers of vaccination rate in population terms are education and trust in government or health systems. Messaging around vaccination benefit must be more positive. We could use non-financial nudges in messaging. The elderly need to understand that their children and grandchildren will be under significant threat if the health system collapses. The best way to protect the system is for the vulnerable to be vaccinated. We should consider financial benefits, possibly a further cash voucher to any person who is booked for the first vaccine before a specified date with the second instalment paid only on completion of the follow-up. However, in the context of a potentially rapid surge in Omicron this will not be enough. As much as I feel inherently uncomfortable with mandates, as in my previous article, the risks to population health from the unvaccinated elderly and vulnerable overloading and crashing the health system, is so great that I believe targeted mandates are not only justifiable, but essential. Given the time sensitivity, it is my opinion that the mandates should be introduced with immediate effect. They should be targeted to specifically drive rates in the most vulnerable fragments of the population.
3. Social distancing restrictions
Social distancing is about reducing probability events. The nature of a rapidly evolving Omicron epidemic is that we will need to change the intensity of social distancing restrictions based upon the pressure on the health system. Ideally we should aim to keep schools open as much as possible, whilst accepting that some local or general school closures may be necessary depending on the evolving epidemic. We will need to encourage working from home and continue targeted restrictions.
Eventually we will need to consider moving away from centrally controlled, legally mandated testing and quarantine towards voluntary systems. Case identification and the breaking of transmission chains remains a key component of epidemic control. The current system will be under significant strain at a relatively low threshold of daily cases. Again, transition can be planned or forced. Apart from overloading manpower and testing resources, continuing with protracted quarantine of close contacts is also an active disincentive to voluntary testing. The widespread quarantine of key workers may potentially threaten lifelines within the city.
4. Eventual removal of close contact quarantine and hospitalisation of all cases
The hospitalisation of every case and quarantining of contacts was effective in the early stages of zero Covid. It is likely that this will eventually not be possible due to the increased transmissibility of Omicron. The epidemic has already exceeded contact tracing capacity and the only reason we have not run out of quarantine beds is because we are now locking down buildings. At some point we will likely require a pivot. Symptomatic and positive patients will probably need to isolate at home, for five days or until they test negative on home testing, whichever happens later. Direct contacts will need to test themselves regularly and isolate.
Border quarantine could be immediately reduced to 10 days hotel quarantine. Border controls can be relaxed as the percentage of positive arrivals falls below a predetermined percentage or community cases make the incremental risk of extra cases acceptable.
5. Pivot to home rapid testing
When the strategy is zero Covid, accuracy of testing is essential. The great advantage of PCR tests is accuracy in diagnosis. The two major downsides are 1) they take time to get results 2) they are less effective at telling when someone is infectious. Rapid tests are not as accurate and hence not as good as a diagnostic test. However, they are potentially an excellent public health tool. They still have high sensitivity and specificity. They have been used widely in Europe and the US but only when the epidemic was already out of control. One possible strategy in Hong Kong would be to provide free rapid tests to the population and encourage key workers and anyone symptomatic to test and isolate when positive. There would be no compulsory quarantine but we could collect data online on a voluntary basis in order to track the epidemic and plan resources. We could still do selective PCR testing for genotyping exactly as was done in the UK and Denmark.
Hong Kong is currently focused on elimination. This policy made sense in the context of buying time to drive high vaccination rates before a planned transition. We must now at least consider the possibility that the inherent infectivity of Omicron will overload the testing, tracing and quarantine system. Any change of strategy should ideally involve an evidence-based analysis of what has and what has not worked so far, both in Hong Kong and internationally. Zero Covid was without question the right strategy for Hong Kong until summer 2021. Whilst transitioning in a planned and structured way in spring of 2022 would certainly have been a better option, we must now accept the reality of the evolving science of Omicron. If we ignore the evolving evidence, Omicron, or even possibly a new variant, may drive the strategy for us regardless. The prudent thing to do now is to communicate the different possible scenarios and the likely response in different situations and to focus decisively on boosting vaccination rates from the most vulnerable down.
1. Owens, D. (2003, May). SARS - The view from the community. The Hong Kong Practitioner. Retrieved January 25, 2022, from https://www.hkcfp.org.hk/Upload/HK_Practitioner/2003/hkp2003vol25may/editorial.html
2. Transitioning from covid-19 elimination to sustainable endemicity in East Asia. The BMJ. (2021, August 20). Retrieved January 25, 2022, from https://blogs.bmj.com/bmj/2021/08/11/transitioning-from-covid-19-elimination-to-sustainable-endemicity-in-east-asia/
3. OT&P Healthcare. (2022, January 10). Is Hong Kong's 21-day quarantine evidence-based or justified? OT&P – Internationally Accredited Medical Clinics in Hong Kong. Retrieved January 25, 2022, from https://www.otandp.com/blog/is-hong-kongs-21-day-quarantine-evidence-based-or-justified
4. Oshitani, H. (2022, January 24). What Japan got right about Covid-19. The New York Times. Retrieved January 25, 2022, from https://www.nytimes.com/2022/01/24/opinion/japan-covid.html