COVID-19: A few thoughts from Hong Kong

First published: 03^rd June 2020

TL;DR: Love Thy Neighbour, Wear A Mask

As the Covid-16 pandemic continues and some places are relaxing their social distancing rules, I would like to offer my perspective from Hong Kong, and what I think the lesson is for the world. At the end, I've put a timeline of events that I feel are significant, on a personal level, in Hong Kong, Mainland China and the rest of the World.

Hong Kong's Success

As of 2 June 2020, Hong Kong has had a total of 1094 confirmed cases, and 4 deaths, despite having suspected cases since 4 January and thousands of residents returning from Wuhan. There were no known cases of local transmission for 15 days, up to 31 May, though a handful of local transmissions have been detected since then. New York is a city of roughly similar size, it recorded its first case two months later, on 1 March, but it has suffered over 29 thousand deaths, and 373 thousand total cases. How did Hong Kong fight Covid-19 so successfully? Will this success continue?

Hong Kong had Experience

In 2003, the SARS outbreak affected Hong Kong worse than any other place, except the origin, Mainland China. Hong Kong had 1755 cases and 299 deaths, including 8 frontline health workers. There is a memorial to those health workers in Hong Kong Park.

Many trends that started in the SARS outbreak have persisted. People started wearing surgical masks. Shared surfaces, such as escalator handrails and door handles, were regularly disinfected. Lift buttons were covered in plastic sheets so they could also be wiped with disinfectant. Schools and kindergartens checked pupils' temperatures at least daily. After the outbreak was over, some measures were discontinued or not followed diligently. However, although most people stopped wearing masks, it was no longer unusual to see them around. Temperature checks for arriving travellers continued, it's a simple walk through an area monitored by thermal imaging cameras.

Also feeding in to this were other factors: a distrust of information from Mainland China, and the recent protests. Hong Kong currently enjoys freedom of speech, and gets enough news from China to see when there is censorship (see below), so there was growing concern about this new disease.

During 2019, there were many protests in Hong Kong, initially about a proposed law that would introduce extradition to China, but widening to include other concerns. Protestors began self-organising, without central leadership, with groups discussing possible actions, and individuals making whatever contribution they felt comfortable with. Many wore masks, initially surgical masks, perhaps to conceal their identity, with some moving to respirators as more tear gas was used. The government responded by introducing a ban on wearing masks at "unlawful and unauthorised assemblies" in October 2019, but it was legally challenged. The appeal was decided in April 2020, prompting many to question why the government was insisting on anti-mask legislation during a global pandemic. Therefore, as the pandemic started, there were a large number of people in Hong Kong who were used to discussing events and making personal decisions according to their view of the public good, possibly in defiance of official advice.

Hong Kong Responded

Combined, these factors led to a fast response at the beginning of the Covid-19 outbreak. People started taking action in January, the plastic over lift buttons reappeared, although there were no announcements saying it should be done. Many people still had an old box of masks left over, and they started using them despite advice that a surgical mask doesn't do much to protect you. By the end of January, most people on the street were wearing masks. Around that time, I counted people on my normal walk to work. Out of 120, 75% were, in my opinion, wearing a mask correctly. I didn't count those that left their nose exposed, or were using the smoker's "neck mask".

The supply of masks varied. By the end of January, masks were sold out and people were asking overseas friends and relatives to send them. On 4 February, Chief Executive Carrie Lam ordered officials not to wear masks, to conserve stocks for medical workers, but she apologised for the remarks a day later. By 15 March, masks were available in some vending machines. Community groups and political parties sourced masks and distributed them. The government sourced a washable cloth mask, and started distributing one to each resident, starting 6 May.

The Hong Kong Centre for Health Protection (CHP) enhanced surveillance of the novel pneumonia from 31 December 2019. Contact tracing is an established part of Hong Kong's strategy for disease response.

Hong Kong did not go into full lockdown, but many activities were reduced. Public transport usage in February was down 40%. Schools closed normally for the Chinese New Year on 25 January, but did not reopen at the end of the holiday (classes are resuming gradually from 27 May to 15 June). Government employees started working from home on 28 January and the high speed rail from the Mainland was suspended but major border checkpoints remained open. Health workers petitioned the government, demanding border closure. Sports grounds, museums and libraries closed from 29 January. Massage parlours and beauty salons were not closed until 10 April.

Six thousand health workers went on strike from 3 to 7 February, demanding complete closure of the border with the Mainland. The government further restricted the border crossings, but denied that the change was prompted by the strike. The health workers faced a difficult ethical dilemma: seeing the growing evidence of a dangerous epidemic, should they strike for better protection of the entire society, or continue working to fulfil their duty to their existing patients? Arguments could be made on either side, and, as an outsider, I can only respect their individual decisions according to their consience. As the number of worldwide infections rose, on 25 March Hong Kong closed its borders to all non-residents. Residents are tested on arrival and required to self-quarantine for 14 days.

Information Flow in China

Mainland China considers public health to be part of national security and the police will take action on any "unauthorised" disclosure of public health information. China had the first report in the SARS outbreak in November 2002, but did not report the situation to the WHO until February 2003, delaying the fight against the epidemic.

In the Covid-19 outbreak, Dr Li Wenliang in Wuhan sent a message to colleagues, warning them about a new pneumonia, and advising them to take precautions on 30 December. He was accused of "making false comments" that had "severely disturbed the social order" by the police. He later died of Covid-19. As January proceeded, the Hong Kong Centre for Health Protection (CHP) reported a handful of cases of novel pneumonia in people returning from Wuhan each day, but the Chinese National Health Commission (NHC) reported no, or few cases. On 12 January, 7 people who had returned from Wuhan were admitted to Hong Kong hospitals with pneumonia, but the NHC reported no new cases in the Mainland. It does not seem credible that there could be so many infected people returning from Wuhan, without a substantial number of infections throughout that city, so the NHC was actively ignoring the evidence.

Conclusion

Hong Kong's basic preparedness, particularly in temperature checks for arriving travellers and contact tracing for unusual diseases, provided an early warning. However, the public led the government in many aspects of the response. In the early stages, the government advised against wearing masks and did not completely close the border with the Mainland. As we now know, many people with Covid-19 are symptomless carriers, so the checks did not catch every arriving person who was infected. This led to local transmission, and, beacuse contact tracing is imperfect, cases with no known link to the source. Fortunately, the public chose to take action themselves, most people started wearing masks, reducing contact and social distancing. As a result, up until June, Hong Kong has had a remarkably low number of cases and deaths. I think that the early warning provided by the existing government measures was important, but the government response was inadequate. While the borders remained open, more symptomless cases were entering Hong Kong with the potential for local transmission. The public willingness to take action, particularly wearing masks, reduced that transmission sufficiently to slow the rise and allow continued comprehensive contact tracing.

As everyone around the world gradually comes out of their varying lockdowns, I recommend continuing to wear a mask in public places. A reusable cloth face covering is probably sufficient. This isn't to protect you as much as it is to protect your neighbours. Assume you may be a symptomless carrier, and responsibly reduce the chance of you infecting someone else. If your neighbours do the same, maybe we can all stay well until a vaccine is developed.

Updated: 03^rd June 2020

Date	Personal	Hong Kong	China	World
2019-12-08			First known case recorded in Wuhan, only reported much later.
2020-12-30			Dr Li Wenliang sent a message to fellow doctors in a chat group warning them about the outbreak and advising they wear protective clothing to avoid infection.
2020-01-03		CHP reports 44 Wuhan-related cases detected in Hong Kong	Dr Li Wenliang was summoned to the Public Security Bureau where he was told to sign a letter. In the letter he was accused of "making false comments" that had "severely disturbed the social order."
2020-01-04		CHP reports 3 new Wuhan-related cases. Gov't steps up disease monitoring Disease contingency plan set
2020-01-05		7 new cases in HK	59 Wuhan-related cases detected
2020-01-06		Disease prevention meeting held 6 new Wuhan-related cases reported
2020-01-07		9 new Wuhan-related cases reported Law change to fight disease set
2020-01-08		8 new Wuhan-related cases reported HA ready for Wuhan outbreak Protective gear supply adequate
2020-01-09		CHP gives update on Wuhan cases "coronavirus. not as severe as SARS. no definite evidence of human-to-human transmission." HK enters winter flu season
2020-01-10		5 new Wuhan-related cases reported
2020-01-11		SARG reps to visit Wuhan Meeting on Wuhan cases set 7 new Wuhan-related cases reported	One dead from novel coronavirus
2020-01-12		7 new Wuhan-related cases recorded	Coronavirus data released
2020-01-13		1 new Wuhan-related case recorded
2020-01-14		3 new Wuhan-related cases recorded CE on virus control measures
2020-01-15		4 new Wuhan-related cases recorded Meeting on Wuhan cases held Human transmission of virus possible
2020-01-16		Disease prevention meeting held 2 new Wuhan-related cases recorded		Japan infection case monitored
2020-01-17		4 more Wuhan-related cases recorded Surveillance boost for Wuhan cases	One more person has died among the 41 patients diagnosed with having the novel coronavirus infection
2020-01-18		7 new Wuhan-related cases recorded	Four more cases of novel coronavirus infection were recorded in Wuhan
2020-01-19		11 new Wuhan-related cases recorded	17 more cases of novel coronavirus infection were recorded in Wuhan
2020-01-20		7 new Wuhan-related cases recorded New preventive measures: Reporting by Medical practitioners; Travellers flying Wuhan to Hong Kong must fill out a health declaration form.	Real scale of the outbreak revealed by prominent Chinese pulmonologist Dr. Zhong Nanshan, who admitted that the outbreak had entered the human-to-human transmission stage.
2020-01-21		11 new Wuhan-related cases recorded	72 more novel coronavirus infection cases were reported in Hubei Province yesterday, including 60 cases in Wuhan. total number of novel coronavirus infection cases in the Mainland was 291	Taiwan infection case monitored
2020-01-22		18 new Wuhan-related cases recorded
2020-01-23		Health declaration applies to Express Rail LinkHealth declaration form system to cover all inbound travellers using the high speed rail. For contact tracing, close contacts will be quarantined, surveillance will be organised for other contacts. Citizens are urged to avoid visiting Wuhan. If the trip is unavoidable, they should wear a surgical mask and continue to do so until 14 days after returning to Hong Kong. 35 new Wuhan-related cases recorded Help for Hong Kongers in Wuhan Wuhan virus: Hong Kong holiday camps become quarantine zones as Lunar New Year festival cancelled
2020-01-24		70 new Wuhan-related cases recorded Public hospitals mobilise resources	China expands quarantine efforts as Wuhan virus death toll climbs to 26
2020-01-25		65 Wuhan-related cases recorded No delay in fight against virus: CE Hospital visits suspended LNY school holiday extended Hong Kong declares Wuhan virus outbreak ’emergency’ – the highest warning tier
2020-01-26		HK bans Hubei residents to fight virus Quarantine centre sites explained 77 new Wuhan-related cases recorded Gov't clarifies face mask situation Gov’t containing virus’ spread Money not a constraint in virus fight Children’s facilities to close		UK has zero cases (personal email)
2020-01-27	"We're mostly staying home, using masks when we go out." (personal email) "Hong Kong is sort-of locked down... the New Year fairs have been cancelled, Disneyland and Ocean Park are closed, but entry from the Mainland is still allowed, just fill in a health declaration saying you're not from Hubei" (personal email)	China coronavirus: why calls to close Hong Kong border have split medical sector Doctors urge patient honesty 2 new infections confirmed Advice for citizens who visited Hubei		"the latest on the BBC says it's infectious before symptoms appear, which is very worrying, and they have footage from inside the quarantine area showing much worse conditions than the official announcements." (personal email)
2020-01-28		Customs dismisses rumours Masks for medical sector ensured Further measures to fight virus: It is not meaningful to talk about the closure of all boundary control points. They will cease issuing the Individual Visit Scheme permits 78 new Wuhan-related cases recorded Schools to resume classes Feb 17 Gov’t staff to work from home Public facilities to close in virus fight Gov’t rejects disease-related rumour Wuhan coronavirus: Travel between Hong Kong and China slashed, but gov’t resists pressure to close border Wuhan coronavirus: Hong Kong asks employers to let staff work from home, as leisure facilities close until further notice
2020-01-29		Gov’t striving to boost mask supply Customs conducts mask checks 56 Wuhan-related cases reported Face mask rumours unfounded HK probes 2 infection cases Wuhan coronavirus: Over 15,000 Hong Kong medical workers join new union, threaten strike unless gov’t closes border		Wuhan coronavirus: More airlines halt China flights as death toll hits 132 with 6,000 infected
2020-01-30		Questionable masks seized 95 Wuhan-related cases reported Gov’t ensures mask supply: CS Police dismiss face mask rumours No free face masks offered Health advice for foreign helpers Employers urged to help virus fight Mask handout rumours refuted Hongkongers queue overnight to buy face masks amid citywide shortage First known case of local transmission	Improvised barricades across China as online shaming spreads
2020-01-31		Boundary closure not the answer: CE "Complete closure of the boundary control points is not the right answer." Gov't aims to boost mask supply 2 more infections confirmed	Wuhan doctor who was punished for trying to warn of coronavirus succumbs to the disease
2020-02-01	Recommended overseas friends and family to buy facemasks. (personal email)	Academy fit for quarantine use Gov’t clarifies mask-related rumours HK Post prioritises mask deliveries Many people have been asking overseas contacts to send facemasks.	"Various reports suggest that the outbreak is far larger in China than the authorities are admitting. " (personal email)	"WHO has declared a Global Health Emergency, due to evidence of person-to-person spread outside of China. " (personal email) UK: "Masks have already sold out on all websites I looked at. Wholesalers in UK had sold out and struggling to get supplies. Nobody around here wearing masks but reports of people in London using them near Chinatown and some pics of people at Heathrow in masks. Two cases in UK yesterday." (personal email)
2020-02-02		HA calls on staff to stay on duty Local transmission not ruled out Gov’t responds to call for strike
2020-02-03		More boundary points to close 36 Wuhan-related cases reported Smart device for home quarantine More quarantine facilities set Hong Kong hospital strike kicks off as top doctor backs mainland China border closure
2020-02-04		Cross-boundary transport normal Measures for Filipino helper contracts Buildings quarantine explained HK reports 1st coronavirus death Carrie Lam orders Hong Kong officials not to wear masks
2020-02-05		No food shortage in HK Act together against disease: CE Prudent approach to safeguard HK Local infection cases reported "Compassion is in order, for the innocent who are infected and the selfless medical workers" Hong Kong to quarantine all travellers entering from mainland China for 14 days
2020-02-06	Coronavirus Phishing	Masks pass safety tests 109 mask scams reported Gov't appeals to cruise passengers DH alert on email, website hoax Class resumption criteria explained New HKDSE plan to be announced Concerted effort to procure masks Surgical mask deliveries prioritised
2020-02-07		2 more infections reported https://www.news.gov.hk/eng/2020/02/20200207/20200207_223646_625.html">Multi approach to procure masks Quarantine arrangement set HA welcomes staff resuming duty Arrivals down https://www.news.gov.hk/eng/2020/02/20200207/20200207_170816_140.html">Rumours on voluntary work refuted Appeal for help sincere: CS Schools operating on a limited basis Hospital staff decide to end their strike Resign, strike or endure? The dilemma of Hong Kong’s ‘dirty team’ doctors
2020-02-08		161 under mandatory quarantine Hong Kong's despicable hospital strike over coronavirus crisis
2020-02-10		Employees' compensation explained No curb on mask supplies, price Hospital services to be adjusted Quarantined people must stay home
2020-02-17		Democratic Party receives shipment of 350 million masks, for distribution throughout HK, main to the elderly and others at special risk. Also distributing alcohol spray and other disinfectant supplies.
2020-02-20			Inspectors in Wuhan scour coronavirus epicentre for infected residents
2020-02-21			29-year-old Chinese doctor dies of coronavirus in Wuhan
2020-02-27	Phishing for Chief Executive Fans	Help for cruise passengers continues Hong Kong's Hospital Authority targets medics who went on strike to urge border closure
2020-02-28	Should We Be Wiping Doorhandles With Warm Yoghurt?
2020-03-01			‘No one cares’: Wuhan residents adapt to find food during coronavirus lockdown
2020-03-03	"So, is it really that much of an imposition to follow good medical advice? Wash your hands frequently, and, as I'm in HK, I'll wear a mask when I'm out, not so much for my protection, but it's worth it if I'm a symptomless carrier and it prevents someone else being infected." (comment in online forum)
2020-03-03		Hong Kong’s iconic Jumbo Kingdom floating restaurants that feted the Queen, Tom Cruise, to close ‘until further notice’ as viral outbreak dents revival efforts
2020-03-05				Self Isolate
2020-03-09		Coronavirus roller coaster: Octopus card usage drops for fast food, transport, but booms at Hong Kong’s grocery stores Public transport transactions were down 40 per cent in February
2020-03-10			Coronavirus: China leader Xi Jinping pays first visit to outbreak epicentre Wuhan	Cancel Everything
2020-03-12				Biology of the new coronavirus
2020-03-15	"What should the vending machine in a fancy apartment complex lift lobby stock?" Masks! (facebook post)
2020-03-19			Wuhan police ‘inappropriately’ punished whistleblower doctor Li Wenliang, Chinese gov’t probe concludes
2020-03-20				"As we have been in lockdown in Spain since last Sunday  only able to go out for food we have decided  to come home early." (personal email)
2020-03-25		The HK Government has now admitted that the quarantine wristband and app does not work as advertised.
2020-04-04				To mask or not to mask: WHO makes U-turn while US, Singapore abandon pandemic advice and tell citizens to start wearing masks
2020-04-05	(facebook post) "Yes, I would say wear a mask whenever you are near someone not from your household. I wear one whenever I'm on the street, but HK is crowded. If you don't get within 2m of people on your walk, then it probably isn't necessary. But wear one in shops." "I wouldn't use the N95 masks, leave those for medical workers and people in high risk situations. we've sewn some cloth masks, 2 layers and we put a kitchen towel in between, throw away the tissue after use and wash for re-use. Probably not as effective as the disposable medical masks, but we won't run out."			"In UK masks only being worn in hospitals, carers and some people serving in shops. We are in lockdown and if out for food or permitted exercise are social distancing." (personal email)
2020-04-07				Homemade Masks
2020-04-09	"Not the best time to uphold a ban on wearing masks in public." (facebook post)	Appeal court rules Hong Kong’s mask ban is constitutional at unauthorised protests
2020-04-17		Explainer: After months of protests, is Hong Kong selectively enforcing covid-19 laws?
2020-04-23				COVID-19 Superspreader Events in 28 Countries: Critical Patterns and Lessons
2020-04-27				Whose coronavirus strategy worked best? Scientists hunt most effective policies
2020-04-30		Dr Davison: Hong Kong govt’s use of hotels for Covid-19 quarantine is a recipe for disaster
2020-05-01	"Yes, restaurants are still open, but half capacity. Some are using plastic shields to divide tables. No drinking alcohol." (facebook post)
2020-05-04		Four Months into Our Fight Striking the Right Balance Civil servants and public services would return to normal working/operating hours
2020-05-05		Distribution of one reusable CuMask+™ to each Hong Kong citizen and 10 disposable masks to each household.
2020-05-10	Repulse Bay (facebook post)
2020-05-12		A letter from Hong Kong to Covid-ravaged Britain: What on earth are you doing?
2020-05-16				Masks Help Stop the Spread of Coronavirus – The Science Is Simple
2020-05-17		Coronavirus: hamster research shows effectiveness of masks ‘huge’ in Covid-19 battle, Hong Kong scientists say
2020-05-19		Prohibition of group gatherings with more than eight persons in public places would remain in force until 4 June, with a broadening of exemption to cover religious gatherings
2020-05-21		Public swimming pools and barbecue sites would reopen
2020-05-23		Beaches would be opened progressively
2020-05-27		S3 to S5 students resume school
2020-05-30				Countries/areas with reported cases of Coronavirus Disease-2019 (COVID-19)(Last updated on June3, 2020, 11am)