What can countries learn from Hong Kong’s response to the COVID-19 pandemic?

Border control and social distancing

Before the first locally reported case, Hong Kong expected and was on the alert for cases of COVID-19. On Jan. 3, 2020, noncontact temperature screening (using thermal imaging) was implemented at border checkpoints for travellers arriving from Wuhan, China, by rail or air transportation.2 Subsequently, visitors from Wuhan and other affected areas of China were not allowed to enter Hong Kong. Eleven of the city’s 14 border crossings were closed with the aim to maintain only essential traffic, and traveller screening interventions included body temperature checks and questions about symptoms of COVID-19 at airports and all borders. Primary and secondary schools under the Education Bureau were closed on Jan. 27, followed soon afterward by colleges and universities. Working from home was implemented for civil servants (first from Jan. 29 to Mar. 1, then suspended, and restarted on Mar. 23 until the time of writing this analysis). Owing to a growing number of cases in people returned from overseas, the Hong Kong government banned the entry of all non–Hong Kong residents from overseas countries (except those from Taiwan and Macao), on Mar. 25, 2020.3 On Mar. 29, gatherings of more than 4 people in public places were prohibited,4 and on Apr. 1, karaoke, mah-jong parlours and nightclubs were forced to close.5

Contact tracing, testing and mandatory quarantine

A 14-day quarantine period for everyone entering Hong Kong from the mainland was mandated and enforced on Mar. 19, 2020.6 Aggressive contact tracing and quarantine of close contacts of confirmed cases was undertaken, with several quarantine centres converted from existing retreat centres, a camping site and a new housing estate. People with close contact to infected people but without symptoms were not tested for COVID-19. However, these contacts, as well as travellers arriving in or returning to Hong Kong in the past 14 days before Mar. 25 from regions with a high number of COVID-19 cases (including Daegu and Gyeongsangbuk-do in Korea; Iran; and Emilia-Romagna, Lombardy and Veneto in Italy) were sent to quarantine centres. These centres are not health care facilities but are places for accommodation with monitoring and provision of meals by staff hired by Hong Kong’s Department of Health.

After Mar. 25, all returning Hong Kong residents were asked to complete a mandatory 14-day self-quarantine under surveillance using electronic wristbands paired with a mobile app. Anyone found to have not complied with self-quarantine was considered to have committed a criminal offence. Up to Mar. 30, 54 people were found guilty of breaching quarantine orders and were sent to quarantine centres,7 and 3 people were found guilty by law and were imprisoned for 10 days to 3 months.8

Screening and surveillance

An enhanced laboratory surveillance program for patients attending public primary care clinics and accident and emergency departments with fever and mild respiratory symptoms (Jan. 13 and ongoing)9 was implemented to provide timely feedback on the severity of the outbreak in the community. The program contributed data for policy-makers to decide on whether designated primary care clinics needed to be opened for people with fever or relevant symptoms. To facilitate accurate identification of COVID-19 among suspected cases in clinical settings, the government linked the record system of the Immigration Department with that of the public hospitals to provide an accurate travel history for case identification.

For screening, diagnostic tests were administered at the airport for Hong Kong residents returning from countries with a high prevalence of COVID-19, such as the United States, United Kingdom, Italy and other European countries. During the second wave of the COVID-19 epidemic in Hong Kong, with almost all newly reported cases being returning travellers who were infected outside of Hong Kong, a deep throat saliva test for SARS-CoV-210 at a designated area in the airport was required for all inbound travellers who had been in the US, the UK, European countries and Hubei province (regardless of symptoms), those aged 65 years and older, and those residing with adults aged 65 and older. People who tested positive were admitted to hospital for treatment, and their close contacts (those who travelled with them) were sent to the quarantine centres. People who tested negative could choose compulsory quarantine either at home or at a designated place (e.g., hotel) for 14 days.

These measures appear to have been effective in curbing the potential exponential rise of cases during the early period of the epidemic,11 and implementation of more recent measures appear to have slowed the increase of local cases (Figure 2).

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Figure 2:

Number of confirmed imported and local cases of coronavirus disease 2019 (COVID-19) in Hong Kong (Jan. 23, 2020, to Apr. 13, 2020) according to the Centre for Health Protection (CHP), Hong Kong. Note: AED = accident and emergency department, GOPC = general outpatient clinic.

Communication with the general public

The website of Hong Kong’s Centre for Health Protection (www.chp.gov.hk/en) provides a list of buildings and information on the flights, trains or ships with passengers with COVID-19. If a flight is found to have carried a person who tested positive for COVID-19, the flight number is placed on the website. The neighbouring passengers of the infected person would be contacted, regarded as close contacts and sent to the quarantine centre. For the rest of the passengers, the information on the website is provided to ensure transparency and for other passengers to self-monitor for symptoms (no further action is taken by the government with regard to passengers who were not close neighbours of the index passenger). The information provided on the list of buildings with infected people serves a similar purpose as part of a communication strategy to increase transparency of information.

Updates on the latest number of COVID-19 cases of all affected countries as well as a geographical map of Hong Kong highlighting areas with confirmed cases are available on the same website. Health advice and the number of a hotline regarding people who are suspected to have COVID-19 are provided, and a daily press conference reporting on the latest local situation on COVID-19 has been held by government and hospital officials since January.

Conclusion

Hong Kong’s experience of the 2003 SARS epidemic may explain both the government and residents’ enhanced public health preparedness and willingness to respond quickly in the face of the COVID-19 threat. Other countries may learn from Hong Kong’s aggressive containment approach, including tracing all close contacts followed by mandatory, supported quarantine of these contacts. However, as all public health interventions have potential benefits and risks, a balanced analysis that takes local contextual factors into account is needed so that the most appropriate actions are taken.