Covid-19’s resurgence in Hong Kong holds a lesson: Defeating it demands persistence

As a mysterious virus raced through Wuhan, China, 570 miles to the north, residents in Hong Kong acted on instinct. They swaddled their faces in paper-thin masks and slathered on sanitizer, even on strangers, and obediently sheltered indoors, some doing so before their government closed schools and universities and offices sent workers home. The new coronavirus seemed to be contained by early March, with case numbers nearly flat and just four deaths, this despite a shared border with mainland China and infections racing through South Korea, Japan, and Europe.

Epidemiologists and journalists lauded the Chinese territory for controlling the spread, and Hong Kongers emerged from their tiny apartments to resume life. They headed back to work and the gym, even dined out for noodles and dim sum, as they welcomed home residents and students who had been stuck overseas.

With most everyone’s guard down, the predator lashed back last week. Cases of Covid-19 surged.

Hong Kong logged a daily record of 48 new infections Saturday as travelers returned home, and as of Wednesday, the city of 7.4 million had reported more than 400 cases. This week, the government ordered all residents back home, and closed public sports facilities, museums, and libraries that had just reopened. What’s more, the city stopped admitting visitors for two weeks. As an extra measure against socializing, the government demanded that bars stop serving alcohol.

Physicians and scientists in Hong Kong said they were not surprised by the jump in cases. The pandemic will work in waves, said Keiji Fukuda, former assistant director-general for health security at the World Health Organization and a medical professor at the University of Hong Kong. “This is going to be a difficult situation for the next several months. I don’t think any of us believes this will resolve in the next six weeks or two months. … Hong Kong is going to be affected by what’s going on in other regions and other countries.”

Even as a growing chorus in the U.S. and other countries calls for a quick end to sharp restrictions on civic life, Hong Kong’s message is clear: It will take remarkable persistence to control the coronavirus — a herculean effort by both governments and their citizens.

In fact, many Hong Kong residents said they never abandoned their caution or sanitation routines. Each morning, Sven Johannsen, a German national and Hong Kong resident for five years, dons his N95 particulate respirator for his four-stop subway ride to work. He summons the elevator with a knee bump and avoids touching buttons or railings, and applies hand sanitizer after every contact. At all times, he’s prepared to be cleansed.

The other day he grabbed several Korean respirators on sale outside a pharmacy ($3.22 each) and walked inside to pay. “Wait!” a female voice cried. The tiny employee pointed a temperature gun toward Johannsen’s distant forehead on his 6-foot-6 frame. At the all-clear beep, he continued toward the cashier. “Wait!” The woman cried again. She squeezed a great blob of sanitizer into Johannsen’s hand.

The young data scientist said he had urged friends and family in Europe to be as vigilant as Hong Kongers — shelter inside, sanitize — but his entreaties were shrugged off. Recently he heard that young Germans had gathered for large “corona parties.” “I think Hong Kong is the safest place now, in the world,” he said. “Every single person takes it seriously.”

Hong Kongers’ robust hygiene habits were nurtured in tragedy. In 2003, an earlier coronavirus scourge known as SARS infected more than 1,700 people and killed nearly 300. Among those were eight medical workers, including a doctor who died of pneumonia after she helped patients on ventilators in the infectious disease ward.

Residents remember the young women’s funeral, the weeks home from school, the anxiety about whose family would be touched next. The population internalized that experience, Fukuda said. When the new coronavirus broke this year, residents didn’t think twice about wearing masks. They were accustomed to doing so for every sniffle and cough, and getting their temperature taken when arriving at the airport or their child’s kindergarten. When the government and private industry failed to provide enough masks, some Hong Kongers imported or sewed their own. It didn’t hurt that many people had grown resourceful networks last summer during massive, sometimes violent, protests against the government that has fought pleas for democratic change.

While its government systems were late and often imperfect, Hong Kong’s tactics became something of a model for the rest of the world. What made the difference, physicians and epidemiologists say, have been Hong Kong citizens themselves.

“It has been a difficult few months for Hong Kong citizens. … The consensus of the Hong Kong citizen is the government has been slow and not proactive enough,” said Gabriel Choi, a family physician and president of the Hong Kong Medical Association, which represents private doctors. “The citizens did most of the work themselves.”

Soon after researchers learned that a virus had sickened people who had been near a wet market in Wuhan, China, researchers at the University of Hong Kong said in January that the number stricken would surely be many times higher than the numbers being reported. Hong Kong, they said, needed “draconian” measures because the virus risked becoming a global epidemic. This was weeks before the World Health Organization decreed that the virus was a global health emergency.

The Hong Kong government has been inconsistent with its mask instructions; at one point, Chief Executive Carrie Lam urged government officials not to wear masks so they would save on supplies, an order that some physicians feared would frighten the public. Many doctors believed the widespread use of face coverings — even for sufferers of common colds, even by children and people walking outside — snipped the epidemic’s spread.

With so many fearful of illness, supplies ran low. China is the world’s leading mask manufacturer, and yet shipments were not reaching the territory in the south. Hospital employees became agitated that protective face shields, gloves, and gowns were low. As prices shot up — to nearly $40 for a box of 50 masks — and residents failed to find supplies on Amazon, a few enterprising individuals proposed production hubs that have since begun to stitch and package. Many Hong Kong families that once made a living sewing clothes have put their skills to work making cotton masks.

Hong Kong frugality has come in handy. After Lam Yik-tsz, a family physician, failed to get supplies in stores or through the medical association, she worked her contacts. Her housekeeper sent mask packs from Thailand. On the street she wears a cotton one and sprays the outer layer with alcohol, saving the disposable masks for visits with patients.

Alfred Wong, a cardiologist, said he understood the concern that universal mask wearing will deplete supplies. “The thing is, Hong Kong is such a densely populated city, once you leave home, you’re surrounded by other human beings,” he said. “There’s no way you can avoid the chances of getting infected.” As a safeguard, university medical professors spoke daily on TV and urged the public to keep one meter apart from others.

One of the greatest challenges to fighting the disease has been the public’s skeptical, even antagonistic response to the government. The city exploded in protests last year over a proposed law that would have allowed extraditions to mainland China. (The bill was withdrawn but the government’s crackdown fanned a larger, ongoing democracy campaign.)

Weeks back, when Hong Kong infectious disease specialists estimated the number of Wuhan infections had rocketed to 25,000 — even though mainland officials put the number at 2,800 nationwide then — Hong Kong physicians urged that residents limit their movements and that the border be sealed. Many people strongly backed that idea, and their anger grew when the government refused.

In February, a new labor union comprised of hospital nurses and doctors went on strike, demanding that the city bar arrivals from China. The Hong Kong government, ever more deferential to Beijing in recent years, held firm. At one point officials said that a closed border would hinder supplies from entering Hong Kong, a comment that triggered consumer panic that emptied stores of rice and toilet paper.

The government instead stopped trains and planes from Wuhan, and closed many of the border entry areas, but a few remained open and the territory never sealed itself off. In addition, Hong Kong began a mandatory 14-day quarantine at either a government center or a hotel for any arrival who had traveled in mainland China in the prior 14 days. Those staying at home needed to keep away from others and measure their body temperature twice daily and record symptoms such as a sore throat or a cough. The city’s social welfare department provided meals and necessities.

The restrictions grew. The government expanded the two-week quarantine to travelers from other hard-hit countries, including the United Kingdom, the United States, and much of Europe before it recently stopped all tourists and non-residents from entering.

The new protocols have been flawed. There were not enough civil servants and students drafted to check on shut-ins to ensure they followed orders. Many tracking bracelets given to airport arrivals failed. Some patients have not cooperated and left their homes to shop and dine out. (A few, with telltale plastic bracelets, were videoed by outraged residents.) The government does not have the manpower to monitor all violators, Choi said.

Benjamin Cowling, an epidemiologist at the University of Hong Kong, and several other physicians, said the Hong Kong government did not act fast enough when news trickled in about the new virus in Wuhan. But the mass social distancing effort — isolating ill people at home, tracking and quarantining those exposed to the sick, closing schools, work-at-home measures, closing public meeting places — seems to have trimmed the illness’ rampage.

Cowling was among a team that concluded in a soon-to-be-published study that tracing people who were in contact with the sick, and then putting them in isolation, quarantine, or medicinal treatment, was effective but costly. “If everyone stays at home for prolonged period, transmission will stop,” Cowling said.

The only way containment can work, he said, is if everyone with a suspected infection is tested. “There’s a role for government actions and role for individual behaviors. We need both,” he said in an interview.

Through the winter, hospital employees were especially tense. After all, SARS had exploded in a teaching hospital in 2003, when 114 health workers were sickened. Then too, personnel were short of masks and protective gear. Wards then were not fitted with negative pressure rooms to direct air flow away from other patients. In three months of that year, 386 medical and health care workers had contracted SARS, and eight died.

Wong, the cardiologist, was expecting a new baby with his wife, a nurse. He volunteered to be on an early so-called dirty team at his hospital in February, before she gave birth. Each shift, the 15 physicians monitored up to 50 patients suspected of being infected. After seeing one person, each doctor and nurse removed his gloves and washed his hands, then removed his gown, and washed, then cap and so on, with the face shield and the mask stripped last, a routine performed a dozen times per shift. With each discarded layer, doctors were aware they were depleting stock and fighting the world for more supplies.

In February, Wong assumed that the coronavirus would be Hong Kong’s “SARS 2.0.” “This time it cannot happen again, we must not let history repeat itself,” he said then. “Our aim is to protect all of us.”

After a week on the ward, medical staff started to think it would not be as bad as they feared. “People are super vigilant,” he said. “Basically they are super scared.”

The city embraced testing, even of people without symptoms. Currently, about 1,000 people undergo screens each day, although Yuen Kwok-yung, the University of Hong Kong chief epidemiologist, said that number needs to double to unspool chains of infections.

To find infected people, and alleviate the crowding at hospitals and clinics, the city’s hospital authority developed a so-called deep saliva test. When a simple survey of symptoms finds that someone has a low-grade fever with cough or sneezing, the patient is given a sputum jar and instructed to gargle and spit, producing mucus from deep in the throat. That sample is left at certain clinics, alleviating the need for a technician to administer the test.

Despite these measures, Yuen recently predicted that the virus will linger in Hong Kong for two years unless a vaccine is developed and administered widely. That is a long time to keep up the habits of constant washing and sanitizing and sampling, and residents may backslide, he said.

Fukuda, an internist, spent much of his career investigating influenza outbreaks and developing response protocols, in stints with the Centers for Disease Control and Prevention in the United States and the World Health Organization. He said he was impressed by the efforts to control Covid-19 in Hong Kong. “I have a lot of admiration for how everyone has dealt with it here.

“In many parts of world, including the U.S., they are still not believing there’s an issue. People in Hong Kong immediately grasped the impact,” he said. “I think that combination, the government having learned and put in place structural changes and the public, despite misgivings, trying to implement various recommendations, made a big, big difference from 2003. That’s a lesson a lot of countries haven’t learned.”