Editorial

Hong Kong Academy of Medicine. CC BY-NC-ND 4.0

EDITORIAL

Kidney Health for All: bridging the gap in kidney health education and literacy

Robyn G Langham, MB, BS, PhD^{1 #}; Kamyar Kalantar-Zadeh, MD, PhD^{2 #}; Ann Bonner, RN, PhD³; Alessandro Balducci, MD^{4 #}; LL Hsiao, MD, PhD^{5 #}; Latha A Kumaraswami, BA^{6 #}; Paul Laffin, MS^{7 #}; Vassilios Liakopoulos, MD, PhD^{8 #}; Gamal Saadi, MD^{9 #}; Ekamol Tantisattamo, MD, MPH²; Ifeoma Ulasi, MB, BS, MSc^{10 #}; SF Lui, MD^{11 #}; for the World Kidney Day Joint Steering Committee^#

¹ St Vincent’s Hospital, Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia

² Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, University of California Irvine School of Medicine, Orange, California, United States

³ School of Nursing and Midwifery, Griffith University, Southport, Queensland, Australia

⁴ Italian Kidney Foundation, Rome, Italy

⁵ Brigham and Women’s Hospital, Renal Division, Department of Medicine, Boston, Massachusetts, United States

⁶ Tamilnad Kidney Research (TANKER) Foundation, The International Federation of Kidney Foundations–World Kidney Alliance (IFKF–WKA), Chennai, India

⁷ International Society of Nephrology, Brussels, Belgium

⁸ Division of Nephrology and Hypertension, First Department of Internal Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece

⁹ Nephrology Unit, Department of Internal Medicine, Faculty of Medicine, Cairo University, Giza, Egypt

¹⁰ Renal Unit, Department of Medicine, College of Medicine, University of Nigeria, Ituku-Ozalla, Enugu, Nigeria

¹¹ International Federation of Kidney Foundations–World Kidney Alliance, The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong

^# Members of the World Kidney Day Steering Committee

Corresponding author: Dr Robyn G Langham (rlangham@unimelb.edu.au)

Full paper in PDF

Abstract

The high burden of kidney disease, global disparities in kidney care, and poor outcomes of kidney failure bring a concomitant growing burden to persons affected, their families, and carers, and the community at large. Health literacy is the degree to which persons and organisations have or equitably enable individuals to have the ability to find, understand, and use information and services to make informed health-related decisions and actions for themselves and others. Rather than viewing health literacy as a patient deficit, improving health literacy largely rests with healthcare providers communicating and educating effectively in codesigned partnership with those with kidney disease. For kidney policy makers, health literacy provides the imperative to shift organisations to a culture that places the person at the centre of healthcare. The growing capability of and access to technology provides new opportunities to enhance education and awareness of kidney disease for all stakeholders. Advances in telecommunication, including social media platforms, can be leveraged to enhance persons’ and providers’ education; The World Kidney Day declares 2022 as the year of “Kidney Health for All” to promote global teamwork in advancing strategies in bridging the gap in kidney health education and literacy. Kidney organisations should work towards shifting the patient-deficit health literacy narrative to that of being the responsibility of healthcare providers and health policy makers. By engaging in and supporting kidney health–centred policy making, community health planning, and health literacy approaches for all, the kidney communities strive to prevent kidney diseases and enable living well with kidney disease.

Given the high burden of kidney disease and global disparities related to kidney care, in carrying forward our mission of advocating Kidney Health for All, the challenging issue of bridging the well-identified gap in the global understanding of kidney disease and its health literacy is the theme for World Kidney Day (WKD) 2022. Health literacy is defined as the degree to which persons and organisations have—or equitably enable individuals to have—the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.1 Not only is there is growing recognition of the role that health literacy has in determining outcomes for persons affected by kidney disease and the community in general, but there is an emergent imperative for policy makers worldwide to be informed and cognizant of opportunities and real measurable outcomes that can be achieved through kidney-specific preventative strategies.

The global community of people with kidney disease

Most people are not aware of what kidneys are for or even where their kidneys are. For those afflicted by disease and the subsequent effects on overall health, effective healthcare provider communication is required to support individuals to be able to understand what to do, to make decisions, and to take action. Health literacy involves more than functional abilities of an individual; it is also the cognitive and social skills needed to gain access to, understand, and use information to manage health conditions.2 It is also contextual3 in that as health needs change, so too does the level of understanding and ability to problem solve alter. Health literacy is, therefore, an interaction between individuals, healthcare providers, and health policy makers.4 This is why the imperatives around health literacy are now recognised as indicators for the quality of local and national healthcare systems and healthcare professionals within them.5 For chronic kidney disease (CKD), as the disease progresses alongside other health changes and increasing treatment complexities, it becomes more difficult for individuals to manage.6 Promoted in health policy for around a decade involving care partnerships between health-centred policy, community health planning, and health literacy,7 current approaches need to be shifted forward (Table 1).

Table 1. Summary characteristic of kidney health promotion, involving kidney health–centred policy, community kidney health planning, and kidney health literacy, and proposed future direction

Assessing health literacy necessitates the use of appropriate multidimensional patient-reported measures, such as the World Health Organization–recommended Health Literacy Questionnaire (available in over 30 languages) rather than tools measuring only functional health literacy (eg, Rapid Estimate of Adult Literacy in Medicine or Short Test of Functional Health Literacy in Adults).8 It is therefore not surprising that studies of low health literacy (LHL) abilities in people with CKD have been demonstrated to be associated with poor CKD knowledge, self-management behaviours, and health-related quality of life and in those with greater co-morbidity severity.7 Unfortunately, most CKD studies have measured only functional health literacy, so the evidence that LHL results in poorer outcomes, particularly that it increases healthcare utilisation and mortality9 and reduces access to transplantation,10 is weak.

Recently, health literacy is now considered to be an important bridge between lower socioeconomic status and other social determinants of health.4 Indeed, this is not a feature that can be measured by the gross domestic product of a country, as the effects of LHL on the extent of CKD in the community are experienced globally regardless of country income status. The lack of awareness of risk factors of kidney disease, even in those with high health literacy abilities, is a testament to the difficulties in understanding this disease, and why the United States, for instance, recommends that a universal precautions approach towards health literacy is undertaken.11

So, what does the perfect health literacy programme look like for people with CKD? In several high-income countries, there are national health literacy action plans with the emphasis shifted to policy directives, organisational culture, and healthcare providers. In Australia, for instance, a compulsory health literacy accreditation standard makes the healthcare organisation responsible for ensuring providers are cognizant of individual health literacy abilities.12 Although many high-income countries, healthcare organisations, non-governmental organisations, and jurisdictions are providing an array of consumer-facing web-based programmes that provide detailed information and self-care training opportunities, most are largely designed for individual/family use that are unlikely to mitigate LHL. There is, however, substantial evidence that interventions improving healthcare provider communication are more likely to improve understanding of health problems and abilities to adhere to complex treatment regimens.13

Access to information that is authentic and tailored specifically to the needs of the individual and the community is the aim. The challenge is recognised acutely in more remote and low- to middle-income countries of the world, specifically the importance of culturally appropriate knowledge provision. The principles of improving health literacy are the same, but understanding how to proceed, and putting consumers in charge, with a co-design approach, is critical and may result in a different outcome in more remote parts of the world. This principle especially applies to communities that are smaller, with less access to electronic communication and healthcare services, where the level of health literacy is shared across the community and where what affects the individual also affects all the community. Decision support systems are different, led by elders, and in turn educational resources are best aimed at improving knowledge of the whole community.

A systematic review of the evaluation of interventions and strategies shows this area of research is still at an early stage,14 with no studies unravelling the link between LHL and poor CKD outcomes. The best evidence is in supporting targeted programmes on improving communication capabilities of healthcare professionals as central. One prime example is ‘teach-back’, a cyclical, simple, low-cost education intervention, which shows promise for improving communication, knowledge, and self-management in the CKD populations in low- or high-income countries.15 Furthermore, the consumer-led voice has articulated research priorities that align closely with principles felt to be important to the success of education: building new education resources, devised in partnership with consumers, and focussed on the needs of vulnerable groups. Indeed, programmes that address the lack of culturally safe, person-centred and holistic care, along with improving the communication skills of health professionals, are crucial for those with CKD.16

The networked community of kidney healthcare workers

Nonphysician healthcare workers, including nurses and advanced practice providers (physician assistants and nurse practitioners) as well as dietitians, pharmacists, social workers, technicians, physical therapists, and other allied health professionals, often spend more time with persons with kidney disease, compared with nephrologists and other physician specialists. In an ambulatory care setting at an appointment, in the emergency department, or in the in-patient setting, these healthcare professionals often see and relate to the patient first, last, and in between, given that physician encounters are often short and focused. Hence, the nonphysician healthcare workers have many opportunities to discuss kidney disease-related topics with the individuals and their care partners and to empower them.17 18 For instance, medical assistants can help identify those with or at risk of developing CKD and can initiate educating them and their family members about the role of diet and lifestyle modification for primary, secondary, and tertiary prevention of CKD while waiting to see the physician.19 Some healthcare workers provide networking and support for kidney patient advocacy groups and kidney support networks, which have been initiated or expanded via social media platforms (Fig 1).20 21 Studies examining the efficacy of social media in kidney care and advocacy are on the way.22 23

Figure 1. Schematic representation of consumer and healthcare professionals’ collaborative advocacy using social media platforms with the goal of ‘Kidney Health for All’

Like physicians, many activities of nonphysician healthcare workers have been increasingly affected by the rise of electronic health recording and growing access to internet-based resources, including social media, that offer educational materials related to kidney health, including kidney-preserving therapies with traditional and emerging interventions.24 These resources can be used for both self-education and for networking and advocacy on kidney disease awareness and learning. Increasingly, more healthcare professionals are engaged in some types of social media-based activities, as shown in Table 2. At the time of this writing, the leading social media used by many—but not all—kidney healthcare workers include Facebook, Instagram, Twitter, LinkedIn, and YouTube. In some regions of the world, certain social media are more frequently used than others given unique cultural or access constellations (eg, WeChat is a platform often used by healthcare workers and patient groups in China). Some healthcare professionals, such as managers and those in leadership and advocacy organisation positions, may choose to embark on social media to engage those with CKD and their care partners or other healthcare professionals in alliance building and marketing. To that end, effective communication strategies and outreach skills specific to responsible use of social media can provide clear advantages given that these skills and strategies are different and may need modification in those with LHL. It is imperative to ensure the needed knowledge and training for an accountable approach to social media is provided to healthcare providers, so that these outreach strategies are utilised with the needed awareness of their unique strengths and pitfalls, as follows.25

Table 2. Social media that are more frequently used for kidney education and advocacy

(i) Consumers’ and care partners’ confidentiality may not be breached upon posting anything on social media, including indirect referencing to a specific individual or a particular description of a condition unique to a specific person (eg, upon soliciting for transplant kidney donors on social media).26 27
ii) Confidential information about clinics, hospitals, dialysis centres, or similar healthcare and advocacy entities may not be disclosed on social media without ensuring that the needed processes, including collecting authorisations to disclose, are undertaken.
(iii) Healthcare workers’ job security and careers should remain protected with thorough review of the content of the messages and illustrations/videos before online posting.
(iv) Careless and disrespectful language and emotional tones are often counterproductive and may not be justified under the context of freedom of speech.

The global kidney community of policy and advocacy

Policy and advocacy are well-recognised tools that, if properly deployed, can bring about change and paradigm shift at the jurisdictional level. The essence of advocating for policy change to better address kidney disease is, in itself, an exercise in improving health literacy of the policy makers. Policy development, at its core, is a key stakeholder or stakeholder group (eg, the kidney community, which believes that a problem exists that should be tackled through governmental action). There is increasing recognition of the importance of formulating succinct, meaningful, and authentic information, akin to improving health literacy, to present to governments for action.

Robust and efficacious policy is always underpinned by succinct and applicable information; however, the development and communication of this message, designed to bridge the gap in knowledge of relevant jurisdictions, is only part of the process of policy development. An awareness of the process is important to clinicians who are aiming to advocate for effective change in prevention or improvement of outcomes in the CKD community.

Public policies, the plans for future action accepted by governments, are articulated through a political process in response to stakeholder observation, usually written as a directive, law, regulation, procedure, or circular. Policies are purpose fit and targeted to defined goals and specific societal problems and are usually a chain of actions effected to solve those societal problems.28 Policies are an important output of political systems. Policy development can be formal, passing through rigorous lengthy processes before adoption (such as regulations), or it can be less formal and quickly adopted (such as circulars). As already mentioned, the governmental action envisaged by the key stakeholders as a solution to a problem is at its core. The process enables stakeholders to air their views and bring their concerns to the fore. Authentic information that is meaningful to the government is critical. The policy development process can be stratified into five stages (ie, the policy cycle), as depicted by Anderson (1994)29 and adapted and modified by other authors30 (Fig 2). The policy cycle constitutes an expedient framework for evaluating the key components of the process.

Figure 2. Policy cycle involving five stages of policy development

Subsequently, the policy moves on to the implementation phase. This phase may require subsidiary policy development and adoption of new regulations or budgets (implementation). Policy evaluation is integral to the policy processes and applies evaluation principles and methods to assess the content, implementation, or impact of a policy. Evaluation facilitates understanding and appreciation of the worth and merit of a policy as well as the need for its improvement. More important, of the five principles of advocacy that underline policy making,31 the most important for clinicians engaged in this space is that of commitment, persistence, and patience. Advocacy takes time to yield the desired results.

The Advocacy Planning Framework, developed by Young and Quinn in 2002, 30 consists of overlapping circles representing three sets of concepts (way into the process, the messenger, and message and activities) that are key to planning any advocacy campaign:

(i) “Way into the process”: discusses the best approaches to translate ideas into the target policy debate and identify the appropriate audience to target.
(ii) Messenger: talks about the image maker or face of the campaign and other support paraphernalia that are needed.
(iii) Message and activities: describe what can be said to the key target audiences that is engaging and convincing. And how best it can be communicated through appropriate communication tools.

Advocacy is defined as “an effort or campaign with a structured and sequenced plan of action which starts, directs, or prevents a specific policy change.”31 The goal being to influence decision makers through communicating directly with them or getting their commitment through secondary audiences (advisers, the media, or the public) to the end that the decision maker understands, is convinced, takes ownership of the ideas, and finally has the compulsion to act.31 As with improving health literacy, it is the communication of ideas to policy makers for adoption and implementation as policy that is key. There is much to be done with bridging this gap in understanding of the magnitude of community burden that results from CKD. Without good communication, many good ideas and solutions do not reach communities and countries where they are needed. Again, aligned with the principles of developing resources for health literacy, the approach also needs to be nuanced according to the local need, aiming to have the many good ideas and solutions be communicated to communities and countries where they are needed

Advocacy requires galvanising momentum and support for the proposed policy or recommendation. The process is understandably slow as it involves discussions and negotiations for paradigms, attitudes, and positions to shift. In contemplating advocacy activities, multiple factors must be considered, interestingly not too dissimilar to that of building health literacy resources: What obstructions are disrupting the policy making process from making progress? What resources are available to enable the process to succeed? Is the policy objective achievable considering all variables? Is the identified problem already being considered by the policy makers (government or multinational organisations)? Any interest or momentum generated around it? Understandably, if there is some level of interest and if governments already have a spotlight on the issue, it is likely to succeed.

Approaches to choose from include the following31 32:

Advising (researchers are commissioned to produce new evidence-based proposals to assist the organisation in decision making).

Activism: involves petitions, public demonstrations, posters, fliers, and leaflet dissemination, often used by organisations to promote a certain value set.

Media campaign: having public pressure on decision makers helps in achieving results

Lobbying: entails face-to-face meetings with decision makers; often used by business organisations to achieve their purpose.

Here lies the importance of effective and successful advocacy to stakeholders, including policy makers, healthcare professionals, communities, and key change makers in society. The WKD, since inception, has aimed at playing this role. World Kidney Day has gained people’s trust by delivering relevant and accurate messaging and supporting leaders in local engagement, and it is celebrated by kidney care professionals, celebrities, those with the disease, and their caregivers all over the world. To achieve the goal, an implementation framework of success in a sustainable way includes creativity, collaboration, and communication.

The ongoing challenge for the International Society of Nephrology and International Federation of Kidney Foundations—World Kidney Alliance, through the Joint Steering Committee of WKD, is to operationalise how to collate key insights from research and analysis to effectively feed the policy making process at the local, national, and international levels, to inform or guide decision making (ie, increasing engagement of governments and organisations, like World Health Organization, United Nations, and regional organisations, especially in low-resource settings). There is a clear need for ongoing renewal of strategies to increase efforts at closing the gap in kidney health literacy, empowering those affected with kidney disease and their families, giving them a voice to be heard, and engaging with civil society. This year, the Joint Steering Committee of WKD declares “Kidney Health for All” as the theme of the 2022 WKD to emphasise and extend collaborative efforts among people with kidney disease, their care partners, healthcare providers, and all involved stakeholders for elevating education and awareness on kidney health and saving lives with this disease.

Conclusions

In bridging the gap of knowledge to improve outcomes for those with kidney disease on a global basis, an in-depth understanding of the needs of the community is required. The same can be said for policy development, understanding the processes in place for engagement of governments worldwide, all underpinned by the important principle of codesign of resources and policy that meets the needs of the community for which it is intended.

For WKD 2022, kidney organisations, including the International Society of Nephrology and International Federation of Kidney Foundations—World Kidney Alliance, have a responsibility to immediately work towards shifting the patient-deficit health literacy narrative to that of being the responsibility of clinicians and health policy makers. Low health literacy occurs in all countries regardless of income status; hence, simple, low-cost strategies are likely to be effective. Communication, universal precautions, and teach-back can be implemented by all members of the kidney healthcare team. Through this vision, kidney organisations will lead the shift to improved patient-centred care, support for care partners, health outcomes, and the global societal burden of kidney healthcare.

Author contributions

All authors contributed equally to the conception, preparation, and editing of the manuscript.

Conflicts of interest

K Kalantar-Zadeh reports honoraria from Abbott, Abbvie, ACI Clinical, Akebia, Alexion, Amgen, Ardelyx, AstraZeneca, Aveo, BBraun, Cara Therapeutics, Chugai, Cytokinetics, Daiichi, DaVita, Fresenius, Genentech, Haymarket Media, Hospira, Kabi, Keryx, Kissei, Novartis, Pfizer, Regulus, Relypsa, Resverlogix, Dr Schaer, Sandoz, Sanofi, Shire, Vifor, UpToDate, and ZS-Pharma. V Liakopoulos reports nonfinancial support from Genesis Pharma. G Saadi reports personal fees from Multicare, Novartis, Sandoz, and AstraZeneca. E Tantisattamo reports nonfinancial support from Natera. Other authors declared no competing interests.

Funding/support

This editorial received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Declaration

This article was published in Kidney International (Langham RG, Kalantar-Zadeh K, Bonner A, et al. Kidney health for all: bridging the gap in kidney health education and literacy. Kidney International. 2022;101(3):432-440. https://doi. org/10.1016/j.kint.2021.12.017), and reprinted concurrently in several journals. The articles cover identical concepts and wording, but vary in minor stylistic and spelling changes, detail, and length of manuscript in keeping with each journal’s style. Any of these versions may be used in citing this article.

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14. Boonstra MD, Reijneveld SA, Foitzik EM, Westerhuis R, Navis G, de Winter AF. How to tackle health literacy problems in chronic kidney disease patients? A systematic review to identify promising intervention targets and strategies. Nephrol Dial Transplant 2020;36:1207-21. Crossref

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Leveraging the power of health communication: messaging matters not only in clinical practice but also in public health

Hong Kong Med J 2022 Apr;28(2):103–5

https://doi.org/10.12809/hkmj215128

Hong Kong Academy of Medicine. CC BY-NC-ND 4.0

EDITORIAL

Leveraging the power of health communication: messaging matters not only in clinical practice but also in public health

Harry HX Wang, PhD^{1,2,3 #}; YT Li, MPH^{4 #}; Martin CS Wong, MD, MPH^5,6

¹ School of Public Health, Sun Yat-Sen University, Guangzhou, China

² Department of General Practice, The Second Hospital of Hebei Medical University, Shijiazhuang, China

³ Usher Institute, Deanery of Molecular, Genetic and Population Health Sciences, The University of Edinburgh, Scotland, United Kingdom

⁴ State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China

⁵ JC School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong

⁶ Editor-in-Chief, Hong Kong Medical Journal

^# Equal contribution

Corresponding author: Prof Martin CS Wong (wong_martin@cuhk.edu.hk)

Full paper in PDF

In routine clinical practice, communicating with patients in a clear and persuasive manner during patient-provider encounters is increasingly important for effective healthcare. This greatly helps in improving access to care and diagnostic safety, fostering continuous healing relationships, reducing medical errors, strengthening family and social support, enhancing care adherence, increasing patient satisfaction, and avoiding malpractice claims.1 2 3 Moreover, effective communication is a pivotal ingredient in patient engagement and shared decision-making across the care continuum from screening and diagnosis through palliative care built on the patient’s greater knowledge of health problems and the clinician’s better ability to recognise individual patient beliefs, values, needs, and preferences.4 This, in turn, enables the development and dissemination of evidence-based, personalised messages from clinicians to inform diagnosis, treatment options, prognosis, and the likelihood of severe adverse effects for achieving optimal care for patients.5

The benefits of effective health communications in improving patient health outcomes and well-being also extend beyond clinical care. Whether to inform people about their health facts or to exert a long-lasting influence on their behaviour for living a healthier life, the use of different strategies is crucial in public health campaigns spanning a variety of areas, including the ongoing coronavirus disease 2019 (COVID-19) pandemic.6 7 Of equal importance is the integration of health communication in public advocacy and outbreak responses, which necessitate appropriate, practical, and straightforward messages that fill knowledge gaps for the target audience.

From a public health perspective, eye health is a global imperative for achieving universal health coverage and many of the Sustainable Development Goals. Improving eye health contributes substantially to maintaining independence and daily life activities, improving quality of life and well-being, ensuring educational attainment and workplace productivity, and reducing poverty and inequalities.8 Similar to the prevention and management of most chronic diseases, promoting and improving eye health also require a life course approach that aims to minimise risk factors through evidence-based interventions at important life stages from as early as the perinatal period through early childhood to adolescence, and into older age. Therefore, school-based public health efforts that incorporate expertise of education and communication of health messages to facilitate long-term behaviour changes in children and adolescents would have the most impact on reducing disease risk factors and disease onset in later-life.9 Engagement in collaborative endeavours from both teachers and parents has been proven effective in the problem-solving process to support school-age children with developmental disorders and impairments in social interaction.10 Whether the school-family partnership underpinned by teacher-parent communication could be linked with improved behaviour changes, eg, vision screening attendance, in other specific disease contexts such as vision impairment warrants further investigation.

Uncorrected refractive error, including myopia, hyperopia, astigmatism, and anisometropia, serve as the major and most easily avoidable cause of vision impairment among school-age children who are at risk of poor educational performance and social malfunctioning. In this issue of the Hong Kong Medical Journal, Du et al11 explore the association between teacher-parent communication and eye-health seeking behaviours of primary school students in a cross-sectional study conducted in rural China. The authors found that the delivery of a single clear message to parents from the teacher on the student’s inability to see the blackboard clearly could substantially improve the refractive examination attendance and spectacles wearing among students. It adds evidence to extend the benefits of teacher-parent communication beyond better educational experiences, coordinated learning environments, improved academic achievements, and enhanced habits development in daily life. The findings also provide impetus for further in-depth research to advance our understanding of the extent to which different modalities of teacher-parent interactions could inform, educate and empower parents about their child’s eye health issues. This may help in generating evidence for developing well-integrated, innovative strategies to plan and implement school-based eye health initiatives featured by strengthened partnership with teachers, parents, students, and the wider community to address undiagnosed or untreated refractive error and other vision impairment.

At the global level, an earlier report from the World Health Organization in 2019 highlighted the considerable challenges of a continuum of eye care throughout people’s lives: over 2 billion people worldwide are visually impaired or blind, and nearly half of vision impairments could have been prevented or have yet to be addressed through cost-effective and feasible health interventions.12 The subsequent 74th World Health Assembly organised in April 2021 has endorsed the global targets for effective coverage of refractive errors and cataract surgery—the two leading causes of vision impairment and blindness. A 40% point increase in effective coverage of refractive error and a 30% point increase in effective coverage of cataract surgery is envisaged by 2030. Apart from refractive errors and cataract, there are a range of other common ophthalmic conditions that pose enormous threats to healthcare such as glaucoma and diabetic retinopathy, which can lead to eye vision loss if not detected and treated early. Most recently, the Resolution entitled ‘Vision for Everyone; accelerating action to achieve the Sustainable Development Goals’ has been adopted by the United Nations General Assembly in July 2021 to urge the implementation of integrated people-centred eye care in health systems across the wide spectrum of promotive, preventive, curative and rehabilitative services by 2030. The United Nations vision underscores the significance of raising awareness and engaging and empowering people and communities pertaining to eye care needs and the importance of vision for all. To achieve this goal, eye health education and promotion within the wider community needs to reduce barriers that impede the affective dimensions of message dissemination and to optimise knowledge communication and service uptake.

However, achieving effective communication of health messages is never an easy task. Previous studies highlighted the increasing need for strengthening health communication and promotion in socially disadvantaged groups,13 or those living in deprived areas,14 and for care empowerment in managing underdiagnosed long-term conditions that require better professional education and tailored messages in primary care.15 16 The need for health communication efforts and mass media messages promoting infection control measures and use of guidelines in public education is also highlighted in risk communications and community engagement against the COVID-19 outbreak.17

A growing body of evidence indicates that digital communication, eg, mobile messaging for telecommunications or social media platform characterised by multi-channel communications, may offer innovative means for sharing, disseminating and amplifying health messages across all aspects of the communication spectrum to target audience and communities with unique merits such as enhanced audio-visual capabilities, improved attendance at healthcare appointments, and increased uptake of comprehensive eye examinations.18 19

The World Health Organization has also proposed a strategic framework that highlights the principles of accessible, relevant, actionable, timely, credible and trusted, and understandable communication.20 The framework could be used a basis for operationalising effective, integrated and coordinated communication across a broad range of health issues from chronic conditions (eg, vision impairment) to emerging risks (eg, COVID-19), and for measuring the impact of tailored communication efforts on health and well-being over time. A further step towards empirical evidence from well-designed studies on the impact of enhanced health communication with individuals and their families on disease prevention, health promotion, and quality of life through public health measures and its enablers would pave the way for achieving universal health coverage for individuals, communities, and society at large.

Author contributions

All authors contributed to the concept or design; acquisition of data; analysis or interpretation of data; drafting of the article; and critical revision for important intellectual content. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

Conflicts of interest

The authors have declared no conflict of interest.

References

1. Street RL Jr, Makoul G, Arora NK, Epstein RM. How does communication heal? Pathways linking clinician-patient communication to health outcomes. Patient Educ Couns 2009;74:295-301. Crossref

2. van Dael J, Gillespie A, Neves AL, Darzi A. Patient–clinician communication research for 21st century health care. Br J Gen Pract 2022;72:52-3. Crossref

3. Burgener AM. Enhancing communication to improve patient safety and to increase patient satisfaction. Health Care Manag (Frederick) 2020;39:128-32. Crossref

4. Kaldjian LC. Concepts of health, ethics, and communication in shared decision making. Commun Med 2017;14:83-95. Crossref

5. Vermeir P, Vandijck D, Degroote S, et al. Communication in healthcare: a narrative review of the literature and practical recommendations. Int J Clin Pract 2015;69:1257-67. Crossref

6. Edwards DJ. Ensuring effective public health communication: insights and modeling efforts from theories of behavioral economics, heuristics, and behavioral analysis for decision making under risk. Front Psychol 2021;12:715159. Crossref

7. Nan X, Iles IA, Yang B, Ma Z. Public health messaging during the COVID-19 pandemic and beyond: lessons from communication science. Health Commun 2022;37:1-19. Crossref

8. Burton MJ, Ramke J, Marques AP, et al. The Lancet Global Health Commission on Global Eye Health: vision beyond 2020. Lancet Glob Health 2021;9:e489-551. Crossref

9. Bay JL, Hipkins R, Siddiqi K, et al. School-based primary NCD risk reduction: education and public health perspectives. Health Promot Int 2017;32:369-79. Crossref

10. Azad GF, Kim M, Marcus SC, Mandell DS, Sheridan SM. Parent-teacher communication about children with autism spectrum disorder: an examination of collaborative problem-solving. Psychol Sch 2016;53:1071-84. Crossref

11. Du K, Huang J, Guan H, Zhao J, Zhang Y, Shi Y. Teacher-to-parent communication and vision care-seeking behaviour among primary school students. Hong Kong Med J 2022;28:152-60. Crossref

12. World Health Organization. World Report on Vision. Geneva: World Health Organization; 2019.

13. Hon KL, Leung KK. Healthcare and health promotion for the sub-health state Hong Kong population. Hong Kong Med J 2021;27:73. Crossref

14. Zhou Q, An Q, Wang N, et al. Communication skills of providers at primary healthcare facilities in rural China. Hong Kong Med J 2020;26:208-15. Crossref

15. Lam K, Chan WS, Luk JK, Leung AY. Assessment and diagnosis of dementia: a review for primary healthcare professionals. Hong Kong Med J 2019;25:473-82. Crossref

16. Kalantar-Zadeh K, Li PK, Tantisattamo E, et al. Living well with kidney disease by patient and care partner empowerment: kidney health for everyone everywhere. Hong Kong Med J 2021;27:97-8. Crossref

17. Yu EY, Leung WL, Wong SY, Liu KS, Wan EY; HKCFP Executive and Research Committee. How are family doctors serving the Hong Kong community during the COVID-19 outbreak? A survey of HKCFP members. Hong Kong Med J 2020;26:176-83. Crossref

18. Atta S, Omar M, Kaleem SZ, Waxman EL. The use of mobile messaging for telecommunications with patients in ophthalmology: a systematic review. Telemed J E Health 2022;28:125-37. Crossref

19. Maitra C, Rowley J. Delivering eye health education to deprived communities in India through a social media-based innovation. Health Info Libr J 2021;38:139-42. Crossref

20. World Health Organization. Strategic Communications Framework for WHO in the Western Pacific Region. Manila: WHO Regional Office for the Western Pacific; 2017.

Breast cancer screening—towards a broader coverage of the general population

Hong Kong Med J 2022 Apr;28(2):100–2

https://doi.org/10.12809/hkmj215127

Hong Kong Academy of Medicine. CC BY-NC-ND 4.0

EDITORIAL

Breast cancer screening—towards a broader coverage of the general population

CY Lui, FHKCR, FHKAM (Radiology)¹; Julian CY Fong, FHKCR, FHKAM (Radiology)¹; Martin CS Wong, MD, MPH^2,3

¹ Hong Kong Women’s Imaging Limited, Hong Kong

² Jockey Club School of Public Health and Primary Care, The Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong

³ Editor-in-Chief, Hong Kong Medical Journal

Corresponding author: Dr CY Lui (cylui@hkwi.com.hk)

Full paper in PDF

The primary purpose of breast cancer screening is to detect breast cancer earlier at an asymptomatic stage hopefully before it becomes more advanced or metastasised, which is the major cause of patient death. The breast cancer detected under screening are usually smaller in size with better prognosis,1 2 and patients can therefore benefit from less extensive surgical treatment with fewer complications such as lymphoedema. It may also reduce morbidity secondary to the use of systematic chemotherapy, and lower its recurrence rate

In 2021, the Cancer Expert Working Group on Cancer Prevention and Screening (CEWG) updated its recommendations on breast cancer screening for the female general population of Hong Kong. Women with certain combinations of risk factors are recommended to consider mammography screening every 2 years.3 Addressing the rising breast cancer incidence in Hong Kong, the updated recommendation is a big leap forward compared to the previous version which only mentioned ‘insufficient scientific evidence to recommend or against mammography screening’.

The benefits of mammography have been widely reported in Western populations.4 However, whether studies from Western populations are directly applicable in Chinese populations remains controversial, primarily because this population generally has denser breast tissue and difference in incidence. In this respect, a 10-year study conducted in Taiwan, involving over 1.4 million women of mainly Chinese ethnicity, found that universal biennial mammography was associated with reduction of mortality by 41% and stage II+ breast cancer by 30%, compared with annual clinical breast examination.5 In Hong Kong, Lui et al6 found that the crude cancer detection rate of an opportunistic screening programme was five per 1000 mammograms performed. Experience from Hong Kong Breast Cancer Foundation found a detection rate of 7.5 per 1000 asymptomatic women screened.7 These data suggested that mammography screening is useful to detect breast cancers in Hong Kong.

Potential risks of breast screening have also been overstated, including overdiagnosis and overtreatment of ductal carcinoma in situ (DCIS) detected by mammography screening. However, Duffy et al8 studied over 5 million women screened in the United Kingdom for four consecutive yearly screening rounds, and showed that there was a significant negative association between detection of DCIS at screening and invasive interval cancers. For every three screen-detected DCIS, there was one less invasive interval cancer over the next 3 years. These results indicate that early detection of DCIS and subsequent treatment is worthwhile in prevention of future invasive diseases.

Another risk that is often overstated is the effect of screening causing anxiety among patients. Anxiety in patients who received breast cancer screening tends to be short-term, and these women have a high tolerance for false positive results.9 10 11 Findings from the longitudinal DMIST (Digital Mammographic Imaging Screening Trial) showed that the anxiety associated with false positive mammogram was only transient with no measurable health utility decrement, yet it increased women’s intention to undergo future breast cancer screening.12 Although there is potential for false positive results to cause anxiety and lead to unnecessary biopsy and treatment, the situation can be much alleviated with updated technology and quality assurance by experts with adequate experience in breast screening.

Bilateral two-view full-field digital mammography is currently the standard of screening mammography. With technological advancements, digital breast tomosynthesis (DBT), also known as 3D mammogram, has become more widely used. Friedewald et al13 found that DBT was associated with a 41% increase in invasive cancer detection, 49% increase in positive predictive value for recall, 21% increase in positive predictive value for biopsy, and 15% reduction of overall number of recalls.

Older studies reported that the radiation dose of DBT was much higher than that of conventional two-dimensional (2D) digital mammography. However, these studies often compared the radiation dose between “DBT combined with digital mammography” and “digital mammography only”. Using newer DBT technology with synthesised 2D mammogram capacity without separate scanning for 2D images, the radiation dose of DBT is comparable to that of conventional 2D digital mammography—and just less than half of the United States Food and Drug Administration Mammography Quality Standards Act dose limit for mammography.14 And with the use of DBT, it is associated with fewer additional radiation exposure from recall for additional cone compression view. This newer DBT technology is now widely available in Hong Kong.

To implement a successful breast cancer screening programme in Hong Kong, modern hardware and manpower readiness are equally important. The imaging centre should have mammography machines, radiographers, and radiologists that meet the standards recommended by Hong Kong College of Radiologists.15 Quality assurance, including regular auditing of the programme’s performance should be in place. Multidisciplinary meetings with radiologists, surgeons, pathologists, and oncologists working in as a team should be held regularly to discuss relevant cases and to facilitate further investigations or treatment plans. There should also be administrative support to follow up on screening and biopsy results, and provide timely arrangement of further investigation or treatment if cancer is suspected or confirmed. A system should be implemented to remind patients to attend the next screening appointment.

To prepare for large-scale breast cancer screening, forward planning is essential, such as training of an adequate number of mammographers, radiologists with a special interest in breast screening, and breast surgeons specialised in early breast cancer surgery and treatment.

Whereas the risks of screening are frequently discussed, the harms of not screening are often overlooked. Those women not attending screening are associated with development of a significantly larger tumour, a more advanced stage of disease at diagnosis, poorer prognosis, lower survival rate, and higher recurrence rate. There is also a higher cost and extent of treatment, especially if there is a need for chemotherapy for advanced disease. It has been estimated that the cost of treating advanced metastatic breast cancer exceeds US$250 000 per patient, and the average cost of treating advanced cancer in the first year after diagnosis is almost double that of early cancers.16 In addition to the cost for treatment, there are extra societal costs, including productivity loss and staff turnover, as well as the time and expenses of the caretakers of the patients.

The relatively dense breast tissue among Chinese women not only impairs the performance and resulting benefits of mammography, but also is an independent risk factor for breast cancer. The technology of DBT, supplemented by ultrasound or magnetic resonance imaging (MRI), may be used to enhance the sensitivity for detecting cancer. Whereas supplementary ultrasound is widely used because of its easy availability, a recent study found that contrast enhanced MRI provides the greatest increase in cancer detection and reduce interval cancers and late-stage disease.17 The abbreviated MRI technique will reduce the cost and improve the availability of this technology. It is hoped that the CEWG may take this newer evidence into consideration in its next update.

With the updated recommendation of CEWG on risk-based screening, and the experience of opportunistic mammography screening in Hong Kong since 1993,6 we believe that Hong Kong should have the capability and expertise to organise quality, population-based screening similar to other Asian countries and cities. Because breast screening is a primary care activity, we anticipate that district health centres may play a crucial role to enhance awareness and promote its implementation in the community as one of their key roles and functions. We are confident that the findings from evaluation of the Breast Cancer Screening Pilot Programme started on 6 September 2021 could further inform policy formulation.

Author contributions

All authors contributed to the editorial, approved the final version for publication, and take responsibility for its accuracy and integrity.

Conflicts of interest

The authors have declared no conflict of interest.

References

1. Tabar L, Tot T, Dean PB. Breast Cancer—The Art and Science of Early Detection with Mammography: Perception, Interpretation, Histopathologic Correlation. Germany: Thieme; 2004: 174-7.

2. Tabár L, Duffy SW, Vitak B, Chen HH, Prevost TC. The natural history of breast carcinoma: what have we learned from screening? Cancer 1999;86:449-62. Crossref

3. Cancer Expert Working Group on Cancer Prevention and Screening (August 2018 to July 2021); Tsang TH, Wong KH, Allen K, et al. Update on the Recommendations on Breast Cancer Screening by the Cancer Expert Working Group on Cancer Prevention and Screening. Hong Kong Med J 2022;28:161-8.

4. Sitt JC, Lui CY, Sinn LH, Fong JC. Understanding breast cancer screening—past, present, and future. Hong Kong Med J 2018;24:166-74. Crossref

5. Yen AM, Tsau HS, Fann JC, et al. Population-based breast cancer screening with risk-based and universal mammography screening compared with clinical breast examination: a propensity score analysis of 1 429 890 Taiwanese women. JAMA Oncol 2016;2:915-21. Crossref

6. Lui CY, Lam HS, Chan LK, et al. Opportunistic breast cancer screening in Hong Kong; a revisit of the Kwong Wah Hospital experience. Hong Kong Med J 2007;13:106-13.

7. Hong Kong Breast Cancer Foundation. Fact Sheet (last updated on 1 April 2021). Available from: https://www.hkbcf.org/en/about_us/main/upload/category/442/self/6080f662635ff.pdf. Accessed 20 Mar 2022.

8. Duffy SW, Dibden A, Michalopoulos D, et al. Screen detection of ductal carcinoma in situ and subsequent incidence of invasive interval breast cancers: a retrospective population-based study. Lancet Oncol 2016;17:109-14. Crossref

9. Lowe JB, Balanda KP, Del Mar C, Hawes E. Psychologic distress in women with abnormal findings in mass mammography screening. Cancer 1999;85:1114-8. Crossref

10. Ekeberg Ø, Skjauff H, Kåresen R. Screening for breast cancer is associated with a low degree of psychological distress. Breast 2001;10:20-4. Crossref

11. Schwartz LM, Woloshin S, Sox HC, Fischhoff B, Welch HG. US women’s attitudes to false positive mammography results and detection of ductal carcinoma in situ: cross sectional survey. BMJ 2000;320:1635-40. Crossref

12. Tosteson AN, Fryback DG, Hammond CS, et al. Consequences of false-positive screening mammograms. JAMA Intern Med 2014;174:954-61. Crossref

13. Friedewald SM, Rafferty EA, Rose SL, et al. Breast cancer screening using tomosynthesis in combination with digital mammography. JAMA 2014;311:2499-507. Crossref

14. Skaane P, Bandos AI, Eben EB, et al. Two-view digital breast tomosynthesis screening with synthetically reconstructed projection images: comparison with digital breast tomosynthesis with full-field digital mammographic images. Radiology 2014;271:655-63. Crossref

15. Mammography Statement. Revised version 2015. Hong Kong College of Radiologists. Available from: https://www.hkcr.org/templates/OS03C00336/case/lop/HKCR%20Mammography%20Statement_rev20150825.pdf. Accessed 20 Mar 2022.

16. Montero AJ, Eapen S, Gorin B, Adler P. The economic burden of metastatic breast cancer: a U.S. managed care perspective. Breast Cancer Res Treat 2012;134:815-22. Crossref

17. Berg WA, Rafferty EA, Friedewald SM, Hruska CB, Rahbar H. Screening algorithms in dense breasts: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2021;216:275-94. Crossref

Expert witnesses and areas of expertise

Hong Kong Med J 2022 Feb;28(1):4–5 | Epub 14 Feb 2022

https://doi.org/10.12809/hkmj215125

EDITORIAL

Expert witnesses and areas of expertise

James SP Chiu, FHKAM (Surgery), LLB (Hons) Lond; Gilberto KK Leung, FHKAM (Surgery), LLM

Professionalism and Ethics Committee, Hong Kong Academy of Medicine

Corresponding author: Dr James SP Chiu (drjameschiu@yahoo.com.hk)

Full paper in PDF

Expert witnesses play important roles in medicolegal and disciplinary proceedings through the provision of opinions that are within their respective areas of expertise. Contentions may occasionally arise concerning the expertise of an individual witness and whether the scope of his expertise has been exceeded in certain situations.

Defining specialists and experts

The terms “specialist” and “expert” are often used interchangeably but they may carry different meanings in the case of professionals. In 1998, the Medical Council of Hong Kong established a Specialist Register to provide for specialist registration of medical practitioners who have been awarded Fellowships of the Hong Kong Academy of Medicine or who have achieved a comparable professional standard and have applied to the Medical Council of Hong Kong for specialist registration.1 By contrast, there is no official list of medical experts in Hong Kong and the term “expert” is not defined in Cap. 1 Interpretation and General Clauses Ordinance or Cap. 4A The Rules of the High Court. The Hong Kong Academy of Medicine maintains a list of Academy Fellows who are willing to serve as expert witnesses in their respective specialties. However, disputing parties and their legal advisers may freely engage any registered doctor or dentist of their choice to be their expert witness, whether the individual is on the Academy’s list or not.

Duties and responsibilities of expert witnesses in relation to their expertise

In the landmark case of The Ikarian Reefer,2 the court set out the duties and responsibilities of expert witnesses in civil cases, two of which are related to expertise. First, an expert witness should provide independent assistance to the Court by way of objective unbiased opinion in relation to matters within his expertise. Second, an expert witness should make it clear when a particular question or issue falls outside his expertise. Similarly, the Code of Conduct for Expert Witnesses3 provides that an expert witness has an overriding duty to help the Court impartially and independently on matters relevant to the expert’s area of expertise. A report by an expert witness must (in the body of the report or in an annexure) specify, if applicable, that a particular question or issue falls outside his field of expertise. In Zahid Anwar v Graceful Sound Limited,4 Bharwaney J stated that, “Experts are instructed to assist the court by offering their expert opinion on areas which are within their specialist experience and which are not matters of common knowledge”.

Matters relating to an expert witness’ areas of expertise

Medicine has evolved to include many specialties under which there are multiple subspecialties. Professional expertise is accumulated from years of studying, training, and personal experience in a specific area of medicine. It follows that not all specialists are competent expert witnesses. A specialist in Gastroenterology and Hepatology may not act as an expert witness for a case concerning endoscopic retrograde cholangiopancreatography, sphincterotomy, and extraction of common bile duct stones if he does not have substantial knowledge and practical experience in these procedures.

In a recent Hong Kong case, the expert witness for the defendants was a specialist in paediatrics, and that for the plaintiffs was a specialist in paediatric surgery. The court acknowledged that the relevant standard to be applied under the Bolam test on the issue of liability for medical negligence was whether the defendant (who was a paediatrician) had acted in accordance with the practice accepted as proper by a responsible body of “medical men skilled in that particular art”, which particular art was that of paediatric specialists and not that of paediatric surgery specialists.5 The boundary becomes less clear when a specialist in general surgery is asked to comment on an orthopaedic case. It may be proper for him to comment on general principles of postoperative care but not detailed surgical techniques in orthopaedics. The situation is even more challenging when the case involves several body systems and multidisciplinary care. Medical and dental practitioners invited to be expert witnesses should be mindful of any limitations of their areas of expertise in relation to the medicolegal issue at hand and to act within those boundaries as a matter of duty to the court and professional respect towards their peers who possess the relevant specialised skills and knowledge. In cases involving matters of multiple areas of expertise, the practitioner may suggest the parties to invite suitable experts of other specialties or subspecialties to be witnesses, if necessary.

Medical and dental practitioners appointed to give evidence in courts, tribunals, or inquests are advised to: consider seeking legal advice; provide answers truthfully based on their personal knowledge and beliefs; avoid making up answers; avoid answering questions that are beyond their scope of practice; and exercise the right to refuse to answer questions that could result in self-incrimination.6

Potential consequences of giving mistaken evidence

Misleading or “manifestly wrong” expert evidence can have untoward and far-reaching consequences. The professional or academic status of an expert witness by itself offers no excuses. In the United Kingdom case of R v Sally Clark,7 a prosecution expert witness was Professor Sir Roy Meadow, an Emeritus Professor of Paediatrics and Child Health. Evidence relating to statistics were given by the professor, who did not disclose his lack of expertise in statistics. Mrs Clark was convicted of the murder of her two sons and received two life sentences in 1999. Her appeal was dismissed. It later transpired that Professor Meadow made one mistake, which was to misunderstand and misinterpret the statistics. Mrs Clark made a second appeal and was set free in 2003. Her father then made a complaint to the General Medical Council (GMC) alleging serious professional misconduct on the part of Professor Meadow. In 2005, the GMC found him guilty, and his name was erased from the register. He appealed to the High Court and the order of the GMC was quashed. The GMC appealed to the Court of Appeal in 2006.8 There were two distinct parts of the appeal. The first was whether an expert witness should be entitled to immunity from disciplinary, regulatory or fitness to practise proceedings in relation to statements made or evidence given by him in or for the purpose of legal proceedings. The second entailed a consideration of the GMC’s challenge to the High Court judge’s decision that Professor Meadow was not guilty of serious professional misconduct. The Court of Appeal allowed the first part of the appeal and held that the Fitness to Practice Panel of the GMC had jurisdiction to entertain the allegations against Professor Meadow. However, the second part of GMC's appeal on the issue of 'serious professional misconduct' was rejected.

Training for expert witnesses

Specialists do not automatically make good expert witnesses. It is advisable for anyone interested to take up this job to undergo formal training first. Start with simple cases and work closely with instructing lawyers to gain experience and accumulate the necessary skills. Otherwise, it can result in unpleasant experience if he has to appear in courts or tribunals and may even become a defendant himself or cause irreversible harm to the parties.

Author contributions

Both authors contributed to the editorial, approved the final version for publication, and take responsibility for its accuracy and integrity.

Conflicts of interest

The authors have declared no conflict of interest.

References

1. The Medical Council of Hong Kong. Available from: https://www.mchk.org.hk/english/registration/specialist_registration.html. Accessed 25 Nov 2021.

2. The Ikarian Reefer [1993] Lloyd’s Rep 68, pp 81-82.

3. Cap. 4A, The Rules of the High Court, Appendix D.

4. Zahid Anwar v Graceful Sound Limited & Ors HCPI 410/2008 & HCPI 370/2009

5. Sun Ming Lok v Choy Wing Ho & St Teresa’s Hospital HCPI 200/2017

6. Tsang C, Lee V. Coroner’s inquest—What do you need to know? Hong Kong Medical Association News, October 2021: 23.

7. R v Sally Clark [2003] EWCA Crim 1020

8. GMC v Professor Sir Roy Meadow [2006] EWCA Civ 1390

Why is a special section “Healthcare in Mainland China” so crucial for HKMJ?

Hong Kong Med J 2022 Feb;28(1):6

https://doi.org/10.12809/hkmj215126

EDITORIAL

Why is a special section “Healthcare in Mainland China” so crucial for HKMJ?

Jingchun Nie, PhD¹; Yaojiang Shi, PhD^1,2; Hao Xue, PhD^1,2

¹ Center for Experimental Education in Economics (CEEE), Shaanxi Normal University, Xi’an, Shaanxi, China

² Section Editor, ‘Healthcare in Mainland China’, Hong Kong Medical Journal

Corresponding author: Dr Hao Xue (xuehjjx@gmail.com)

Full paper in PDF

In order to promote high-quality research from mainland China among medical professionals in Hong Kong, the Hong Kong Medical Journal (HKMJ) Editorial Board launched a Special Section titled “Healthcare in Mainland China” in June 2021.1 We hope that studies from mainland China in this special section can speak to and shed light on healthcare in other developing countries and regions, and provide insight into Chinese healthcare practice for HKMJ’s international readers.

For the past 2 years, coronavirus disease 2019 (COVID-19) has exerted a heavy burden on public health worldwide, and there is an increasing body of evidence reporting various effects and impacts of COVID-19. However, few studies have provided epidemiological and clinical characteristics of patients affected at the early stage of the COVID-19 outbreak.

In this current issue of HKMJ under the “Healthcare in Mainland China” section, Gao et al2 report a retrospective study that included laboratory-confirmed 96 cases of COVID-19 in a hospital in Hangzhou City from 15 January 2020 to 30 March 2020. The authors investigated epidemiological, demographic, clinical, radiological, and laboratory features involving these cases; and found that, during the early stage of the COVID-19 outbreak, half of the patients were part of familial clusters. Therefore, they suggested that strict prevention and control measures during self-isolation should be implemented. They also found that patients aged >60 years with underlying co-morbidities were prone to lymphocytopenia and severe infection.

China is the world’s most populous country, and the large population presents numerous healthcare issues. For example, China accounted for 24% of newly diagnosed cases and 30% of cancer-related deaths worldwide in 2020.3 There were also an estimated 93.8 million prevalent cases of cardiovascular diseases overall during 2016 in China, accounting for about 17.8% of the global burden.4 5 Moreover, nearly half of all vision problems among children globally occur in China.6 To address such a volume of challenges, China’s total healthcare expenditure was >7.2 trillion yuan in 2020, with >1.0 million clinics and hospitals, and >13.5 million medical personnel.7 In addition, there is a significant income disparity between urban and rural areas and between coastal and inland regions in mainland China. All of these factors lead to a broad and diverse wealth of healthcare research in the region.

We highly appreciate and sincerely welcome more researchers and healthcare professionals to submit their research on healthcare in mainland China for consideration for publication in HKMJ. The HKMJ review process is highly selective, and only the highest quality submissions are accepted for publication. We hope to promote global healthcare improvement by providing our valued international and local readers with high-quality research from mainland China.

Author contributions

All authors contributed to the editorial, approved the final version for publication, and take responsibility for its accuracy and integrity.

Conflicts of interest

The authors have declared no conflict of interest.

References

1. Shi YJ, Xue H, Wong MCS. Call for papers: special section “Healthcare in Mainland China”. Hong Kong Med J 2021;27:174. Crossref

2. Gao J, Zhang S, Zhou K, Liu J, Pu Z. Epidemiological and clinical characteristics of patients with COVID-19 from a designated hospital in Hangzhou City: a retrospective observational study. Hong Kong Med J 2022;28:54-63. Crossref

3. Cao W, Chen HD, Yu YW, Li N, Chen WQ. Changing profiles of cancer burden worldwide and in China: a secondary analysis of the global cancer statistics 2020. Chin Med J (Engl) 2021;134:783-91. Crossref

4. Li X, Wu C, Lu J, et al. Cardiovascular risk factors in China: a nationwide population-based cohort study. Lancet Public Health 2020;5:e672-81. Crossref

5. Liu S, Li Y, Zeng X, et al. Burden of cardiovascular diseases in China, 1990-2016: findings from the 2016 Global Burden of Disease Study. JAMA Cardiol 2019;4:342-52. Crossref

6. Resnikoff S, Pascolini D, Mariotti SP, Pokharel GP. Global magnitude of visual impairment caused by uncorrected refractive errors in 2004. Bull World Health Organ 2008;86:63-70. Crossref

7. Wang L, Chen Y. Determinants of China’s health expenditure growth: based on Baumol’s cost disease theory. Int J Equity Health 2021;20:213. Crossref

Combating antimicrobial resistance during the COVID-19 pandemic

Hong Kong Med J 2021 Dec;27(6):396–8 | Epub 17 Nov 2021

https://doi.org/10.12809/hkmj215124

EDITORIAL

Combating antimicrobial resistance during the COVID-19 pandemic

Edmond SK Ma, FHKAM (Community Medicine)^1,2; KH Kung, MMedSc, FHKAM (Community Medicine)²; Hong Chen, MPH, FHKAM (Community Medicine)²

¹ Epidemiology Adviser, Hong Kong Medical Journal

² Infection Control Branch, Centre for Health Protection, Department of Health, Hong Kong SAR Government, Hong Kong

Corresponding author: Dr Edmond SK Ma (edmond_sk_ma@dh.gov.hk)

Full paper in PDF

Global attention has been drawn to combat coronavirus disease 2019 (COVID-19), draining tremendous government resources, political commitment, public health measures, manpower of healthcare professionals, media, and public interest. The COVID-19 has also seriously affected the global effort against antimicrobial resistance (AMR). According to a survey conducted in late 2020 by the World Health Organization (WHO) AMR Surveillance and Quality Assessment Collaborating Centres Network, 63% (35 out of 56 countries) reported an increase in total prescriptions of antibiotics, with 47% (23/49), 57% (27/47), and 40% (18/45) of countries reporting increased use of WHO Access, Watch, and Reserve antibiotics, respectively.1 More importantly, 37% (13/35) and 40% (12/30) of countries reported an increase in multidrug-resistant organism (MDRO) healthcare-associated infections and MDRO infections in long-term care facilities, respectively. Outbreaks and increases in AMR acquisition, such as carbapenemase-producing Enterobacteriaceae, have also been reported by hospitals during the COVID-19 pandemic.2 3 4

The situation of MDRO in Hong Kong is worrisome. The Hospital Authority has reported a higher rate of methicillin-resistant Staphylococcus aureus bacteraemia detected after 48 hours of admission in 2020 and the first half of 2021, compared with that of previous years, although this may be due to a reduction in hospital admission of milder cases.5 An outbreak of Candida auris, an often highly resistant emerging infection, during the third wave of the COVID-19 pandemic is also concerning. From 29 June 2020 to 9 October 2020, the Hospital Authority reported 41 patients with Candida auris colonisation to the Infection Control Branch of the Centre for Health Protection for infection control advice after discharge to residential care homes.6 The number of cases of carbapenem-resistant Enterobacteriaceae discharged to residential care homes for the elderly rose from 242 cases in 2019 to 259 cases in 2020, and then sharply to 329 cases between January and August 2021.

The COVID-19 pandemic has affected antimicrobial stewardship activities and driven AMR in various ways. Drifting of resources, including laboratory capacity, reduced reagents and consumables, physician and nursing manpower, and public health staff, have undermined antimicrobial stewardship programmes in many countries. Weakened infection control due to fatigue and heavy workload of healthcare workers, and shortages of personal protective equipment in the early days of the pandemic further aggravated the problem. Hospital admission may increase the risk of healthcare-associated infections and the transmission of MDROs, which in turn may lead to increased antimicrobial use. Disruption to routine immunisation activities, due to COVID-19-related measures, has led to reductions in overall vaccination coverage globally, potentially leading to an overuse of antimicrobials.7 8 9 Low-level exposure to biocidal agents can strengthen drug-resistant strains and enhance the risk of cross resistance to antibiotics, particularly those that treat Gram-negative bacteria.10

Another important impact of COVID-19 on increasing AMR is secondary bacterial infection among patients with COVID-19. Empirical treatment of patients with COVID-19 using antibiotics is common. A meta-analysis involving 154 studies and over 30 000 patients revealed that 74.6% of patients with COVID-19 received antibiotics, significantly higher than the estimated prevalence of bacterial co-infection.11 This is echoed by another review of studies published on hospitalised patients with COVID-19, which revealed 72% (1450/2010) of patients received antibiotics but only 8% (62/806) had bacterial or fungal co-infections.12 The most common type of secondary infection of COVID-19 was pneumonia (especially ventilator-associated pneumonia), followed by bloodstream and urinary tract infections, and the most commonly used agents included fluoroquinolones, cephalosporins, carbapenems, azithromycin, vancomycin, and linezolid.13 14 Those with complications of COVID-19 may require mechanical ventilation or other invasive devices, which increases the risk of acquiring hospital-associated pathogens that are often highly resistant, such as methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, and Acinetobacter baumannii.15

Despite the challenges posed to AMR, the COVID-19 pandemic also creates some opportunities, such as enhanced infection control measures among healthcare workers and the high alertness of personal hygiene among the general public. These measures, which include cough etiquette, hand hygiene, wearing of masks, and social distancing, have helped to reduce various infections, in particular those caused by respiratory pathogens.16 17 18 In addition, increased fear of attending healthcare facilities and postponement of elective hospital procedures have resulted in fewer medical consultations and antibiotic prescriptions. Surveillance data on wholesale antimicrobial consumption in Hong Kong show a substantial reduction (28.3%) in daily defined doses of antimicrobials from 19.02 million in 2019 to 13.63 million in 2020. In particular, there were major reductions (of between 35.3% and 51.5%) in wholesale supply to general practitioners of amoxicillin with or without beta-lactamase inhibitor, azithromycin, and cefuroxime, which are commonly prescribed to manage upper and lower respiratory tract infections. In Hong Kong, social distancing measures imposed by public health authorities, school and kindergarten closures, work-from-home policies, other restrictions involving catering businesses and scheduled premises such as fitness centres, beauty salons, karaoke establishments and sport centres, have all helped limit transmission through the respiratory route and person-to-person contact of not only COVID-19 but also other infections. Enhanced environmental hygiene using diluted household bleach containing 5.25% sodium hypochlorite can kill severe acute respiratory syndrome coronavirus 2 and other pathogens including MDROs.

Although more research is needed to dissect the intermingled relationship between COVID-19 and AMR, it is of utmost importance to maintain efforts against AMR. The theme for World Antibiotic Awareness Week, held on 18 to 24 November 2021, was “Spread Awareness, Stop Resistance”. The dedicated page on the Centre for Health Protection website (https://www.chp.gov.hk/en/features/47850. html) includes access to the latest IMPACT (Interhospital Multi-disciplinary Programme on Antimicrobial ChemoTherapy) guideline, an evidence-based clinical guideline to ensure that patients receive the right antibiotic, at the right dose, at the right time, and for the right duration that leads to the best clinical outcome for the treatment or prevention of infection while producing low risk for subsequent resistance. The website also allows access to patient education and publicity materials on AMR. Similar to COVID-19, AMR is a complex global priority and everyone has a role to play.

Author contributions

All authors contributed to the editorial, approved the final version for publication, and take responsibility for its accuracy and integrity.

Conflicts of interest

The authors have declared no conflict of interest.

Funding/support

This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

References

1. Tomczyk S, Taylor A, Brown A, et al. Impact of the COVID-19 pandemic on the surveillance, prevention and control of antimicrobial resistance: a global survey. J Antimicrob Chemother 2021;76:3045-58. Crossref

2. Tiri B, Sensi E, Marsiliani V, et al. Antimicrobial Stewardship Program, COVID-19, and infection control: spread of carbapenem-resistant Klebsiella pneumoniae colonization in ICU COVID-19 patients. What did not work? J Clin Med 2020;9:2744. Crossref

3. Farfour E, Lecuru M, Dortet L, et al. Carbapenemase-producing Enterobacterales outbreak: another dark side of COVID-19. Am J Infect Control 2020;48:1533-6. Crossref

4. Gomez-Simmonds A, Annavajhala MK, McConville TH, et al. Carbapenemase-producing Enterobacterales causing secondary infections during the COVID-19 crisis at a New York City hospital. J Antimicrob Chemother 2021;76:380-4. Crossref

5. Hospital Authority, Hong Kong SAR Government. MRSA bacteremia in HA Hospitals—2021-Q1 & 2021-Q2. Available from: https://www.ha.org.hk/haho/ho/cico/MRSA_Bacteremia_in_HA_hospitals_2021Q1_2021Q2.pdf. Accessed 12 Sep 2021.

6. Centre for Health Protection, Department of Health, Hong Kong SAR Government. Letter to doctor: alert on the rise in Candida auris colonisation in Hong Kong. Available from: https://www.chp.gov.hk/files/pdf/lti_c_auris_20201015_eng.pdf. Accessed 12 Sep 2021.

7. Bramer CA, Kimmins LM, Swanson R, et al. Decline in child vaccination coverage during the COVID-19 pandemic—Michigan Care Improvement Registry, May 2016-May 2020. MMWR Morb Mortal Wkly Rep 2020;69:630-1. Crossref

8. McDonald HI, Tessier E, White JM, et al. Early impact of the coronavirus disease (COVID-19) pandemic and physical distancing measures on routine childhood vaccinations in England, January to April 2020. Euro Surveill 2020;25:2000848. Crossref

9. Saxena S, Skirrow H, Bedford H. Routine vaccination during covid-19 pandemic response. BMJ 2020;369:m2392. Erratum in: BMJ 2020;369:m2435. Crossref

10. Getahun H, Smith I, Trivedi K, Paulin S, Balkhy HH. Tackling antimicrobial resistance in the COVID-19 pandemic. Bull World Health Organ 2020;98:442-442A. Crossref

11. Langford BJ, So M, Raybardhan S, et al. Antibiotic prescribing in patients with COVID-19: rapid review and meta-analysis. Clin Microbiol Infect 2021;27:520-31. Crossref

12. Rawson TM, Moore LS, Zhu N, et al. Bacterial and fungal coinfection in individuals with coronavirus: a rapid review to support COVID-19 antimicrobial prescribing. Clin Infect Dis 2020;71:2459-68.

13. Clancy CJ, Buehrle DJ, Nguyen MH. PRO: The COVID-19 pandemic will result in increased antimicrobial resistance rates. JAC Antimicrob Resist 2020;2:dlaa049. Crossref

14. Clancy CJ, Nguyen MH. Coronavirus disease 2019, superinfections, and antimicrobial development: what can we expect? Clin Infect Dis 2020;71:2736-43. Crossref

15. Knight GM, Glover RE, McQuaid CF, et al. Antimicrobial resistance and COVID-19: intersections and implications. Elife 2021;10:e64139. Crossref

16. Wan WY, Thoon KC, Loo LH, et al. Trends in respiratory virus infections during the COVID-19 pandemic in Singapore, 2020. JAMA Netw Open 2021;4:e2115973. Crossref

17. Park KY, Seo S, Han J, Park JY. Respiratory virus surveillance in Canada during the COVID-19 pandemic: an epidemiological analysis of the effectiveness of pandemic-related public health measures in reducing seasonal respiratory viruses test positivity. PLoS One 2021;16:e0253451. Crossref

18. Tanislav C, Kostev K. Fewer non-COVID-19 respiratory tract infections and gastrointestinal infections during the COVID-19 pandemic. J Med Virol 2021 Sep 7. Epub ahead of print. Crossref

Airborne transmission of SARS-CoV-2: ventilation improvement strategies in preparation for school re-opening

Hong Kong Med J 2021 Oct;27(5):328–9 | Epub 30 Aug 2021

https://doi.org/10.12809/hkmj215122

EDITORIAL

Airborne transmission of SARS-CoV-2: ventilation improvement strategies in preparation for school re-opening

David C Lung, MRCPCH (UK), FRCPath¹; Mike YW Kwan, MSc (Applied Epidemiology) (CUHK), FHKAM (Paediatrics)²; CB Chow, MD, FHKAM (Paediatrics)³

¹ Department of Pathology, Queen Elizabeth Hospital/Hong Kong Children’s Hospital, Hong Kong

² Paediatric Infectious Disease Unit, Department of Paediatrics and Adolescent Medicine, Princess Margaret Hospital, Hong Kong

³ Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong

Corresponding author: Dr Mike YW Kwan (mike_kwan@hotmail.com)

Full paper in PDF

Airborne transmission of COVID-19

Hong Kong has adopted a multifaceted approach to minimise the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the community since 2020. Measures currently implemented, which include mask wearing, social distancing, hand hygiene, and border controls, mainly address transmission by the droplet route. However, airborne transmission of SARS-CoV-2 in confined spaces has been largely overlooked.

Short-range airborne transmission is currently recognised as a predominant route for transmission of SARS-CoV-2.1 The US Centers for Disease Control and Prevention have also acknowledged the importance of transmission of coronavirus disease 2019 (COVID-19) through inhalation of viruses in the air at distances farther than six feet (2 m).2 Several important factors contribute to increased risk, including: enclosed space with inadequate ventilation; increased exhalation of respiratory fluid (eg, shouting, singing, exercise); and prolonged exposure (>15 minutes).

Enhancing ventilation in schools has been recognised as an important measure for re-opening of schools in multiple countries.3 In addition, a recent study in the US has demonstrated that mask wearing can markedly reduce COVID-19 outbreaks at schools.4

Will airborne transmission happen at schools?

After nearly 15 months of prolonged interruption of in-person learning since early 2020 in Hong Kong, the Education Bureau announced the resumption of face-to-face classes for all kindergartens and primary and secondary schools after the Easter holidays on 26 March 2021.5 However, other than the usual mandatory mask wearing and social distancing measures, there were no enhancements to infection control measures at schools. The compliance with mask wearing advice is often poor, especially in children; at least 13 outbreaks of upper respiratory tract infection, mostly caused by Rhinovirus, occurred between April and June 2021.6 This suggests that COVID-19 transmission chains could occur at schools despite the current measures, and that there is an urgent need to examine and enhance ventilation at schools.

Although regulations pertaining to schools in Hong Kong state that “all school premises shall be adequately ventilated and lighted”,7 8 there is no clear definition or quantification of how well the ventilation should be. In the US, fresh air supply in classrooms (for ages 5-8 and ≥9 years) and other education facilities should be at least 5 L/s per person, in accordance with the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) standard 62.1-2016.9 In Hong Kong, standards for new buildings recommend that fresh air provision in normally occupied spaces should exceed the minimum ASHRAE standard by at least 30%.10 Applied to the school setting, this would be equivalent to 6.5 L/s per person. The World Health Organization has recently stated that indoor ventilation should be 10 L/s per person (around 8-10.4 air changes per hour [ACH] depending on the ceiling height).11

Potential solution

A similar problem was encountered by the catering industry. Prior to March 2021, multiple clusters of COVID-19 cases occurred, resulting in restaurants being forced to suspend dine-in service or shorten business hours. To address the potential airborne transmission of COVID-19 in dine-in catering premises, the Hong Kong SAR Government decided to promote enhancement of ventilation. The current ventilation requirement for restaurants is 17 m³/h per person (around 3.8-4.9 ACH depending on ceiling height).12 Aiming to reduce the risk of airborne transmission of COVID-19 in mask-off indoor settings, the Government set a target of 6 ACH for these premises. A mandatory registration scheme was launched on 18 March 2021, whereby catering business operators were required to report whether their business premises attained ≥6 ACH. For premises unable to meet this requirement, air purifiers (with high-efficiency particulate arrestance filters or ultraviolet devices) had to be installed before 30 April 2021. The Government also formed a working group to promote compliance and ensure the smooth implementation of these requirements.13 As of July 2021, most dine-in restaurants met the requirements, and no large clusters of cases in dine-in restaurant settings have been reported since April 2021, despite many individuals confirmed to have COVID-19 visiting multiple restaurants during their infectious period.

Schools, just like restaurants, are subject to the same risk, because compliance with mask wearing advice, especially among children, cannot be guaranteed at all times. Therefore, all possible measures should be optimised before the resumption of schools in September 2021. Air conditioning alone does not ensure adequate ventilation, since most are recirculating air and there may be insufficient fresh air to dilute the indoor air and contaminated particles. It is understandable that changing the heating, ventilation, and air conditioning system at schools may not be always possible, especially within such a short period of time. However, using the experience of restaurants in Hong Kong as an example, alternative means to improve ventilation can be adopted, such as high-efficiency particulate arrestance filters and ultraviolet-C devices.3 14 15

With support from the Government and collaboration with architectural and engineering professionals, technology can be implemented to construct buildings with an infection resilient environment, using a combination of ventilation, air cleaning, and environmental monitoring. This approach could greatly reduce the chance of infection of the inhabitants and the environment.16

Although a fully vaccinated population is the best defence against COVID-19, this will be unachievable within the short period of time before the next school term begins. It is time for relevant stakeholders to review the latest scientific evidence and international recommendations and to revise current policies, prioritising ventilation in schools as a major infection control measure for the safe re-opening of schools. Schools should act promptly and modify ventilation settings to prepare for the new term and the expected winter surge in COVID-19 cases.

Author contributions

All authors contributed to the editorial, approved the final version for publication, and take responsibility for its accuracy and integrity.

Conflicts of interest

DC Lung is a member of the “Working Group on Implementing the Requirement on Air Change or Air Purifiers in Dine-in Restaurants under Cap. 599F”. All other authors have disclosed no conflicts of interest.

References

1. To KK, Sridhar S, Chiu KH, et al. Lessons learned 1 year after SARS-CoV-2 emergence leading to COVID-19 pandemic. Emerg Microbes Infect 2021;10:507-35. Crossref

2. Centers for Disease Control and Prevention. Scientific Brief: SARS-CoV-2 transmission. Available from: https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/sars-cov-2-transmission.html. Accessed 21 Jul 2021.

3. Centers for Disease Control and Prevention. Ventilation in schools and childcare programs: how to use CDC building recommendations in your setting. Available from: https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/ventilation.html. Accessed 23 Jul 2021.

4. Gettings J, Czarnik M, Morris E, et al. Mask use and ventilation improvements to reduce covid-19 incidence in elementary schools—Georgia, November 16-December 11, 2020. MMWR Morb Mortal Wkly Rep 2021;70:779-84. Crossref

5. Government announces class arrangements after Easter holidays: Press release. 26 Mar 2021. Education Bureau, Hong Kong SAR Government. Available from: https://www.info.gov.hk/gia/general/202103/26/P2021032600480.htm. Accessed 1 Aug 2021.

6. Centre for Health Protection, Department of Health, Hong Kong SAR Government. Media Room. Available from: https://www.chp.gov.hk/en/media/116/index.html. Accessed 21 Jul 2021.

7. Department of Justice, Hong Kong SAR Government. Education Regulations (Cap. 279, section 84). Available from: https://www.elegislation.gov.hk/hk/cap279A. Accessed 1 Aug 2021.

8. Education Bureau, Hong Kong SAR Government. Guidelines for registration of a new school. Available from: https://www.edb.gov.hk/attachment/en/sch-admin/sch-registration/about-sch-registration/2020%20Guidelines/1b_eguide-non-purpose-built_Dec%202020. pdf. Accessed 26 Aug 2021.

9. ANSI/ASHRAE Standard 62.1-2019. Ventilation for Acceptable Indoor Air Quality; 2019.

10. Hong Kong Green Building Council. BEAM Plus New Buildings Version 2.0 (2021 Edition). Available from: https://www.hkgbc.org.hk/eng/beam-plus/file/BEAMPlus_New_Buildings_v2_0.pdf. Accessed 1 Aug 2021.

11. World Health Organization. Roadmap to improve and ensure good indoor ventilation in the context of COVID-19. Available from: https://www.who.int/publications/i/item/9789240021280. Accessed 1 Aug 2021.

12. Department of Justice, Hong Kong SAR Government. Cap. 132 Public Health and Municipal Services Ordinance.

13. Food and Environmental Hygiene Department, Hong Kong SAR Government. Guide on Compliance with Requirement on Air Change / Air Purifiers in Seating Areas of Dine-in Catering Premises. Available from: https://www.fehd.gov.hk/english/licensing/guide_general_reference/guide_on_compliance_with_requirement_on_air_change.html. Accessed 1 Aug 2021.

14. Olsiewski PJ, Bruns R, Gronvall GK, et al. School Ventilation: A Vital Tool to Reduce COVID-19 Spread. The Johns Hopkins Center for Health Security; 2021.

15. ASHRAE. Guidance for the re-opening of schools. Available from: https://www.ashrae.org/file%20library/technical%20resources/covid-19/guidance-for-the-re-opening-of-schools.pdf. Accessed 1 Aug 2021.

16. Chartered Institution of Building Service Engineers. Infection resilient environments: buildings that keep us healthy and safe: initial report. Available from: https://www.raeng.org.uk/publications/reports/infection-resilient-environments. Accessed 1 Aug 2021.

mRNA COVID vaccine and myocarditis in adolescents

Hong Kong Med J 2021 Oct;27(5):326–7 | Epub 16 Aug 2021

https://doi.org/10.12809/hkmj215120

EDITORIAL

mRNA COVID vaccine and myocarditis in adolescents

Mike YW Kwan, MSc (Applied Epidemiology) (CUHK), FHKAM (Paediatrics)^{1 #}; Gilbert T Chua, MB, BS, FHKAM (Paediatrics)^{2 #}; CB Chow, MD, FHKAM (Paediatrics)^{1,2 #}; Sabrina SL Tsao, MB, BS(UK), FACC²; Kelvin KW To, MD, FRCPath³; KY Yuen, MD, FRCPath³; YL Lau, MD (Hon), FRCPCH²; Patrick Ip, MPH, FHKAM (Paediatrics)²

¹ Department of Paediatrics and Adolescent Medicine, Princess Margaret Hospital, Hong Kong

² Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong

³ Department of Microbiology, Carol Yu Centre for Infection, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong

^# These authors contributed equally to the work.

Corresponding authors: Prof KY Yuen (kyyuen@hku.hk), Prof YL Lau (lauylung@hku.hk), Dr Patrick Ip (patricip@hku.hk)

Full paper in PDF

In Hong Kong, the coronavirus disease 2019 (COVID-19) vaccination programme started on 26 February 2021. CoronaVac (an inactivated virus vaccine developed by Sinovac) and Comirnaty (BNT162b2 mRNA vaccine co-developed by BioNTech and Pfizer, and manufactured and distributed in China by Fosun Pharma) are the available formulations for public use. Comirnaty is safe and provides good antibody response, including for patients aged 12 to 15 years with clinical efficacy in protecting against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection of 100%.1 On 14 June 2021, the Food and Health Bureau, Hong Kong SAR Government lowered the age limit for receiving the Comirnaty vaccine to ≥12 years.2

Since April 2021, there have been reports that myocarditis and pericarditis occur more frequently in adolescents and young adults after mRNA COVID-19 vaccinations internationally.3 4 5 In Hong Kong, Comirnaty is the only mRNA technology platform COVID-19 vaccine available, but others are available elsewhere (eg, from Moderna).

Myocarditis and pericarditis have many virological and immunological causes, and are known to occur after vaccination; for example, the incidence of myocarditis after smallpox vaccination is around 12 to 16.1 per million vaccinated individuals.6 Myocarditis can also occur after SARS-CoV-2 infection alone or as a consequence of multisystem inflammatory syndrome in children after COVID-19 or paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2.3 7 8

Reported cases of myocarditis after mRNA COVID-19 vaccination are mostly male adolescents and young adults aged between 12 and 24 years who received the second dose of the mRNA vaccine.9 10 11 12 13 14 These heart complications are exceedingly rare, but are increasingly reported as hundreds of million doses of mRNA COVID-19 vaccines have been administered worldwide.4 5 9 10 The typical symptoms of myocarditis and pericarditis are chest pain, shortness of breath, and palpitations occurring within 1 week (usually 2-4 days) after vaccination. The condition is mild in most of the affected individuals, with only minimal treatment required and full recovery within a few days.

Although myocarditis and pericarditis have many virological and immunological causes, a causal link was suspected due to the immunological reaction to the mRNA COVID-19 vaccine. Individuals are recommended to rest and refrain from heavy strenuous activities for 1 week after mRNA COVID-19 vaccination, which will be helpful during the rare occurrence of myocarditis or pericarditis. Individuals experiencing chest pain, shortness of breath, or palpitations after receiving the mRNA vaccine are advised to seek immediate medical attention.

Myocarditis and pericarditis are diagnosed according to the Brighton Collaboration case definitions,11 which include clinical symptoms (cardiac or non-specific symptoms), elevated myocardial biomarkers (troponin T, troponin I, or CK myocardial band), electrocardiographic, echocardiogram or cardiac magnetic resonance abnormalities and with other alternative aetiologies for symptoms excluded.12 Supportive therapy is the mainstay of treatment with cardiac treatment and intervention if needed. Individuals with myocarditis/pericarditis are advised to rest until symptoms resolved.12

Based on the latest scientific data, the benefits of COVID-19 vaccination to the individual, family members, and society outweigh the reported known and potential risks of vaccination (including the possibility of myocarditis and pericarditis) in the current pandemic.13 Owing to the recent emergence of SARS-CoV-2 variants with increased transmissibility, higher rates of vaccination will be required to achieve sufficient herd immunity to prevent further community spread and allow society to return to normal.

On 30 June 2021, a joint consensus statement was issued by the Hong Kong Paediatric Society, The Hong Kong Society for Paediatric Immunology Allergy and Infectious Diseases, the Hong Kong College of Paediatric Nursing, and the Hong Kong Paediatric Nurses Association.14 The consensus statement appeals to children and adolescents (aged ≥12 years), parents, adult household members, and child-carers to receive the COVID-19 vaccine for self-protection, and for the physical health and long-term psychosocial development of all children in Hong Kong.

The Centers for Disease Control and Prevention and the Food and Health Bureau of Hong Kong SAR Government endorse the use of Comirnaty vaccine in adolescents mainly because the benefits of vaccination exceed the risks of SARS-CoV-2 infection.15 Although there is no alternative vaccine for this age-group currently available, data are being gathered on CoronaVac, which utilises the inactivated virus platform. If this proves safe and effective for children and adolescents, and is approved for use, CoronaVac may be an alternative for this age-group in Hong Kong.

Author contributions

All authors contributed to the concept or design of the study, acquisition of the data, analysis or interpretation of the data, drafting of the manuscript, and critical revision of the manuscript for important intellectual content. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

Conflicts of interest

All authors have disclosed no conflicts of interest.

References

1. Frenck RW, Jr, Klein NP, Kitchin N, et al. Safety, immunogenicity, and efficacy of the BNT162b2 Covid-19 vaccine in adolescents. N Engl J Med 2021;385:239-50. Crossref

2. Persons aged 12 to 15 can make reservations to receive BioNTech vaccine from tomorrow. Press release. Hong Kong SAR Government. 10 Jun 2021. Available from: https://www.info.gov.hk/gia/general/202106/10/P2021061000556.htm. Accessed 22 Jul 2021.

3. Siripanthong B, Nazarian S, Muser D, et al. Recognizing COVID-19–related myocarditis: The possible pathophysiology and proposed guideline for diagnosis and management. Heart Rhythm 2020;17:1463-71. Crossref

4. Marshall M, Ferguson ID, Lewis P, et al. Symptomatic acute myocarditis in seven adolescents following Pfizer-BioNTech COVID-19 vaccination. Pediatrics 2021 Jun 4. Epub ahead of print.

5. Starekova J, Bluemke DA, Bradham WS, et al. Evaluation for myocarditis in competitive student athletes recovering from coronavirus disease 2019 with cardiac magnetic resonance imaging. JAMA Cardiol 2021;6:945-50. Crossref

6. Keinath K, Church T, Kurth B, Hulten E. Myocarditis secondary to smallpox vaccination. BMJ Case Rep 2018;2018:bcr2017223523. Crossref

7. Feldstein LR, Tenforde MW, Friedman KG, et al. Characteristics and outcomes of US children and adolescents with multisystem inflammatory syndrome in children (MIS-C) compared with severe acute COVID-19. JAMA 2021;325:1074-87. Crossref

8. Whittaker E, Bamford A, Kenny J, et al. Clinical characteristics of 58 children with a pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2. JAMA 2020;324:259-69. Crossref

9. Gargano JW, Wallace M, Hadler SC, et al. Use of mRNA COVID-19 vaccine after reports of myocarditis among vaccine recipients: update from the Advisory Committee on Immunization Practices—United States, June 2021. MMWR Morb Mortal Wkly Rep 2021;70:977-82. Crossref

10. Abu Mouch S, Roguin A, Hellou E, et al. Myocarditis following COVID-19 mRNA vaccination. Vaccine 2021;39:3790-3. Crossref

11. Myocarditis/pericarditis case definition. 16 July 2021. Available from: https://brightoncollaboration.us/myocarditis-case-definition-update/. Accessed 22 Jul 2021.

12. Maron BJ, Udelson JE, Bonow RO, et al. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 3: Hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy and other cardiomyopathies, and myocarditis: a scientific statement from the American Heart Association and American College of Cardiology. Circulation 2015;132:e273-80. Crossref

13. Wallace M, Oliver S. COVID-19 mRNA vaccines in adolescents and young adults: benefit-risk discussion. ACIP Meeting. 23 June 2021. Available from: https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2021-06/05-COVID-Wallace-508.pdf. Accessed 23 Jul 2021.

14. Joint Statement of The Hong Kong Paediatric Society, The Hong Kong Society for Paediatric Immunology Allergy and Infectious Diseases, Hong Kong College of Paediatric Nursing and Hong Kong Paediatric Nurses Association on occurrence of myocarditis and pericarditis after mRNA COVID-19 vaccination (30 June 2021). Available from: http://www.medicine.org.hk/hkps/statements.php. Accessed 21 Jul 2021.

15. Authorisation of COVID-19 vaccines under the Prevention and Control of Disease (Use of Vaccines) Regulation (Cap.599K). Available from: https://www.fhb.gov.hk/en/our_work/health/rr3.html. Accessed 7 Jul 2021.

Well-being of Academy Fellows and specialty trainees: what is the problem?

Hong Kong Med J 2021 Oct;27(5):324–5 | Epub 5 Oct 2021

https://doi.org/10.12809/hkmj215123

EDITORIAL

Well-being of Academy Fellows and specialty trainees: what is the problem?

WC Leung, MD, FHKAM (Obstetrics and Gynaecology)¹; Rosalie Lo, PsyD, FHKPS²; Jeremy YC Teoh, FRCSEd (Urol), FHKAM (Surgery)³; Aaron Cheng, MSc, FRSPH⁴; Martin CS Wong, MD, MPH⁵; Gilberto KK Leung, MB, BS (Lon), FHKAM (Surgery)⁶; for the Task Force on Well-being of the Hong Kong Academy of Medicine

¹ Honorary Secretary, Hong Kong Academy of Medicine

² Honorary Advisor, Task Force on Well-being, Hong Kong Academy of Medicine

³ Chair, Young Fellows Chapter, Hong Kong Academy of Medicine

⁴ Chief Executive Officer, Hong Kong Academy of Medicine

⁵ Editor, Hong Kong Academy of Medicine

⁶ President, Hong Kong Academy of Medicine

Corresponding author: Dr WC Leung (leungwc@ha.org.hk)

Full paper in PDF

In this issue of Hong Kong Medical Journal, Kwan et al1 report the results of a survey of young doctors in Hong Kong (residents in training and specialists within 10 years of registration), showing high rates of burnout using the Copenhagen Burnout Inventory (73% reported personal burnout; 71% reported work-related burnout; and 55% reported client-related burnout) and depression using the Patient Health Questionnaire-9 (21%). Although the worldwide prevalence of burnout among medical professionals is increasing,2 the local situation in Hong Kong1 3 4 is alarming and the Hong Kong Academy of Medicine is committed to tackling this problem. A Well-being Charter has been promulgated in confirmation of the commitment of the Academy and its 15 constituent Colleges.

Hong Kong Academy of Medicine Well-being Charter

The Academy is mandated and empowered to promote and advance healthcare for Hong Kong citizens and foster a spirit of cooperation among medical and dental practitioners.

Quality patient care and doctors’ well-being go hand in hand, and the Academy is committed to assuming a leading role in cultivating and promoting the well-being of Fellows and trainees of its constituent Colleges as a shared responsibility among individual doctors, respective employing institutions, and policy makers.

The Academy shall:

acknowledge the importance of well-being of medical and dental practitioners in contributing towards high quality and effective patient care;

prioritise Fellows’ and trainees’ well-being as a prerequisite for fulfilling their professional duties towards patients and the community;

promote the well-being of its Fellows and trainees as a necessary condition for their flourishing and whole-person development;

foster a caring and supportive culture within the healthcare professions;

strengthen professionalism across disciplines and foster interprofessional collaboration from the institutional perspective;

encourage and facilitate healthcare practitioners to attend to their physical, mental, and social health and to respond to burnout, stress, or emotional challenges promptly and proactively;

engage a network and establish mechanisms to provide up-to-date knowledge, self-care tools, peer support and professional assistance for medical and dental practitioners;

organise mental health training and embed awareness of well-being in training and continuous professional development for medical and dental practitioners;

promulgate good practices among institutions to build supportive systems at the organisational level through the establishment of effective communication channels, deployment of appropriate resources, and quality improvement strategies; and

advocate policy changes and propose initiatives to the Government and other policy makers on professional well-being issues and the alignment of values and practices for the betterment and well-being of the profession.

The Academy has set up a Task Force on Well-being, involving an Honorary Advisor (R Lo), the Academy Officers and secretariat staff, as well as representatives from the Social Subcommittee, the Young Fellows Chapter and the 15 Colleges. In line with the Charter, the Task Force on Well-being is following an incremental ASAP (Awareness; Self-care; Ask for help; Promotion of well-being) approach to promote well-being and to manage stress and burnout.

Awareness

Helping you understand and recognise the causes, signs, and symptoms of burnout, stress, and other mental well-being issues

Self-care

Providing practical advice for enhancing well-being and managing stress

Ask for help

Facilitating a peer support network for you

Providing information on getting professional help

Promotion of well-being

Cultivating a culture of care and support among Fellows

Making recommendations for well-being improvement at the organisational level

Organising or promoting well-being programmes and activities

Further details will be available on a dedicated page on the Academy website (https://well-being.hkam.org.hk/") to facilitate this ASAP approach.

Author contributions

Conflicts of interest

All authors have disclosed no conflicts of interest.

References

1. Kwan KY, Chan LW, Cheng PW, Leung GK, Lau CS; for the Young Fellows Chapter of the Hong Kong Academy of Medicine. Burnout and well-being in young doctors in Hong Kong: a territory-wide cross-sectional survey. Hong Kong Med J 2021;27:Epub 5 Oct 2021. Crossref

2. The Lancet. Physician burnout: a global crisis. Lancet 2019;394:93. Crossref

3. Siu CF, Yuen SK, Cheung A. Burnout among public doctors in Hong Kong: cross-sectional survey. Hong Kong Med J 2012;18:186-92.

4. Ng AP, Chin WY, Wan EY, Chen J, Lau CS. Prevalence and severity of burnout in Hong Kong doctors up to 20 years post-graduation: a cross-sectional study. BMJ Open 2020;10:e040178. Crossref

Scientific research on COVID-19 conducted in Hong Kong in 2020

Hong Kong Med J 2021 Aug;27(4):244–6 | Epub 16 Aug 2021

https://doi.org/10.12809/hkmj215121

EDITORIAL

Scientific research on COVID-19 conducted in Hong Kong in 2020

Harry HX Wang, PhD^1,2; Ling Chen, MD³; Hanyue Ding, MPH²; Junjie Huang, MD²; Martin CS Wong, MD, MPH^2,4

¹ School of Public Health, Sun Yat-Sen University, Guangzhou, China

² JC School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong

³ Department of General Practice, Zhongnan Hospital of Wuhan University, Wuhan University, Wuhan, China

⁴ Editor-in-Chief, Hong Kong Medical Journal

Corresponding author: Prof Martin CS Wong (wong_martin@cuhk.edu.hk)

Full paper in PDF

Much research has been conducted into the coronavirus disease 2019 (COVID-19) pandemic internationally and regionally.1 2 3 4 Before the pandemic became widespread, researchers in Hong Kong have alerted health authorities to initiate emergency measures.5 6 The accumulated scientific evidence on COVID-19, including clinical characteristics, transmission, risk factors, diagnostic testing and screening, immune responses, treatment and pharmaceutical prophylaxis, and vaccines has greatly helped inform the infection prevention, early recognition, rapid identification, and disease control of COVID-19. Research attention paid to the routine clinical management of chronic conditions are of equal importance in the wider context of the pandemic, given the dynamic links between COVID-19 and underlying health conditions.7

In this issue of the Hong Kong Medical Journal, Yee et al8 reviewed institutional data from all urology centres in the government-run healthcare sector in Hong Kong during the COVID-19 pandemic, to assess the changes in urology practice and resident training. Compared with a control period, the authors report drastic reductions of 28.5% to 49.6% in the numbers of operating sessions, clinic attendances, cystoscopy sessions, prostate biopsies, and shockwave lithotripsy sessions across all the centres reviewed. The number of surgeries performed by residents was also reduced dramatically during the pandemic. Key aspects of urology practice have undergone substantial changes, which resulted as a response to challenges including shortages in frontline healthcare resources such as personal protective equipment, or rigid management of patient flow in hospitals. Similar challenges were identified in primary care during the early phase of the COVID-19 outbreak, as shown in a cross-sectional study conducted among family doctors affiliated with the Hong Kong College of Family Physicians.9 In other specialist services such as obstetrics and gynaecology practices, restrictive measures intended to limit the spread of COVID-19 resulted in an increased psychological burden on pregnant women who experienced cancellation of prenatal exercises, antenatal talks, hospital tours, and postnatal classes.10 Local researchers also advocated the importance of identifying and prioritising ‘time-sensitive’ patients for assisted reproductive technology.11 From a clinical perspective, the gap in clinical preparedness for COVID-19 necessitates further frontline research to develop risk triage protocols with optimal diagnostic performance and a widely accepted ‘gold-standard’ cut-off level to inform guideline recommendations and support clinical management decisions.12

Research conducted to explore the epidemiological and clinical manifestations of COVID-19 has substantially contributed to reducing community spread of severe acute respiratory syndrome coronavirus 2 in Hong Kong. A local investigation using data retrieved from the Clinical Management System of the Hospital Authority demonstrated the successful role of the first public COVID-19 temporary test centre in identifying infected individuals in a large-scale high-turnover setting.13 The volume and complexity of information documented in electronic health records, including clinical symptoms, imaging investigations, contact history, nucleic acid testing and vaccination records, has been growing exponentially to underpin digital solutions that support efforts to limit the spread of COVID-19. Big data analytics, artificial intelligence, and machine learning techniques have gained increasing prominence in generating reliable evidence that can help measure personalised clinical risk of severe illness and may potentially contribute to regional and global forecasts.14 Such progress will inevitably be accelerated by increasing uptake of electronic health records and mobile apps in mass data collection to support scientific research and public health measures. Nevertheless, due consideration in protecting personally identifiable information and ensuring data privacy in the context of COVID-19 is becoming a controversial but crucial concern over individual-level data exchange and sharing that deserves concomitant research.

Coping with COVID-19 requires simultaneous inputs from and participation of different medical disciplines. A local study conducted by radiologists assessed the use of computed tomography (CT) scanning of the thorax as a non-invasive imaging modality in exploring viral pneumonia patterns that were commonly encountered in affected patients.15 This provides an opportunity to gain temporal insights into the extent of lung involvement on CT images and determine the accuracy of CT severity scoring in clinical triage and the prediction of post-COVID outcomes. It is highly sensitive, accessible, portable, and easy to operate,16 playing an important role in identification of COVID-19.17 A group of specialists in ophthalmology, anaesthesiology, otorhinolaryngology, pathology and surgery, together with other relevant stakeholders, have formulated a risk stratification protocol with structured workflow for emergency surgeries.18 It bears a wider applicability to frontline healthcare staff with regard to timely assessment and decision making in the arrangement of emergency operations across different disciplines. There have also been suggestions to use chemoprophylaxis in adjunct with health behaviours and social distancing measures,19 which could achieve a synergistic effect.20 Meanwhile, social distancing remains an important strategy along with concurrent measures of infection control, even for individuals who have completed the vaccination course.21 A deeper understanding of such dynamic interaction warrants extensive research that bridges biostatistics and mathematical modelling. In managing COVID-19, there will continue to be a reliance on multidisciplinary clinical work to optimise patient care, following guidelines and recommendations that are both internationally recognised and locally adaptable, given the availability of resources and the changing severity of the pandemic. High-quality evidence generated from appropriately designed, well-planned, and ethically approved studies are continuously needed.

Behavioural research conducted to understand people’s behaviours and their linkage to knowledge, beliefs, and concerns is a key step to shape the messages on prevention measures delivered to target population and thus enhance risk communications and community engagement against the spread of COVID-19.22 An example was illustrated in an observational study published recently in the Hong Kong Medical Journal, which assessed the public views on face mask performance, reuse of surgical mask, and health information source among pedestrians in well-populated locations in Hong Kong.23 The authors brought behavioural insights into the issues of a high mask reuse rate during the initial spread of COVID-19 and the popularity of social media over government websites for information seeking. Research drawing on valuable perspectives from social science disciplines that twin with the biomedical understanding of the COVID-19 carries a great potential to inform the planning of effective behavioural interventions, as the containment of complex epidemics is as much behavioural as medical. A further step towards empirical evidence on behaviour changes and cultural factors can therefore support the pandemic response through promoting risk and science communication with the public to achieve optimal compliance to infection prevention and control measures.

The above examples, and others published in the Hong Kong Medical Journal (https://www. hkmj.org/COVID-19), are a small part of the huge volume of research activities led by local researchers in Hong Kong in response to the global pandemic of COVID-19. Despite the rapid progress made, many unknown but unique characteristics of severe acute respiratory syndrome coronavirus 2 are yet to be uncovered. Uncertainties remain on issues such as the natural history of COVID-19, the impact of viral changes over time, the long-term effectiveness and safety of vaccines, and the cost-effectiveness of different public health and social epidemic control measures. Ongoing medical and translational research is required that thinks globally and acts locally, to investigate the epidemiological, clinical, therapeutic, and service aspects of COVID-19 management, incorporating the latest advances in virology, immunology, molecular microbiology, and other disciplines of laboratory-based basic science.

Author contributions

Conflicts of interest

The authors have declared no conflict of interest.

References

1. Park JJ, Mogg R, Smith GE, et al. How COVID-19 has fundamentally changed clinical research in global health. Lancet Glob Health 2021;9:e711-20. Crossref

2. Wong MC, Ng RW, Chong KC, et al. Stringent containment measures without complete city lockdown to achieve low incidence and mortality across two waves of COVID-19 in Hong Kong. BMJ Glob Health 2020;5:e003573. Crossref

3. Huang J, Teoh JY, Wong SH, Wong MC. The potential impact of previous exposure to SARS or MERS on control of the COVID-19 pandemic. Eur J Epidemiol 2020;35:1099-103. Crossref

4. Wong SY, Tan DH, Zhang Y, et al. A tale of 3 Asian cities: how is primary care responding to COVID-19 in Hong Kong, Singapore, and Beijing. Ann Fam Med 2021;19:48-54. Crossref

5. Hon KL, Leung KK. Severe acute respiratory symptoms and suspected SARS again 2020. Hong Kong Med J 2020;26:78-9. Crossref

6. To KK, Yuen KY. Responding to COVID-19 in Hong Kong. Hong Kong Med J 2020;26:164-6. Crossref

7. Clark A, Jit M, Warren-Gash C, et al. Global, regional, and national estimates of the population at increased risk of severe COVID-19 due to underlying health conditions in 2020: a modelling study. Lancet Glob Health 2020;8:e1003-17. Crossref

8. Yee CH, Wong HF, Tam MH, et al. Effect of SARS and COVID-19 outbreaks on urology practice and training. Hong Kong Med J 2021 Feb 26. Epub ahead of print. Crossref

9. Yu EY, Leung WL, Wong SY, Liu KS, Wan EY; HKCFP Executive and Research Committee. How are family doctors serving the Hong Kong community during the COVID-19 outbreak? A survey of HKCFP members. Hong Kong Med J 2020;26:176-83. Crossref

10. Hui PW, Ma G, Seto MT, Cheung KW. Effect of COVID-19 on delivery plans and postnatal depression scores of pregnant women. Hong Kong Med J 2021;27:113-7. Crossref

11. Lee WY, Mok A, Chung JP. Potential effects of COVID-19 on reproductive systems and fertility; assisted reproductive technology guidelines and considerations: a review. Hong Kong Med J 2021;27:118-26. Crossref

12. Knight SR, Ho A, Pius R, et al. Risk stratification of patients admitted to hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: development and validation of the 4C Mortality Score. BMJ 2020;370:m3339. Crossref

13. Leung WL, Yu EL, Wong SC, et al. Findings from the first public COVID-19 temporary test centre in Hong Kong. Hong Kong Med J 2021;27:99-105. Crossref

14. Abd-Alrazaq A, Alajlani M, Alhuwail D, et al. Artificial intelligence in the fight against COVID-19: scoping review. J Med Internet Res 2020;22:e20756. Crossref

15. Li SK, Ng FH, Ma KF, Luk WH, Lee YC, Yung KS. Patterns of COVID-19 on computed tomography imaging. Hong Kong Med J 2020;26:289-93. Crossref

16. Chan JC, Kwok KY, Ma JK, Wong YC. Radiology and COVID-19. Hong Kong Med J 2020;26:286-8. Crossref

17. Wong SY, Kwok KO. Role of computed tomography imaging in identifying COVID-19 cases. Hong Kong Med J 2020;26:167-8. Crossref

18. Wong DH, Tang EW, Njo A, et al. Risk stratification protocol to reduce consumption of personal protective equipment for emergency surgeries during COVID-19 pandemic. Hong Kong Med J 2020;26:252-4. Crossref

19. Law SK, Leung AW, Xu C. Are face masks useful for limiting the spread of COVID-19? Hong Kong Med J 2020;26:267-8. Crossref

20. Hui KK. Povidone-iodine and carrageenan are candidates for SARS-CoV-2 infection control. Hong Kong Med J 2020;26:464. Crossref

21. Zee JS, Lai KT, Ho MK, et al. Serological response to mRNA and inactivated COVID-19 vaccine in healthcare workers in Hong Kong: preliminary results. Hong Kong Med J 2021 Jun 24. Epub ahead of print. Crossref

22. Jalloh MF, Nur AA, Nur SA, et al. Behaviour adoption approaches during public health emergencies: implications for the COVID-19 pandemic and beyond. BMJ Glob Health 2021;6:e004450. Crossref

23. Tam VC, Tam SY, Khaw ML, Law HK, Chan CP, Lee SW. Behavioural insights and attitudes on community masking during the initial spread of COVID-19 in Hong Kong. Hong Kong Med J 2021;27:106-12. Crossref

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