Importance of sustaining non-pharmaceutical interventions for COVID-19 until herd immunity

Hong Kong Med J 2021 Apr;27(2):95–6
https://doi.org/10.12809/hkmj215112
© Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
 
EDITORIAL
Importance of sustaining non-pharmaceutical interventions for COVID-19 until herd immunity
Junjie Huang, MD, MSc1; Wanghong Xu, PhD2,3; Zhijie Zheng, MD, PhD2,4; Martin CS Wong, MD, MPH5,6
1 Editor, Hong Kong Medical Journal
2 International Editorial Advisory Board, Hong Kong Medical Journal
3 School of Public Health, Fudan University, Shanghai, China
4 Department of Global Health, School of Public Health, Peking University, Beijing, China
5 Editor-in-Chief, Hong Kong Medical Journal
6 The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
 
Corresponding author: Prof Martin CS Wong (wong_martin@cuhk.edu.hk)
 
 Full paper in PDF
 
Currently, treatments for coronavirus disease 2019 (COVID-19) are still under development and are largely supportive. Effective supportive therapies include oxygen and ventilation for patients with COVID-19 who are severely or critically ill. Among the available pharmaceutical interventions for patients with COVID-19, dexamethasone has been shown to shorten the period on a ventilator and reduce mortality of patients with severe and critical COVID-19; however, others including hydroxychloroquine, remdesivir, lopinavir/ritonavir, and interferon regimens show very limited benefits.1 In this theme issue of Hong Kong Medical Journal, we focus on the latest research on COVID-19, in particular non-pharmaceutical interventions for COVID-19 such as face mask wearing, community testing, or contact tracking and tracing.
 
Reports on the use of face masks during the COVID-19 pandemic have found differences among various regions and countries. Discrepancies in face mask wearing between cultures have also caused stigmatisation on some occasions. In general, Asian populations are more accepting of face mask wearing.2 An example is Hong Kong, where the high rate of face mask wearing is often attributed to the territory’s previous experience with severe acute respiratory syndrome in 2003.3 Despite the dense population and proximity to the epidemic centre, the number of cases has remained modest in Hong Kong. In this issue of Hong Kong Medical Journal, Tam et al4 report the results of an interesting two-part study on the mask wearing behaviour of the Hong Kong population conducted in February 2020. Although the authors found that the mask wearing rate was as high as 94.8%, 13% of pedestrians observed wore their mask incorrectly, with 42.5% of them worn too low, exposing the nostrils or mouth and 35.5% of them worn ‘inside-out’ or ‘upside-down’. The authors also found that among respondents to a survey, 78.9% of them reused face masks, and 65.9% of them tended to obtain relevant information from social media rather than potentially more reliable sources such as government websites. The authors highlight the need for more intensive health education.
 
It is also important to provide early COVID-19 testing and regular surveillance, especially for high-risk populations. International guidelines recommend a series of healthcare policy strategies that could prepare a nation for early testing, surveillance, and reporting for infectious pandemics of global concern.5 In this issue of Hong Kong Medical Journal, Leung et al6 report the characteristics and outcomes of 1258 participants tested between March and April 2020 at a temporary test centre providing early testing for COVID-19 among high-risk residents with mild symptoms. The authors found that 86 individuals tested positive for COVID-19 (test positive rate of 6.8%). Among them, 40 (46.5%) were young individuals aged 15 to 24 years, and 81 (94.2%) had a recent history of overseas travel. The authors concluded that the temporary test centre had been successful in early detection of COVID-19 among high-risk residents. Healthcare providers need to promote early testing among high-risk subjects of COVID-19 to prevent widespread community outbreak. Since that study was conducted, the Hong Kong Government strengthened the local testing capabilities, by establishing community testing centres for providing self-paid testing services to citizens, as well as compulsory testing for certain persons subject to the epidemic development and the need for infection control in Hong Kong.
 
Tracing the close contacts of COVID-19 confirmed cases is also crucial to control the pandemic. Also in this issue, Mak et al7 report the formulation of a departmental COVID-19 contingency plan utilising a system for patient tracking and facilities management, which facilitated contact tracing. The doctors and allied health staff, who serve two hospitals, also prepared a split team arrangement whereby the possibility of cross-contamination or exposure was minimised by having staff work at one hospital only. The authors report that the system was successfully implemented twice, and could be quickly implemented again if the need arises. Recently, the Hong Kong Government developed and prompted the use of a mobile application (LeaveHomeSafe; https://www.leavehomesafe.gov.hk/en/) to facilitate contact tracing throughout the territory. Users of the application scan a QR code on entering a venue, and receive a notification if a later confirmed case of COVID-19 was present at the same venue at about the same time.
 
Non-pharmaceutical interventions for COVID-19 have also been reported elsewhere. For example, a study of 139 countries found that a reduced number of COVID-19 cases was associated with the stringency of different containment interventions, particularly closures of schools, closures of workplaces, and public information campaigns.8 Another study in Hong Kong found that border restrictions, quarantine and isolation, social distancing, and changes in population behaviour (hygiene and reduction of social contact) were significantly associated with control of COVID-19 pandemic.9 However, the implementation of non-pharmaceutical interventions for COVID-19 should be tailored according to the characteristics of pandemic and capacity for individual countries. As reported in this issue by Wang et al,10 the COVID-19 outbreak in Singapore had a dual nature, with infected cases spreading differently in foreign dormitory workers and the community at the same time. Different multipronged approaches were employed to tackle the spread of the virus in the two distinct groups. The vulnerability to COVID-19 and coping capacity are different among countries.11 Therefore, it is imperative to identify the capability framework that could mitigate the COVID-19 pandemic in the global health community.12 The World Health Organization has provided guidelines for building a capability framework to control the transmission of COVID-19.13 The framework consists of several essential domains, including overall coordination, community engagement and risk communication, measurements of public health, health services and case management, prevention and control of pandemic, as well as surveillance mechanism which are important for developing tailored non-pharmaceutical strategies for individual countries
 
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 disclosed no conflicts of interest.
 
References
1. Repurposed antiviral drugs for Covid-19—Interim WHO solidarity trial results. N Engl J Med 2021;384:497-511. Crossref
2. Wong SH, Teoh JY, Leung CH, et al. COVID-19 and public interest in face mask use. Am J Respir Crit Care Med 2020;202:453-5. 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. 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
5. Wong MC, Teoh JY, Huang J, Wong SH. Strengthening early testing and surveillance of COVID-19 to enhance identification of asymptomatic patients. J Infect 2020;81:e112-3. Crossref
6. 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
7. Mak ST, Fung KS, Li KK. Formulation of a departmental COVID-19 contingency plan for contact tracing and facilities management. Hong Kong Med J 2021;27:148-9. Crossref
8. Wong MC, Huang J, Teoh J, Wong SH. Evaluation on different non-pharmaceutical interventions during COVID-19 pandemic: An analysis of 139 countries. J Infect 2020;81:e70-1. Crossref
9. Cowling BJ, Ali ST, Ng TW, et al. Impact assessment of non-pharmaceutical interventions against coronavirus disease 2019 and influenza in Hong Kong: an observational study. Lancet Public Health 2020;5:e279-88. Crossref
10. Wang SS, Teo WZ, Hsu LY. Managing parallel COVID-19 epidemics in a single country. Hong Kong Med J 2021;27:145-7. Crossref
11. Wong MC, Teoh JY, Huang J, Wong SH. The potential impact of vulnerability and coping capacity on the pandemic control of COVID-19. J Infect 2020;81:816-46. Crossref
12. Wong MC, Huang J, Teoh JYC, Wong SH. Identifying a capability framework that could mitigate the coronavirus disease 2019 pandemic in a global health community. J Infect Dis 2020;222:880-1. Crossref
13. Wong MC, Huang J, Wong SH, Teoh JY. The potential effectiveness of the WHO International Health Regulations capacity requirements on control of the COVID-19 pandemic: a cross-sectional study of 114 countries. J R Soc Med 2021;114:121-31. Crossref

One year into COVID-19 pandemic, what do we have to look forward to?

Hong Kong Med J 2021 Apr;27(2):92–4
https://doi.org/10.12809/hkmj215113
© Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
 
EDITORIAL
One year into COVID-19 pandemic, what do we have to look forward to?
Ivan FN Hung, MD, FRCP (Lond, Edin)
Department of Medicine, Queen Mary Hospital, Hong Kong
 
Corresponding author: Prof Ivan FN Hung (ivanhung@hku.hk)
 
 Full paper in PDF
 
At the time of writing, Hong Kong has just experienced the end of a fourth wave of the coronavirus disease 2019 (COVID-19) pandemic after imposing stringent infection control measures.1 With the recent launch of the COVID-19 vaccination programme, we are finally seeing the light at the end of the tunnel. Nevertheless, it will take major efforts from the Hong Kong SAR Government and various parties to reach the herd immunity level in order to lift all infection control measures.
 
In 2003, there was a severe acute respiratory syndrome (SARS) outbreak in Hong Kong and mainland China. Between March and June 2003, 1750 patients were diagnosed to have SARS in Hong Kong, with 286 deaths.2 Despite identification of the SARS coronavirus as the cause of SARS3 and description of the disease pathogenesis model by a team from The University of Hong Kong,4 it was a painful experience with hefty loss of life. The major outbreak in the Amoy Garden estate due to contamination of the sewage in the U-traps which subsequently led to the airborne transmission of the SARS infection among the estate residents highlighted the overcrowded living conditions in Hong Kong.5 By June 2003, 386 healthcare workers were diagnosed to have SARS and eight of them—four doctors, one nurse, and three healthcare assistants–had succumbed.3 The initial shortage of masks and protective clothing for healthcare personnel and the lack of negative pressure isolation facilities resulted in significant nosocomial transmission of the virus. The majority of the diagnoses were made clinically and radiologically, and patients were cohort in large general medical ward. Treatment options were limited to steroids and ventilator support for those who developed respiratory failure. Many patients who were fortunate to recover from the infection suffered from lung fibrosis and the crippling long-term adverse effects of high-dose steroids.6 The SARS outbreak in 2003 highlighted the lack of communication among the health authorities in Hong Kong, mainland China, and the rest of the world. The establishment of the Centre for Health Protection in Hong Kong has helped overcome this shortcoming. The introduction of negative pressure isolation facilities in all major public hospitals hugely reduces the risk of nosocomial transmission and allows infected patients to safely cohort with minimal environmental contamination.7
 
Benefitting from experiences with SARS in 2003 and the swine flu pandemic in 2009, the Department of Health in Hong Kong implemented intense surveillance measures including tight border restrictions, social distancing, and mask wearing in the community.8 Vigorous contact tracing by the Centre of Health Protection enabled early quarantine and isolation. Deep throat saliva sampling for diagnostic screening reduced the human resources needed while maintaining high sensitivity.9 Such measures resulted in a relatively low number of confirmed infections despite the Hong Kong’s status as an international transport hub. The negative pressure isolation facilities in Hospital Authority hospitals allowed prompt isolation and treatment of patients with COVID-19 with moderate to severe disease and identified risk factors. The establishment of a community treatment facility at AsiaWorld-Expo allowed the isolation of large number of confirmed patients with mild disease, thus relieving the pressure on isolation bed facilities. The recent establishment of an infection control centre at North Lantau Hospital will further increase the number of negative pressure beds available.
 
Various measures have been shown to reduce the complication rate and shorten hospital stay for patients with COVID-19. Early treatment from symptom onset with the triple combination of interferon beta-1b, lopinavir-ritonavir, and ribavirin resulted in significantly quicker clinical improvement and shorter duration of viral shedding in patients hospitalised with COVID-19.10 The choice of antivirals was based on results from previous in vitro and in vivo animal studies on repurposing drugs for treatment of SARS 2003, Middle East respiratory syndrome, and SARS-CoV-2.11 12 Remdesivir, low-dose dexamethasone, convalescent plasma, and other immunomodulatory therapies have also been used to treat patients with hyperinflammatory response.13 14 15 16 17 Regular clinical assessment of patients with COVID-19, with regular reverse transcription polymerase chain reaction or biochemical testing, as well as radiological imaging, allows for close monitoring and better prediction of the patient’s progress and for guiding changes to the patient’s treatment. Adopting the immunoglobulin G seroconversion has also facilitated patient’s discharge when clinically deem fit.
 
Looking to the future, safe and effective COVID-19 vaccines are required. At the time of writing (24 March 2021), more than 80 different vaccines are undergoing human clinical trials, and 13 have gained full approval or have been authorised for emergency use.18 The Hong Kong SAR Government has implemented a territory-wide programme to offer COVID-19 vaccinations free of charge for all Hong Kong residents. To ensure the safety and efficacy of the vaccines, the Food and Health Bureau and the Department of Health have set up an Expert Advisory Panel to the Chief Executive. The joint Scientific Committees on Emerging and Zoonotic Diseases and Vaccine Preventable Diseases also regularly review the scientific evidence and relevant data on COVID-19 vaccines procured by the Government, and provide recommendations on the population groups to receive the COVID-19 vaccines. The Expert Committee on Clinical Events Assessment Following COVID-19 Immunisation has been established to provide independent assessment of potential causal links between adverse events following immunisation with any of the COVID-19 vaccines and to provide expert advice to the Government on safety-related matters. The Hong Kong SAR Government has currently procured three different platforms of COVID-19 vaccine from different vendors, including Comirnaty19 (mRNA vaccine), CoronaVac20 (inactivated whole cell vaccine), and Oxford/AstraZeneca21 (ChAdOx1 adenovirus vector vaccine), which will provide a wide choice of COVID-19 vaccines with good safety and efficacy profiles from which Hong Kong residents can choose. The Government is also planning procurement of a fourth COVID-19 vaccine. With a low COVID-19 seroprevalence among the population in Hong Kong, a high COVID-19 vaccination rate will be important to reach the satisfactory herd immunity level to allow relaxation of infection control measures.22 Important data including the long-term safety, clinical efficacy and effectiveness, and neutralising antibody protection against the new SARS-CoV-2 variants (B.1.1.7, B.1.351 and P.1) will be essential to plan for future vaccination programmes. The frequency of COVID-19 vaccination will also depend on the rate of emergence of these new variants.
 
The lessons learned from the SARS outbreak in 2003 have helped to successfully limit the spread of COVID-19 within Hong Kong. Nevertheless, the global effort against the COVID-19 pandemic will require cooperation among governments, international organisations, research institutes, scientists, clinicians, and most important of all, individual citizens.
 
Author contributions
The author contributed to the editorial, approved the final version for publication, and takes responsibility for its accuracy and integrity.
 
Disclosures
IFN Hung is a member of the Advisory Panel on COVID-19 Vaccines; and the co-convener of the Expert Committee on Clinical Events Assessment Following COVID-19 Immunisation for the Hong Kong SAR Government.
 
References
1. Coronavirus disease (COVID-19) in HK. Available from: https://chp-dashboard.geodata.gov.hk/covid-19/en.html. Accessed 24 Mar 2021.
2. Lee SH. The SARS epidemic in Hong Kong: what lessons have we learned? JR Soc Med 2003;96:374-8. Crossref
3. Peiris JS, Lai ST, Poon LL, et al. Coronavirus as a possible cause of severe acute respiratory syndrome. Lancet 2003;361:1319-25. Crossref
4. Peiris JS, Chu CM, Cheng VC, et al. Clinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study. Lancet 2003;361:1767-72. Crossref
5. Chu CM, Cheng VC, Hung IF, et al. Viral load distribution in SARS outbreak. Emerg Infect Dis 2005;11:1882-6. Crossref
6. Chan KS, Zheng JP, Mok YW, et al. SARS: prognosis, outcome and sequelae. Respirology 2003;8:S36-40. Crossref
7. Cheng VC, Wong SC, Chuang V, et al. Absence of nosocomial transmission of coronavirus disease 2019 (COVID-19) due to SARS-CoV-2 in the prepandemic phase in Hong Kong. Am J Infect Control 2020;48:890-6. Crossref
8. Cowling BJ, Ali ST, Ng TW, et al. Impact assessment of non-pharmaceutical interventions against coronavirus disease 2019 and influenza in Hong Kong: an observational study. Lancet Public Health 2020;5:e279-88. Crossref
9. To KK, Tsang OT, Leung WS, et al. Temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by SARS-CoV-2: an observational cohort study. Lancet Infect Dis 2020;20:565-74. Crossref
10. Hung IF, Lung KC, Tso EY, et al. Triple combination of interferon beta-1b, lopinavir-ritonavir, and ribavirin in the treatment of patients admitted to hospital with COVID-19: an open-label, randomised, phase 2 trial. Lancet 2020;395:1695-704. Crossref
11. Yuan S, Chan CC, Chik KK, et al. Broad-spectrum host-based antivirals targeting the interferon and lipogenesis pathways as potential treatment options for the pandemic coronavirus disease 2019 (COVID-19). Viruses 2020;12:628. Crossref
12. Chu CM, Cheng VC, Hung IF, et al. Role of lopinavir/ritonavir in the treatment of SARS: initial virological and clinical findings. Thorax 2004;59;252-6. Crossref
13. Beigel JH, Tomashek KM, Dodd LE, et al. Remdesivir for the treatment of COVID-19—final report. N Engl J Med 2020;383:1813-26. Crossref
14. RECOVERY Collaborative Group; Horby P, Lim WS, et al. Dexamethasone in hospitalized patients with Covid-19. N Engl J Med 2021;384:693-704. Crossref
15. Libster R, Pérez Marc G, Wappner D, et al. Early high-titer Crossref
16. Guaraldi G, Meschiari M, Cozzi-Lepri A, et al. Tocilizumab in patients with severe COVID-19: a retrospective cohort study. Lancet Rheumatol 2020;2:e474-84. Crossref
17. Kalil AC, Patterson TF, Mehta AK, et al. Baricitinib plus remdesivir for hospitalized adults with Covid-19. N Engl J Med 2021;384:795-807. Crossref
18. World Health Organization. The COVID-19 candidate vaccine landscape and tracker. https://www.who.int/publications/m/item/draft-landscape-of-covid-19-candidate-vaccines. Accessed 24 Mar 2021.
19. Dagan N, Barda N, Kepten E, et al. BNT162b2 mRNA Covid-19 vaccine in a nationwide mass vaccination setting. N Engl J Med 2021 Feb 14. Epub ahead of print. Crossref
20. Centre for Health Protection, Department of Health, Hong Kong SAR Government. Consensus interim recommendations on the use of CoronaVac in Hong Kong. https://www.chp.gov.hk/files/pdf/consensus_interim_recommendations_on_the_use_of_coronavac_in_hk_as_of_19_feb_2021.pdf. Accessed 24 Mar 2021.
21. Ramasamy MN, Minassian AM, Ewer KJ, et al. Safety and immunogenicity of ChAdOx1 nCoV-19 vaccine administered in a prime-boost regimen in young and old adults (COV002): a single-blind, randomised, controlled, phase 2/3 trial. Lancet 2021;396:1979-93. Crossref
22. To KK, Cheng VC, Cai JP, et al. Seroprevalence of SARS-CoV-2 in Hong Kong and in residents evacuated from Hubei province, China: a multicohort study. Lancet Microbe 2020;1:e111-8. Crossref

Vaccine hesitancy and COVID-19 vaccination in Hong Kong

Hong Kong Med J 2021 Apr;27(2):90–1
https://doi.org/10.12809/hkmj215115
© Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
 
EDITORIAL
Vaccine hesitancy and COVID-19 vaccination in Hong Kong
Paul KS Chan, MD, FRCPath1; Martin CS Wong, MD, MPH2; Eliza LY Wong, PhD, FHKCHSE2
1 Department of Microbiology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
2 The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
 
Corresponding author: Prof Paul KS Chan (paulkschan@cuhk.edu.hk)
 
 Full paper in PDF
 
Although the case fatality rate of coronavirus disease 2019 (COVID-19) is lower compared with deadly diseases such as smallpox and Ebola virus disease,1 the associated health and economic burden is alarming. Shifting healthcare technology and facilities to vaccine development and massive production became an international common goal. The arrival of COVID-19 vaccines was perceived as the end of health and economic suffering, and the rebirth of tourism and many other industries. Data from clinical trials of vaccines made by both the new and conventional platforms showed promising results, but the rolling out of vaccination is really challenging in some parts of the world.
 
In 2019 before the emergence of COVID-19, the World Health Organization (WHO) identified vaccine hesitancy as one of 10 major threats to global health.2 Hong Kong has a comprehensive childhood immunisation programme with an excellent uptake, and vaccine hesitancy is not often considered a problem locally. However, there are bits and pieces of information indicating that this may not be the case. In May 2009, when the WHO influenza alert level was raised to Phase 5 signifying that a pandemic was imminent, our survey indicated that only 47.9% of healthcare workers at public hospital intended to accept the flu H1N1 vaccine when available.3 The acceptance for H5N1 vaccine (another flu with pandemic threat) was even lower (34.8%). Such low intention to accept turned out to be true when the vaccination programme for pandemic flu H1N1 was initiated in Hong Kong.
 
In early 2005, Hong Kong faced a heavy flu season due to a new influenza strain (H3N2 Switzerland). The government decided to implement an extra dose of vaccine incorporated with the new strain before the summer peak. Healthcare workers again showed a low (31.8%) intention to accept.4
 
One may argue that, from these data on flu vaccines, we cannot infer a low acceptance of COVID-19 vaccines, because of the vast difference in health and economic impact. However, our repeated cross-sectional studies on the local working population show that acceptance for COVID-19 vaccines has declined from 44.2% during the first wave to 34.8% during the third wave of epidemic.5 Similarly low vaccine acceptance rates were revealed by another study which included more elderly participants, who are considered as the priority group for vaccination.6 That study also identified specific barriers for COVID-19 vaccines. For instance, 43.4% of participants expressed lack of confidence on vaccines produced by new platforms, 52.2% considered the track record of vaccine manufacturers important, and 62.5% regarded the country of vaccine production could affect their acceptance. These are beyond the key safety and efficacy issues that policy makers are focused on. It is notable that government recommendation was the strongest driver for vaccine acceptance, conferring a 10-times-higher odds of receiving vaccines among the study participants.
 
One may optimistically assume that these opinions on willingness or intention to accept will change when the public are offered vaccines. Unfortunately, despite a massive government-led vaccination campaign, the uptake after 1 month of availability was only about 6% of the total population in Hong Kong. Had we underestimated the results of pre-rolling out vaccine acceptance surveys? Had we not proactively addressed vaccine hesitancy? Although there are numerous public education and promotion materials on COVID-19 vaccines being disseminated to the public through various media, combating vaccine hesitancy is another ball game. If we do not develop an effective strategic plan to counter vaccine hesitancy, we will be unable to escape from the COVID-19 pandemic. Efforts to develop and produce vaccines for COVID-19 at unprecedented speed and scales may be in vain.
 
We believe vaccine hesitancy should be addressed by an organised and concerted effort contributed to by various stakeholders in the community. This effort should include more intensive education, provision of more evidencebased information, and public health interventions to enhance vaccine uptake.7 Exemption from travel bans, issuance of vaccination certificates, visitation rights at healthcare facilities, and incentives offered by the commercial sector to the employees are some potential strategies to increase the inoculation rate further, and this requires collaborative initiatives driven by healthcare policies.
 
Author contributions
All authors contributed to the concept and design. PKS Chan drafted the manuscript. MCS Wong and ELY Wong critically reviewed the manuscript. All authors contributed to the editorial, approved the final version for publication, and take responsibility for its accuracy and integrity.
 
Disclosures
PKS Chan is a member of the Expert Committee on Clinical Events Assessment Following COVID-19 Immunisation for the Hong Kong SAR Government. Other authors have disclosed no conflicts of interest.
 
References
1. Streeck H, Schulte B, Kümmerer BM, et al. Infection fatality rate of SARS-CoV2 in a super-spreading event in Germany. Nat Commun 2020;11:5829. Crossref
2. World Health Organization. Ten threats to global health in 2019. Available from: https://www.who.int/news-room/ spotlight/ten-threats-to-global-health-in-2019. Accessed 31 Mar 2021.
3. Chor JS, Ngai KL, Goggins WB, et al. Willingness of Hong Kong healthcare workers to accept pre-pandemic influenza vaccination at different WHO alert levels: two questionnaire surveys. BMJ 2009;339:b3391. Crossref
4. Wong MC, Nelson EA, Leung C, et al. Ad hoc influenza vaccination during years of significant antigenic drift in a tropical city with 2 seasonal peaks: a cross-sectional survey among health care practitioners. Medicine (Baltimore) 2016;95:e3359. Crossref
5. Wang K, Wong EL, Ho KF, et al. Change of willingness to accept COVID-19 vaccine and reasons of vaccine hesitancy of working people at different waves of local epidemic in Hong Kong, China: repeated cross-sectional surveys. Vaccines (Basel) 2021;9:62. Crossref
6. Wong MC, Wong EL, Huang J, et al. Acceptance of the COVID-19 vaccine based on the health belief model: A population-based survey in Hong Kong. Vaccine 2021;39:1148-56. Crossref
7. Dror AA, Eisenbach N, Taiber S, et al. Vaccine hesitancy: the next challenge in the fight against COVID-19. Eur J Epidemiol 2020;35:775-9. Crossref

Primary care doctors and the control of COVID-19

Hong Kong Med J 2021 Apr;27(2):86–7
https://doi.org/10.12809/hkmj215111
© Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
 
EDITORIAL
Primary care doctors and the control of COVID-19
Paul KM Poon *, FFPH, FHKAM (Community Medicine); Samuel YS Wong, FHKAM (Community Medicine), FHKAM (Family Medicine)
Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong
 
Corresponding author: Prof Paul KM Poon (kwokmingpoon@cuhk.edu.hk)
 
 Full paper in PDF
 
In January 2021, Hong Kong marked the grim anniversary of the first reported case of coronavirus disease 2019 (COVID-19) in the territory.1 At the time of writing, Hong Kong has recorded a total of over 10 000 cases and a death toll of nearly 200, against the backdrop of over 110 000 000 cases and 2 500 000 deaths worldwide.1 2 Non-pharmaceutical interventions are capable of containing the pandemic3 with isolation of cases and quarantine of contacts being the fundamental components. However, pre-symptomatic and asymptomatic transmission of COVID-19 can undermine the effectiveness of isolation and quarantine if these measures are not coupled with rapid contact tracing and testing.4
 
In a recent review paper, it was found that neither absence nor presence of signs or symptoms of COVID-19 could accurately rule in or rule out the disease but anosmia or ageusia may be regarded as a red flag, and fever or cough is a sensitive indicator for identifying patients who need testing.5 In this issue of the Hong Kong Medical Journal, Leung et al6 report the findings of a cross-sectional study conducted using data collected from the first public temporary test centre in Hong Kong at the AsiaWorld-Expo. The authors found that although symptoms such as cough, sore throat, and runny nose were reported in 86.0% of persons who tested positive for COVID-19, these symptoms were non-specific and were also reported in 96.3% of persons who tested negative. The authors recommend that gatekeeping healthcare providers stay vigilant in arranging early testing and remain aware of both clinical and epidemiological manifestations of COVID-19. Another study conducted in Australia compared the efficiency and sensitivity of different testing approaches in detecting community transmission chains. The authors found that testing of all patients with respiratory symptoms in the community, in combination with thorough contact tracing, was most effective.7
 
Primary care doctors are the gatekeepers of our healthcare system, and the COVID-19 pandemic has highlighted the important role of primary care from the perspectives of infectious disease control and surveillance in the community. In many countries, primary care doctors are an integral part of surveillance systems for infectious diseases such as influenza.8 Similarly, well-trained primary care doctors are indispensable in the early identification and isolation of COVID-19 cases, by contributing to a successful surveillance system which can also identify changes in transmission patterns and at-risk population subgroups,9 as well as evaluate the efficacy of public health control measures.10
 
The cost-effectiveness of different COVID-19 testing strategies depends on the transmission scenario in the community, in addition to the cost per test.11 Reimer et al12 recommend evidence-based prioritisation of testing, where testing capacity and resources are limited, in order to flatten epidemic curves, lower values of effective reproduction number, and ease the burden on hospitals and intensive care units. Primary care doctors, being the first access point of the healthcare system for most of the general public, are in a prime position to practice evidence-based testing of patients in the community based on clinical assessments.
 
Primary care doctors are vital to the unprecedented global vaccination campaign. Healthcare workers are at a higher risk of contracting COVID-19, and in a systematic review, Bandyopadhyay et al13 found that general practitioners were one of the specialties at the highest risk of death from COVID-19. Healthcare workers, including primary care doctors, are recommended as a priority group for COVID-19 vaccination worldwide, including in Hong Kong14 where the COVID-19 Vaccination Programme was launched in late February.
 
Primary care doctors are also at the forefront of communicating with the community. Wong et al15 found that COVID-19 vaccine acceptance in the Hong Kong community is not high (37.2%; 95% confidence interval=34.5%-39.9%) and perceived severity, benefits of the vaccine, cues to action, access barriers, and harms were among the factors associated with acceptance. Studies from the H1N1 pandemic found that primary care doctors were highly influential in H1N1 vaccine uptake16 and it is reasonable to expect that this will also be the case for COVID-19 vaccines. Primary care doctors will require regular updates and accurate information on the vaccines to communicate clearly with their patients and public health authorities.17
 
A shortage of primary care professionals is associated with a higher death rate due to COVID-19.18 Primary health care has a crucial role in infectious disease epidemic management and well-integrated primary care and public health systems are vital for a cohesive response.19
 
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
All authors have disclosed no conflicts of interest.
 
References
1. Centre for Health Protection, Hong Kong SAR Government. Latest situation of cases of COVID-19. Available from: https://www.chp.gov.hk/files/pdf/local_situation_covid19_en.pdf. Accessed 1 Mar 2021.
2. World Health Organization. WHO coronavirus (COVID-19) dashboard. Available from: https://covid19.who.int/?gclid=CjwKCAiAm-2BBhANEiwAe7eyFCS8TBp9v0BBj5Rl ysLobOmxwRL_p6NvscnuHkCOwNIaSIxv4DQRcRoCl8UQAvD_BwE. Accessed 1 Mar 2021.
3. Bo Y, Guo C, Lin C, et al. Effectiveness of non-pharmaceutical interventions on COVID-19 transmission in 190 countries from 23 January to 13 April 2020. Int J Infect Dis 2021;102:247-53. Crossref
4. Moghadas SM, Fitzpatrick MC, Sah P, et al. The implications of silent transmission for the control of COVID-19 outbreaks. Proc Natl Acad Sci U S A 2020;117:17513-5. Crossref
5. Struyf T, Deeks JJ, Dinnes J, et al. Signs and symptoms to determine if a patient presenting in primary care or hospital outpatient settings has COVID-19 disease. Cochrane Database Syst Rev 2020;7(7):CD013665. Crossref
6. 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
7. Lokuge, K, Banks E, Davis S, et al. Exit strategies: optimising feasible surveillance for detection, elimination and ongoing prevention of COVID-19 community transmission. BMC Med 2021;19:50. Crossref
8. European Centre for Disease Prevention and Control. Facts about influenza surveillance. Available from: https:// www.ecdc.europa.eu/en/seasonal-influenza/surveillance-and-disease-data/facts-sentinel-surveillance. Accessed 1 Mar 2021.
9. Paquette D, Bell C, Roy M, et al. Laboratory-confirmed COVID-19 in children and youth in Canada, January 15-April 27, 2020. Can Commun Dis Rep 2020;46:121-4. Crossref
10. Lai S, Ruktanonchai NW, Zhou L, et al. Effect of non-pharmaceutical interventions to contain COVID-19 in China. Nature 2020;585:410-3. Crossref
11. Du Z, Pandey A, Bai Y, et al. Comparative cost-effectiveness of SARS-CoV-2 testing strategies in the USA: a modelling study. Lancet Public Health 2021;6:e184-91. Crossref
12. Reimer JR, Ahmed SM, Brintz B, et al. Using a clinical prediction rule to prioritize diagnostic testing leads to reduced transmission and hospital burden: A modeling example of early SARS-CoV-2. Clin Infect Dis 2021 Feb 23. Epub ahead of print. Crossref
13. Bandyopadhyay S, Baticulon RE, Kadhum M, et al. Infection and mortality of healthcare workers worldwide from COVID-19: a systematic review. BMJ Glob Health 2020;5:e003097.
14. Centre for Health Protection, Hong Kong SAR Government. Consensus interim recommendations on the use of COVID-19 vaccines in Hong Kong (as of Jan 7, 2021). Available from: https://www.chp.gov.hk/files/pdf/consensus_interim_recommendations_on_the_use_of_covid19_vaccines_inhk.pdf. Accessed 1 Mar 2021.
15. Wong MC, Wong EL, Huang J, et al. Acceptance of the COVID-19 vaccine based on the health belief model: A population-based survey in Hong Kong. Vaccine 2021;39:1148-56. Crossref
16. Danchin M, Biezen R, Manski-Nankervis JA, Kaufman J, Leask J. Preparing the public for COVID-19 vaccines: How can general practitioners build vaccine confidence and optimise uptake for themselves and their patients? Aust J Gen Pract 2020;49:625-9. Crossref
17. Kunin M, Engelhard D, Thomas S, Ashworth M, Piterman L. General practitioners’ challenges during the 2009/A/H1N1 vaccination campaigns in Australia, Israel and England: a qualitative study. Aust Fam Physician 2013;42:811-5.
18. Baltrus PT, Douglas M, Li C, et al. Percentage of Black population and primary care shortage areas associated with higher COVID-19 case and death rates in Georgia counties. South Med J 2021;114:57-62. Crossref
19. Desborough J, Dykgraaf SH, Phillips C, et al. Lessons for the global primary care response to COVID-19: a rapid review of evidence from past epidemics. Fam Pract 2021 Feb 15. Epub ahead of print.

Can COVID-19 vaccines stop the pandemic?

Hong Kong Med J 2021 Apr;27(2):84–5
https://doi.org/10.12809/hkmj215116
© Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
 
EDITORIAL
Can COVID-19 vaccines stop the pandemic?
CS Lau, MD, FHKAM (Medicine)
Department of Medicine, The University of Hong Kong, Hong Kong
 
Corresponding author: Prof CS Lau (cslau@hku.hk)
 
 Full paper in PDF
 
Herd immunity is needed to combat the coronavirus disease 2019 (COVID-19) pandemic. To achieve this, a large proportion of the population must acquire immunisation against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), to protect non-vaccinated, immunologically naïve, and immunocompromised individuals.1 2 The cost of achieving herd immunity through natural infection by SARS-CoV-2 is unacceptable, as millions of people will succumb to the disease. Therefore, a mass vaccination campaign represents the best countermeasure to reduce the burden of COVID-19 and allow the world to return to normalcy.
 
Historically, the development of an effective vaccine took years. For example, even the measles vaccine which was found relatively rapidly took 10 years from the discovery of the pathogen to the development of the first vaccine.3 With COVID-19 vaccines, the world has witnessed extraordinary progress in just 1 year. As of 2 April 2021, the World Health Organization (WHO) has documented 269 COVID-19 vaccine candidates, with 85 of them in clinical evaluation.4 Among these candidates, nine different vaccines across three platforms—inactivated viral, adenoviral vector-based DNA, and nucleoside modified mRNA—have been approved for emergency use in 166 countries, areas, or territories. Typically, vulnerable populations, as well as frontline healthcare workers, are the highest priority for vaccination.5 Almost all COVID-19 candidate vaccines target the spike protein—comprising a membrane-distal S1 subunit and a membrane-proximal S2 subunit—that exists in the virus envelope as a homotrimer.
 
An ideal vaccine should be one that is safe; induces robust immunity and is efficacious in the prevention of infection, symptomatic disease, complications, and transmission; is of high quality; and is stable and easy to distribute, store, and handle for mass administration. The WHO has proposed a number of minimally acceptable attributes and criteria for considerations for the evaluation and prioritisation of COVID-19 vaccines for further development by developers, manufacturers, regulators and funding agencies. Although not all of the nine vaccines currently in use have been enlisted by WHO for emergency use,6 all have been evaluated by respective local ministries of health or equivalent agencies and deemed to be safe, efficacious, and of good quality.
 
In Hong Kong, an inactivated virus vaccine (CoronaVac; Sinovac, China) and an mRNA-based vaccine (Comirnaty; BioNTech, Germany) have been available since the end of February 2021. Although the arrival of COVID-19 vaccines in the city was keenly anticipated, the vaccination rate has been less than desirable thus far. In the first month of the city’s vaccination programme, 6.4% of the total population received a first dose of either vaccine.7
 
For any mass vaccination programmes to be successful, public confidence, which is often undermined by concerns over vaccine safety, is of utmost importance. Regardless of the speed of development of the various COVID-19 vaccines, some adverse events are to be expected. Fortunately, immune-mediated events, such as anaphylaxis, Bell’s palsy, Guillain–Barré syndrome, and transverse myelitis, have been rarely reported so far in association with COVID-19 vaccines. However, with millions, if not billions, of people in the world expected to be exposed to new COVID-19 vaccines in the near future, different strategies must be deployed to systematically monitor the safety profiles of these vaccines. These strategies include detailed analysis of the safety data of phase I, II, and III clinical trials; regular mandatory post-marketing survey studies to be conducted by the developers; and voluntary reporting by vaccinated subjects and their clinicians. On a public health level, national reporting systems such as the Medicines and Healthcare products Regulatory Agency in the UK and the Vaccine Adverse Event Reporting System in the US are designed to detect early safety problems for licensed vaccines.8 Locally, the Department of Health operates a drug safety alert system to capture adverse events following immunisation from the city’s medical practitioners, as well as the Hospital Authority and other health agencies. In addition, the Government has commissioned the University of Hong Kong to conduct a prospective surveillance study on adverse events of special interest following vaccination. These data should be regularly reviewed scientifically, and revealed to the public in an open and timely manner to reassure the public of the robust oversight.
 
On vaccine efficacy, the WHO suggested that a minimum criterion for any acceptable COVID-19 candidate vaccines should be a clear demonstration of at least 50% point estimate “against disease, severe disease, and/or shedding/transmission endpoints” on a population basis in placebo-controlled efficacy trials.9 One common misconception that many readers have when interpreting clinical trial reports concerning COVID-19 vaccine efficacies is that these figures could be compared across studies. This is incorrect as there have been no head-to-head studies comparing two or more COVID-19 vaccines. In addition, the various phase III studies reported so far have been conducted in different countries where the COVID-19 situation may vary significantly, involved different study subject groups and employed variable efficacy endpoints, including different clinical and molecular diagnostic criteria for COVID-19 and its severity. Finally, there are no standardised assays for the measurement of SARS-CoV-2 neutralising antibodies which are a key determinant of a vaccine’s protection rate.
 
Observations made in countries with aggressive vaccination policies suggest that mass vaccination is probably effective in controlling COVID-19. Since December 2020, countries such as Israel, the UK, and the US have launched progressive campaigns to vaccinate most of their populations. By the beginning of April 2021, over 60%, 46%, and 31% of the populations of Israel, the UK, and the US, respectively, have received at least one dose of COVID-19 vaccine. Israel has been particularly aggressive with over 55% of the population fully vaccinated.5 Encouragingly, all three countries have seen a significant drop in the bi-weekly confirmed COVID-19 cases per million people since mid-January (Israel: 94%; UK: 92%; US: 73%) and bi-weekly confirmed COVID-19 deaths per million people since the end of January (Israel: 88%; UK: 95%; US: 72%).10 It should be noted that these countries have continued strict non-pharmaceutical interventions including various social distancing policies. Together with a mass vaccination programme, it seems possible to curb the advancement of COVID-19.
 
So, can vaccination stop the COVID-19 pandemic? This is possible but it will likely take a long time. Worldwide, unfortunately, only 4.7% of the population have been administered at least one dose of any COVID-19 vaccines so far.5 Although the industry has ramped up its efforts in research and development of COVID-19 vaccines, there are too few manufacturers. The increasing production in countries such as Brazil, China, India, and Indonesia may fill the gap but the solution to supply shortage is not yet clear. Coupled with the high cost of vaccines, it is difficult to see how demand could be satisfied or access provided to developing countries, in particular, in the near future. Hong Kong is blessed to have had 15 million doses of vaccines procured for the people so far. It is upon us to get ourselves vaccinated instead of depending on herd immunity. Concerns for vaccine safety and efficacy are understandable but that these are closely monitored locally and internationally, and every effort is being made to reduce vaccine-associated reactions to a minimum. Novel vaccines such as the adenoviral vector and mRNA-based vaccines have their overall effectiveness and safety continuously and carefully monitored.
 
It is not yet known what proportion of the population we need to vaccinate to achieve herd immunity against COVID-19. A threshold value of ~67% will be needed assuming that the basic reproductive number (R0) of the virus is 3.1 2 Unless, and until, we reach this threshold, we will not be certain of protection against the epidemic locally and around the world. This also needs to be achieved as quickly as possible with the emergence of SARS-CoV-2 variants which may be resistant to existing vaccines rendering them less efficacious.11
 
“With a fast moving pandemic, no one is safe, unless everyone is safe”.11
 
Author contributions
The author contributed to the editorial, approved the final version for publication, and takes responsibility for its accuracy and integrity.
 
Disclosures
CS Lau is the convener of the Advisory Panel on COVID-19 Vaccines for the Hong Kong SAR Government.
 
References
1. Mallory ML, Lindesmith LC, Baric RS. Vaccination-induced herd immunity: successes and challenges. J Allergy Clin Immunol 2018;142:64-6. Crossref
2. Randolph HE, Barreiro LB. Herd immunity: understanding COVID-19. Immunity 2020;52:731-41. Crossref
3. Plotkin SA. Vaccines: past, present and future. Nat Med 2005;11(4 Suppl):S5-11. Crossref
4. World Health Organization. Draft landscape and tracker of COVID-19 candidate vaccines. Available from: https://www.who.int/publications/m/item/draft-landscape-of-covid-19-candidate-vaccines. Accessed 5 Apr 2021.
5. Our World in Data. Coronavirus (COVID-19) vaccinations. Available from: https://ourworldindata.org/covid-vaccinations#vaccine-development-vaccines-approved-for-use-and-in-clinical-trials. Accessed 5 Apr 2021.
6. World Health Organization. Status of COVID-19 vaccines within WHO EUL/PQ evaluation process. Available from: ttps://extranet.who.int/pqweb/sites/default/files/documents/Status_COVID_VAX_01April2021.pdf.Accessed 5 Apr 2021.
7. Department of Health, Hong Kong SAR Government. COVID-19 Vaccination Programme: vaccination dashboard. Available from: https://www.covidvaccine.gov.hk/en/dashboard. Accessed 5 Apr 2021.
8. Castells MC, Phillips EJ. Maintaining safety with SARS-CoV-2 vaccines. N Engl J Med 2021;384:643-9. Crossref
9. World Health Organization. WHO target product profiles for COVID-19 vaccines. Available from: https://www.who. int/publications/m/item/who-target-product-profiles-for-covid-19-vaccines. Accessed 5 Apr 2021.
10. Our World in Data. Coronavirus pandemic (COVID-19). Available from: https://ourworldindata.org/coronavirus#coronavirus-country-profiles. Accessed 5 Apr 2021.
11. World Health Organization. COVAX. Working for global equitable access to COVID-19 vaccines. Available from: https://www.who.int/initiatives/act-accelerator/covax. Accessed 5 Apr 2021.

Response to the World Health Organization’s working document for the development of a global action plan to reduce alcohol-related harm: Position Statement of the Hong Kong Alliance for Advocacy Against Alcohol

Hong Kong Med J 2021 Feb;27(1):4–6  |  Epub 1 Feb 2021
https://doi.org/10.12809/hkmj215109
© Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
 
EDITORIAL
Response to the World Health Organization’s working document for the development of a global action plan to reduce alcohol-related harm: Position Statement of the Hong Kong Alliance for Advocacy Against Alcohol
Regina CT Ching, FHKAM (Community Medicine), MScPHM LSHTM (Lond); SP Mak, FHKAM (Community Medicine), FFPH; Martin CS Wong, MD, MPH1; Ming Lam, FHKAM (Psychiatry), MRCPsych; WM Chan, FHKAM (Community Medicine); Margaret FY Wong, DSW, MSocSci; Raymond Liang, MD, FRCP; TH Lam, MD, Hon FHKCCM2; for the Hong Kong Alliance for Advocacy Against Alcohol†
1 JC School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
2 Emeritus Professor, Hon Clinical Professor, School of Public Health, The University of Hong Kong, Hong Kong
†The Hong Kong Alliance for Advocacy Against Alcohol was established under the Hong Kong College of Community Medicine
 
Corresponding author: Dr Regina CT Ching (reginachingching@hotmail.com)
 
 Full paper in PDF
 
 
Background
Globally, alcohol use accounts for approximately 3 million deaths every year and the overall burden of disease and injuries remains high. Health consequences aside, alcohol use incurs significant social and economic losses relating to the justice sector, workforce productivity and unemployment, and pain and suffering of the drinker and other people.
 
In May 2010, the 63rd World Health Assembly endorsed the Global Strategy to Reduce the Harmful Use of Alcohol (Resolution WHA63.13). The Global Strategy gives a strong mandate to the World Health Organization (WHO) to strengthen action at national, regional and global levels and envisions improved health and social outcomes for individuals, families and communities, with considerably reduced morbidity and mortality due to alcohol use and its ensuing social consequences.
 
Despite adoption of the political declarations emanating from high-level meetings of the United Nations General Assembly on noncommunicable diseases in 2011; inclusion of alcohol for prevention and treatment of substance abuse in target 3.5 of the Sustainable Development Goals 2030; introduction of the WHO Global Action Plan for the Prevention and Control of NCDs 2013-2020 (subsequently extended to 2030 to align with the Sustainable Development Goals 2030) and updated evidence on a prioritised set of cost-effective or ‘best-buy’ policy measures known as the SAFER initiative, implementation of the Global Strategy worldwide has been uneven, and resources and capacities falling behind the magnitude of the problems. The Global Strategy has not resulted in considerable reductions in alcohol-related morbidity and mortality and the ensuing social consequences. The levels of alcohol consumption and alcohol-attributable harm continue to be unacceptably high.
 
On this basis, the WHO Executive Board in 2020 requested the WHO Director-General, inter alia, “to develop an action plan (2022-2030) to effectively implement the Global Strategy to reduce the harmful use of alcohol(https://cms.who.int/teams/mental-health-and-substance-use/alcohol-drugs-and-addictive-behaviours/alcohol/global-alcohol-strategy) as a public health priority, in consultation with relevant stakeholders, for consideration by the 75th World Health Assembly in 2022” The WHO Secretariat conducted a web-based consultation (https://www.who.int/news-room/articles-detail/global-action-plan-to-reduce-the-harmful-use-of-alcohol) from 16 November to 13 December 2020 on a working document for development of the action plan open to Member States, United Nations organisations and other international organisations, and non-State actors. All relevant feedback received will be published on the WHO website.
 
The Hong Kong Alliance for Advocacy Against Alcohol (HKAAAA) was established under the Hong Kong College of Community Medicine in 2015 and comprises individuals from the academic, medical and health, social, and education sectors, to advocate for effective evidence-based policies and actions to reduce alcohol-related harms in Hong Kong. The HKAAAA submitted the following Position Statement in response to the WHO consultation.
 
Position statement
The HKAAAA has read the working document for development of an action plan to strengthen implementation of the Global Strategy to reduce the harmful use of alcohol and has the following comments and suggestions:
 
1. The HKAAAA welcomes WHO’ move to develop an action plan to strengthen the Global Strategy to reduce harms related to alcohol use.
 
2. The HKAAAA understands the Global Strategy was set out to support and complement public health policies in Member States at national and local levels to achieve considerable reduced morbidity and mortality as well as improved health and social outcomes for individuals, families and communities, but notes that globally, the levels of alcohol consumption and alcohol-attributable harm continue to be unacceptably high.
 
3. The HKAAAA agrees that considerable challenges for the development and implementation of effective alcohol policies relate to the complexity of the problem, differences in cultural norms and contexts, intersectoral nature of cost-effective solutions and limited political will and government leadership, but considers the influence of powerful commercial interests especially from transnational alcohol companies to be exerting the greatest negative influence of all.
 
4. Economic operators with core roles as developers, producers, distributors, marketers and sellers of alcoholic beverages, have primary commercial responsibilities to their shareholders and must therefore rely on substantial sales either by encouraging heavy drinking or engaging more people to drink, many of whom belong to vulnerable and marginalised groups such as young people, less educated, unemployed, people who are stressed out or suffer from mental ill health, and so on. As such, economic operators have mission and vision that fundamentally conflict with those of the Global Strategy. The HKAAAA is of the view that these economic operators should have no role in developing or influencing the formulation of this action plan, or for that matter, development, implementation and evaluation of alcohol policy at global, national and local levels. These economic operators are not, and should not be construed as, equivalent to other ‘non-state actors’ in the context of the action plan. Neither is there a need to ‘invite’ them to self-regulate or act contrary to their profit-driven goals and objectives.
 
5. As WHO rightly points out, alcohol remains the only psychoactive and dependence-producing substance that exerts a significant impact on global population health that is not controlled at the international level by legally binding regulatory instruments. The HKAAAA urges WHO to set out in the action plan immediate, concrete steps and timeline to formulate a global normative law on alcohol at the intergovernmental level, modelled on the WHO Framework Convention on Tobacco Control, to regulate the distribution, sale and marketing of alcohol within the context of international, regional and bilateral trade negotiations, as well as to protect the development of alcohol policies from interference by transnational corporations and commercial interests.
 
6. The launching of WHO’ SAFER initiative comprising the most cost-effective actions or “best buys” namely, increasing taxes on alcoholic beverages, enacting and enforcing bans or comprehensive restrictions on exposure to alcohol advertising across multiple types of media, and enacting and enforcing restrictions on the physical availability of retailed alcohol, is applauded. However, the HKAAAA considers that political will, government leadership and intergovernmental commitment aside, interference from transnational commercial interests needs to be kept at bay, through global regulatory efforts initiated, coordinated and assured by WHO.
 
7. The HKAAAA recognises that in today’s world that favours free trade, a legally binding regulatory framework provides the bottom line for economic operators in alcohol production and trade as well as operators in other relevant sectors to eliminate marketing and advertising of alcoholic products to minors and other vulnerable groups, prevent heavy drinking, eliminate false health claims, and ensure availability of easily understood consumer information on the labels of alcoholic beverages (including composition, age limits, health warning and contra-indications for alcohol use).
 
8. The HKAAAA further points out the term “harmful use of alcohol” used repeatedly throughout the consultation document implies there are beneficial uses of alcohol, which practically do not exist. This misperception is, to a large extent, influenced and reinforced by commercial messaging and poorly regulated alcohol marketing which deprioritise efforts to counter the harms of alcohol use. This has resulted in low awareness and poor acceptance of the overall negative impact of alcohol consumption on a population’ health, safety and wellness among decision-makers, general public and even healthcare providers. Moreover, it confuses the public and hinders education efforts. The HKAAAA calls on WHO to stop using the term “harmful use of alcohol” and adopt “alcohol-related harm” in its place.
 
9. To reduce interference from commercial interests, the HKAAAA calls on all types of dialogue between economic operators with a stake in alcohol and public institutions (WHO secretariat, Member States, public funded bodies and research institutions, and civil societies) be halted and reduced to a minimum, and if they must go ahead, be documented with respect to the purpose, parties involved, mode, content, expenses and outcome for the sake of transparency and public accountability.
 
10. To help expose and recognise pervasive commercial interference in public policy making and anti-alcohol efforts including ‘corporate social responsibility’ initiatives at transnational, national and local levels in order that public and non-profit organisations may steer clear of commercial interests of economic operators, the HKAAAA requests the WHO to take the lead in a global stock taking exercise that will also serve as baseline for future regulatory work.
 
11. The HKAAAA recommends the setting of SMART (specific, measurable, achievable, relevant and time-bound) objectives relating to all recommended or proposed action within the action plan.
 
12. The HKAAAA suggests biennial publishing of national status reports on alcohol and health, and biennial reporting by action parties to help focus global, national and local anti-alcohol efforts, and strengthen monitoring and public accountability.
 
13. To counteract alcohol marketing in the form of recurrent wine and dine promotions, sports sponsorships and the like, which are often held for days and weeks in a row, HKAAAA supports the WHO to initiate global efforts to organise annual national alcohol awareness drives. HKAAAA, however, considers these drives should last for at least 5 to 7 days, and incorporate health behaviour changes on top of raising awareness. Examples may include public and non-public institutions refraining from serving alcohol at business and private occasions, making pledges to reject alcohol sponsorships, and strengthening support for drinkers who anticipate quitting.
 
Concluding remarks
Alcohol is a toxic substance with dependence producing properties, contributing to 3 million deaths and 5.1% of disease burden every year globally. It is time the health and social damage of drinking be fully recognised and effectively dealt with at global, national and health systems levels, modelled on the WHO Framework Convention on Tobacco Control.
 
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
All authors have disclosed no conflict of interest.
 
Declaration
This Position Statement was submitted in response to the World Health Organization (WHO) online consultation on a working document on developing a global action plan to reduce the harmful use of alcohol (https://www.who.int/news-room/articles-detail/global-action-plan-to-reduce-the-harmful-use-of-alcohol). Relevant submissions will be published on the WHO website in mid-February 2021.
 
Funding/support
This editorial received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
 

Medication adherence among the older adults: challenges and recommendations

Hong Kong Med J 2020 Dec;26(6):476–8
https://doi.org/10.12809/hkmj205108
Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
 
EDITORIAL
Medication adherence among the older adults: challenges and recommendations
Junjie Huang, MD, MSc1; Harry HX Wang, PhD1; Zhijie Zheng, MD, PhD2,3; Martin CS Wong, MD, MPH4,5
1 Editor, Hong Kong Medical Journal
2 International Editorial Advisory Board, Hong Kong Medical Journal
3 Department of Global Health, School of Public Health, Peking University, Beijing, China
4 Editor-in-Chief, Hong Kong Medical Journal
5 The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
 
Corresponding author: Dr Junjie Huang (junjie_huang@link.cuhk.edu.hk)
 
 Full paper in PDF
 
Growing burden of the ageing populations
There is an increasing burden of the elderly population in many countries, with an estimated total of 2.37 billion population aged >65 years globally by 2100.1 In Hong Kong, the number of people aged >65 years is expected to increase from 1.19 million to 2.51 million from 2016 to 2046, then comprising more than one third of the total population.2 The substantial increase in the elderly population will inevitably contribute to the burden of public health and healthcare service, with chronic diseases and multimorbidity being the critical challenges.
 
Chronic diseases associated with ageing populations
The leading causes of morbidity and mortality in the elderly population are chronic diseases. More than 70% of the population aged ≥60 years have one or more chronic diseases in Hong Kong, with hypertension, arthritis, and eye diseases being the most frequent morbidities.3 The major causes of mortality among the elderly population include cancer, heart diseases, cerebrovascular disease, and pneumonia. Moreover, dementia is also very common: local data indicate that almost 1 in 10 community-dwelling elderly individuals have mild cognitive impairment (8.5%) or mild dementia (8.9%) in Hong Kong.4
 
Multimorbidity associated with ageing populations
The proportion of patients presenting with multimorbidity, defined as the presence of two or more chronic conditions, has been rising in the recent decade.5 A cross-sectional community-based study in Hong Kong found that 42% of individuals aged ≥60 years had multimorbidity.6 Multimorbidity poses a heavy clinical and public health burden by increasing healthcare cost and utilisation. Considering most healthcare systems globally are developed to treat single disease, multimorbidity leads to major challenges for healthcare providers.
 
Importance of medication adherence among elderly individuals
Elderly patients with chronic diseases and multimorbidity have a higher risk of polypharmacy and suboptimal medication adherence. In general, adherence rates are lower among elderly individuals with chronic conditions than those with acute diseases, and the rates may differ among disease categories. According to a survey conducted by the World Health Organization, approximately 40% of older patients with chronic conditions do not follow their planned prescriptions.7 Polypharmacy, which is often defined as the concurrent prescription of five or more drugs, is commonly seen among elderly patients with multimorbidity. Approximately two thirds of community-dwelling older patients have polypharmacy.8 A substantial proportion of patients with polypharmacy take 10 or more different types of drugs (“hyperpolypharmacy”). Polypharmacy is more closely related to suboptimal medication adherence than other reasons, such as adverse drug reactions (ADRs), inappropriate medication, or pharmacological interactions.9 As a result, the high prevalence of polypharmacy and hyperpolypharmacy subsequently increased the risk of suboptimal medication adherence among elderly individuals. This situation could be even worse in elderly patients with decreased functionality, in particular among those with cognitive impairment and dementia.10 11 12 13
 
In this issue of the Hong Kong Medical Journal, Wong14 reviewed the medication-related problems among the older population, including medication non-adherence. The results show that the elderly patients are at higher risk of medication-related issues due to the physiological changes with ageing and multiple medications used for multimorbidity. Polypharmacy is associated with inappropriate drug use which may in turn leads to multiple geriatric syndromes and hospitalisation. Also, either intentional or unintentional suboptimal medication compliance can lead to treatment failure. The article points out that a substantial proportion of ADRs are preventable, and that effective strategies are available to tackle these issues to achieve good medication adherence and drug safety. The strategies included deprescribing with the withdrawal of drugs that are considered of minimum, using a patient-centred approach which considers patient preferences when determining the treatment goal, and adopting a multidisciplinary approach in medication management.
 
Medication adherence measures the extent to which individual’s medication taking behaviour complies with the planned prescriptions from physicians. A patient taking a proportion of 80% to 120% for prescribed drugs over a certain period is generally considered as an adherent to medications.7 Medication adherence is crucial and essential as it has a substantial impact on the effectiveness of medications and control of chronic conditions. The World Health Organization has used “adherence enhancing” as an important strategy to effectively tackle chronic conditions.15 By contrast, medications non-adherence is a phenomenon where the individual does not adhere to the prescribed medications by healthcare providers, including under-utilisation, over-utilisation, and incorrect utilisation. There are several ways to measure medication adherence, including completing self-reported questionnaires (eg, Brief Medication Questionnaire16), counting pills, or measuring drug or metabolite levels through a blood test.
 
Suboptimal medication adherence can result from intentional and unintentional factors.17 Intentional non-adherence is caused by patients who simply do not follow the prescribed instructions or intentionally stop taking a medication. Unintentional non-adherence may be caused by forgetfulness or limited knowledge of the diseases or prescribed medications, or by physical, psychological, or mental barriers. Physicians may have inadequate time to discuss with patients on the medication adherence during clinical encounters. Factors for medication non-adherence that are commonly reported include complexity of medications, presence of ADRs, frequent changes to prescriptions, and limited family or social support.
 
The major health consequences of suboptimal medication compliance among elderly patients include poor medication response, decreased treatment safety, and impaired life quality.7 Other consequences increased number of emergency visits, duration of hospitalisations, morbidity, mortality, and healthcare costs. A substantial proportion of preventable ADRs are attributable to suboptimal medication adherence among elderly patients. For instance, 33% to 69% of drug-related hospitalisations are caused by poor medication adherence in the United States, which induces an avoidable annual healthcare cost of US$100 to 300 billion.18 Suboptimal medication adherence among patients is also a source of frustration and job dissatisfaction for healthcare providers.
 
Recommendations
Different strategies to enhance medication adherence among the elderly patients have been investigated. Most strategies aim to modify personal health behaviours by delivering counselling, reminders, education, or a combination of these approaches. These approaches can be generally divided into political, organisational, behavioural, and educational interventions, with different focuses on policy, system and environmental, and patient and their family levels.19
 
Policy level
Policy interventions mainly focus on allocating more resources for enhancing medication adherence to different related sectors, including education, healthcare cost, and health regulations.20 It is important to raise public awareness and knowledge on suboptimal medication adherence among elderly patients. Another typical approach to enhancing medication adherence among elderly patients is to reduce their out-of-pocket expenses for medication prescriptions. Relevant regulations can also be developed to ensure that healthcare professionals have sufficient attention for the issue of medication adherence among patients.
 
System and environmental level
Organisational interventions aim to reduce barriers to medication adherence by pharmacy refills and adherence reminders comprehensively and systematically. This is often carried out by a multidisciplinary team involving physicians, pharmacists, psychologists, and community care givers.21 22 It is important for physicians to enhance communication by listening to patients more about their concerns to determine a compromised medication plan.23 Regular assessment and simplification of treatment prescription by pharmacists is needed. Elderly patients who had suspected psychological problems such as depression should be assessed by psychologists for medication management. Community caregivers are also helpful in medication management for the elderly patients with less family support.24 Behavioural interventions modify the environmental factors to facilitate medication use with instruments among the elderly patients. These interventions include instruments such as alarm clocks, reminder lists, or advanced pillboxes, as well as group social support, surveillance feedback system, and follow-up visits. Mobile health (mHealth) interventions, such as smartphone applications, can also be innovative and promising means to assist in the management of medication adherence for elderly patients with chronic diseases.
 
Patient and their family level
Educational interventions, either based on group or individual learning from healthcare professionals, are useful for promoting medication adherence among elderly patients.25 They provide elderly patients or their caregivers with better knowledge of their health conditions, prescriptions, ADRs, and the importance of compliance to facilitate informed decision-making. It is also useful to encourage elderly patients to be actively involved in the disease management process, for instance, self-monitoring of blood glucose, blood pressure, and blood lipids. Family members are encouraged to assist in medication management, especially for elderly people with decreased functionality, mood disorders, or cognitive impairment.
 
In sum, the improvement of medication adherence in older adults requires efforts from multiple stakeholders. The development of primary care teams with interdisciplinary collaboration is essential to maximise these adherence-enhancing strategies.
 
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 disclosed no conflicts of interest.
 
References
1. Vollset SE, Goren E, Yuan CW, et al. Fertility, mortality, migration, and population scenarios for 195 countries and territories from 2017 to 2100: a forecasting analysis for the Global Burden of Disease Study. Lancet 2020;396:1285-306. Crossref
2. Cheng CP. Elderly care as one of the important government policy agenda. Hong Kong Med J 2018;24:442-3. Crossref
3. Department of Health, Hong Kong SAR Government. Health of the community. Elderly health. Available from: https://www.dh.gov.hk/english/pub_rec/pub_rec_ar/pdf/0001/ch_0116.pdf. 2002: Accessed 19 Nov 2020.
4. Lam LC, Tam CW, Lui VW, et al. Prevalence of very mild and mild dementia in community-dwelling older Chinese people in Hong Kong. Int Psychogeriatr 2008;20:135-48. Crossref
5. Zhang D, Sit RW, Wong C, et al. Cohort profile: The prospective study on Chinese elderly with multimorbidity in primary care in Hong Kong. BMJ Open 2020;10:e027279. Crossref
6. Cheung JT, Yu R, Wu Z, Wong SY, Woo J. Geriatric syndromes, multimorbidity, and disability overlap and increase healthcare use among older Chinese. BMC Geriatr 2018;18:147. Crossref
7. Brown MT, Bussell JK. Medication adherence: WHO cares? Mayo Clin Proc 2011;86:304-14. Crossref
8. Denneboom W, Dautzenberg MG, Grol R, De Smet PA. Analysis of polypharmacy in older patients in primary care using a multidisciplinary expert panel. Br J Gen Pract 2006;56:504-10.
9. Rambhade S, Chakarborty A, Shrivastava A, Patil UK, Rambhade A. A survey on polypharmacy and use of inappropriate medications. Toxicol Int 2012;19:68-73. Crossref
10. Tse MM, Kwan RY, Lau JL. Ageing in individuals with intellectual disability: issues and concerns in Hong Kong. Hong Kong Med J 2018;24:68-72. Crossref
11. Yee A, Tsui NB, Chang YN, et al. Alzheimer’s disease: insights for risk evaluation and prevention in the Chinese population and the need for a comprehensive programme in Hong Kong/China. Hong Kong Med J 2018;24:492-500. Crossref
12. Xue H, Nie J, Shi Y. Crucial role of primary healthcare professionals in the assessment and diagnosis of dementia. Hong Kong Med J 2019;25:427-8. Crossref
13. 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
14. Wong CW. Medication-related problems in older people: how to optimise medication management. Hong Kong Med J 2020;26:510-9. Crossref
15. World Health Organization. Adherence to long-term therapies: evidence for action. Available from: https://www.who.int/chp/knowledge/publications/adherence_full_report.pdf. Accessed 19 Nov 2020.
16. Svarstad BL, Chewning BA, Sleath BL, Claesson C. The Brief Medication Questionnaire: a tool for screening patient adherence and barriers to adherence. Patient Educ Couns 1999;37:113-24. Crossref
17. Hugtenburg JG, Timmers L, Elders PJ, Vervloet M, van Dijk L. Definitions, variants, and causes of nonadherence with medication: a challenge for tailored interventions. Patient Prefer Adherence 2013;7:675-82. Crossref
18. Iuga AO, McGuire MJ. Adherence and health care costs. Risk Manag Healthc Policy 2014;7:35-44. Crossref
19. Fischer F, Lange K, Klose K, Greiner W, Kraemer A. Barriers and strategies in guideline implementation—a scoping review. Healthcare (Basel) 2016;4:36. Crossref
20. Clyne W, White S, McLachlan S. Developing consensus-based policy solutions for medicines adherence for Europe: a Delphi study. BMC Health Serv Res 2012;12:425. Crossref
21. Lee VW, Cheng FW. Multidisciplinary care for better clinical outcomes: role of pharmacists in medication management. Hong Kong Med J 2018;24:96-7. Crossref
22. Chiu PK, Lee AW, See TY, Chan FH. Outcomes of a pharmacist-led medication review programme for hospitalised elderly patients. Hong Kong Med J 2018;24:98-106.
23. Ha JF, Longnecker N. Doctor-patient communication: a review. Ochsner J 2010;10:38-43.
24. Wilson E, Caswell G, Turner N, Pollock K. Managing medicines for patients dying at home: a review of family caregivers’ experiences. J Pain Symptom Manage 2018;56:962-74. Crossref
25. Costa E, Giardini A, Savin M, et al. Interventional tools to improve medication adherence: review of literature. Patient Prefer Adherence 2015;9:1303-14. Crossref

Prevention of postpartum haemorrhage

Hong Kong Med J 2020 Oct;26(5):370–1
https://doi.org/10.12809/hkmj205107
Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
 
EDITORIAL
Prevention of postpartum haemorrhage
WC Leung, MD, FHKAM (Obstetrics and Gynaecology)
Department of Obstetrics and Gynaecology, Kwong Wah Hospital, Hong Kong
 
Corresponding author: Dr WC Leung (leungwc@ha.org.hk)
 
 Full paper in PDF
 
Postpartum haemorrhage (PPH) is an important cause of maternal morbidity and mortality. Prevention is always better than treatment. In this issue of Hong Kong Medical Journal, Tse et al1 have compared the use of carbetocin with oxytocin infusion in reducing the need for additional uterotonics or procedures in women at increased risk for PPH undergoing Caesarean deliveries in a single Hospital Authority (HA) obstetric unit. Carbetocin was better than oxytocin infusion in reducing the requirement of additional uterotonics or procedures in pregnant women undergoing Caesarean sections with multiple pregnancies or major placenta praevia. The findings echo the first of the three recommendations from the territory-wide HA survey on massive PPH conducted in 2013.2 3
 
With the objectives of studying the characteristics of patients with massive primary PPH (defined as ≥1500 mL within the first 24 hours after delivery, which is the clinical indicator for obstetric performance in HA hospitals) and exploring areas for improvement in terms of prevention and treatment, a prospective study2 3 was conducted during the year 2013 in all the eight HA obstetric units using a pre-designed code sheet to record the details of all patients with massive primary PPH, including causes, risk factors, mode of delivery, interventions (uterotonic agents, second-line therapies and emergency hysterectomy), use of blood products, and maternal outcome.
 
Massive primary PPH occurred in 0.76% (n=277) of all deliveries (n=36 510) in HA obstetric units in 2013. The incidence was comparable to those reported in international literature. The majority occurred after Caesarean sections (84.1%). Uterine atony (37.5%), placenta praevia/accreta (49.9%), and uterine wound bleeding/tear during Caesarean section (24.2%) were the three most common causes. The median total blood loss was 2000 mL (range, 1500-20 000 mL). Coagulopathy occurred in 16.2% (n=45). A quarter (n=76, 27.4%) required intensive care or high dependent unit admission. There was no maternal mortality.
 
Second-line therapies (balloon tamponade, compression sutures and uterine artery/internal iliac artery embolisation or surgical ligation) were used in 40.1% (n=111). Emergency hysterectomy was required in 8.7% (n=24). A total of 1052 units of packed cells, 670 units of platelets, 568 units of fresh frozen plasma, and 200 units of cryoprecipitate were transfused.
 
The study identified three areas for improvement: (1) to increase the choice of uterotonic agents (carbetocin has been incorporated into HA Drug Formulary since January 2017, mainly for prevention of PPH in women at risk such as twin pregnancy, large fibroids, polyhydramnios, fetal macrosomia, and placenta praevia. In 2017, a total of 875 ampoules have been used in HA obstetric units, rising to 2500 ampoules in 2018, and 2865 ampoules in 2019); (2) to step up the use (and early use) of second-line therapies, and to watch out for failures from second-line therapy; (3) to reduce the incidence of placenta praevia/accreta through education and to improve its management at multiple care levels.
 
Carbetocin is a long-acting synthetic analogue of oxytocin indicated for prevention of uterine atony after Caesarean section. It is administered as a slow intravenous injection over 1 minute, with a rapid onset of uterine contraction within 2 minutes and lasting for several hours. It is also a heat-stable compound which does not require refrigeration. Latest Cochrane reviews showed that carbetocin may have some additional benefits compared with oxytocin and appears to be without an increase in adverse effects.4 The Carbetocin HAeMorrhage PreventION (CHAMPION) trial5 showed that carbetocin was non-inferior to oxytocin for the prevention of PPH after vaginal delivery as well.
 
The main disadvantage of using carbetocin in preventing PPH is its cost, making it much less cost-effective when compared with other uterotonic drugs.6 For local reference, carbetocin (single dose of 100 μg) costs HK$200, as compared with oxytocin (40 IU infusion, HK$32), syntometrine (single dose, HK$27), and misoprostol (800 μg, HK$7). As a result, when carbetocin was introduced into HA Drug Formulary in 2017, we have limited its use to those women with high-risk factors for PPH after Caesarean sections such as twin pregnancy, large fibroids, polyhydramnios, fetal macrosomia, and placenta praevia. For example, in 2018, only 2500/35 016 or 7.1% of all deliveries in HA had carbetocin for PPH prophylaxis when compared with around 90% of deliveries in private hospitals in Hong Kong. There is capacity to increase the use of carbetocin in HA by including more women with risk factors for PPH such as prolonged induction of labour (eg, oxytocin ≥12 hours), high parity (eg, ≥para 3), history of PPH, and others. These risk factors have not been included in Tse et al’s study.1 Carbetocin should not only be considered for Caesarean sections, but also for vaginal deliveries with same risk factors for PPH. Furthermore, the role of using carbetocin as treatment for PPH could be explored.
 
In addition to single-centre studies on the efficacy of a single drug or procedure on the prevention and treatment of PPH, further studies are required on the overall impact of the introduction of uterotonic drugs such as carbetocin; non-uterotonic drugs such as tranexamic acid; increasing use of second-line procedures7 such as balloon tamponade, compression sutures and uterine artery embolisation; and new patient blood management such as intravenous iron therapy, particularly in the current era of inadequate blood donation, being further aggravated by coronavirus disease 2019 (COVID-19).
 
Interestingly, with all the new modalities of prevention and treatment of PPH, the overall figures of primary PPH ≥500 mL (traditional definition), ≥1000 mL or ≥1500 mL (defined as massive PPH), including emergency hysterectomies for massive PPH, have not been improved in HA from 2013 to 2018 (Table).8 This phenomenon is different from what had been observed in a single obstetric unit over a different time period from 2006 to 2011.9 Fortunately, maternal mortality is still rare. Further studies are definitely indicated to look into the territory-wide HA data (using the Obstetrics Clinical Information System) to see whether the new modalities are not as effective as they are expected to be or our pregnant population is indeed becoming more and more high risk for PPH.
 

Table. Postpartum haemorrhage (% of total deliveries) in Hospital Authority obstetric units8
 
Author contributions
The author contributed to the manuscript, approved the final version for publication, and takes responsibility for its accuracy and integrity.
 
Conflicts of interest
The author has disclosed no conflicts of interest.
 
References
1. Tse KY, Yu FN, Leung KY. Comparison of carbetocin and oxytocin infusions in reducing the requirement for additional uterotonics or procedures in women at increased risk for postpartum haemorrhage following Caesarean section. Hong Kong Med J 2020;26:382-9. Crossref
2. Lau KW, Chan LL, Lo TK, Lau WL, Leung WC; Hospital Authority COC Obstetrics and Gynaecology Quality Assurance Subcommittee. Territory-wide massive primary postpartum haemorrhage (PPH >1,500ml) survey in Hospital Authority obstetric units with recommendations and the way forward. Hospital Authority Convention 2017. Master Class 7.1. Available from: http://www3.ha.org.hk/haconvention/hac2017/ebook/HAC2017_abstract%20day%201.pdf. Accessed 29 Sep 2020.
3. Leung WC. An overview on massive postpartum haemorrhage in Hong Kong. The Hong Kong Medical Diary 2019;24(7):2-3.
4. Gallos ID, Papadopoulou A, Man R, et al. Uterotonic agents for preventing postpartum haemorrhage: a network meta-analysis. Cochrane Database Syst Rev 2018;(12):CD011689. Crossref
5. Widmer M, Piaggio G, Nguyen TM, et al. Heat-stable carbetocin versus oxytocin to prevent hemorrhage after vaginal birth. N Engl J Med 2018;379:743-52. Crossref
6. Pickering K, Gallos ID, Williams H, et al. Uterotonic drugs for the prevention of postpartum haemorrhage: a cost-effectiveness analysis. Pharmacoecon Open 2019;3:163-76. Crossref
7. Kellie FJ, Wandabwa JN, Mousa HA, Weeks AD. Mechanical and surgical interventions for treating primary postpartum haemorrhage. Cochrane Database Syst Rev 2020;(7):CD013663. Crossref
8. Hospital Authority Annual Obstetric Reports 2013 to 2018. Available from: https://www.ekg.org.hk/html/gateway/neweKG/newsp/h1-obs-gyn.jsp (internal access via eKG).
9. Chan LL, Lo TK, Lau WL, et al. Use of second-line therapies for management of massive primary postpartum hemorrhage. Int J Gynaecol Obstet 2013;122:238-43. Crossref

Use of clinical practice guidelines

Hong Kong Med J 2020 Oct;26(5):367–9
https://doi.org/10.12809/hkmj205106
Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
 
EDITORIAL
Use of clinical practice guidelines
Ben YF Fong, MPH(Syd), FHKAM (Community Medicine)
Division of Science, Engineering and Health Studies, College of Professional and Continuing Education, The Hong Kong Polytechnic University, Hong Kong
 
Corresponding author: Dr Ben YF Fong (byffong@gmail.com)
 
 Full paper in PDF
 
In society, guidelines shape the behaviour and steer the activities of people and organisations in all aspects of daily routine. In the clinical setting, professional care and services are often dictated by clinical practice guidelines (CPGs) on topics from screening, assessment, and diagnosis to management of common and specific conditions. There are also CPGs for unusual emerging pandemics: in the case of coronavirus disease 2019 (COVID-19) the World Health Organization has published extensive advice.1
 
According to the National Institute of Health and Care Excellence of the United Kingdom, CPGs contain evidence-based recommendations on the ways healthcare professionals should care for people with defined conditions. Such recommendations are derived from the best available evidence. In addition, CPGs are also of importance to health services operators and managers as such guidelines are essential for quality care.2
 
Effective CPGs are derived from evidencebased medicine, and should be built on the best available published research findings and experience gained from clinical practice. To achieve the optimal usage of CPGs, healthcare professionals should understand the principles of development and evaluation of the guideline. The AGREE II guidelines and associated reporting checklist is considered the international gold standard for developing and evaluating CPGs.3 Quality, relevance, and strength of the best available evidence are examined in detail with a multidisciplinary approach when making recommendations for clinical management. Ideally, CPGs are embedded with flexibility and adaptability to allow for a wide dissemination and adoption. In addition, potential economic implications should not be overlooked.4 Practically, CPGs should be subject to regular structured evaluation and revision to encompass the latest state-of-the-art of clinical practice, new research evidence, current medical advancement, and changed patient values.
 
Topics of CPGs are often selected on the basis of priorities in quality improvement opportunities in medical practice because physicians are expected to provide their patients a certain standard of care. In a review of CPGs, consensus statements, and position statements from various specialties, the authors found that to achieve the optimal benefits from providing the best possible and quality care to the community, topics of CPGs should cover common conditions that doctors encounter regularly.5 In this issue of the Hong Kong Medical Journal, Chan et al from the Hong Kong College of Physicians, representing sub-specialties in Cardiology, Nephrology, Geriatric Medicine, Neurology and Endocrinology, review two recent CPGs from America and Europe on hypertension, both of which have adopted a risk-based approach to treatment.6 On the basis of these guidelines, the authors have developed a Position Statement on the classification of blood pressure, measurement of blood pressure, initiation of medications, treatment targets and strategies, together with particular considerations for geriatric, renal, and diabetic patients.6 In general, the authors concur with the 2018 European Society of Cardiology/European Society of Hypertension guideline, and also note that the reviewed guidelines have helped to improve public awareness of hypertension and the importance of lifestyle changes in managing hypertension.
 
Physicians use CPGs when making clinical decisions, often with discussion with the patient in some settings, about the appropriate care and management of specific conditions or diseases. Reviewing CPGs published in the Hong Kong Medical Journal, some have provided guidance on disease screening and prevention,7 8 whereas others have offered a broad range of clinical topics from management of common clinical complaints to controversial issues based on the most updated evidence.9 10 11 12 13 Guidelines include concise recommendations and instructions for diagnosis, tests, treatment options, drug therapy, management algorithms that may direct the choice of medical, and surgical or other clinical services.14 Because CPGs are never perfect and evidence on their effectiveness is incomplete,14 when making clinical decisions, doctors also consider their experience and knowledge through years of practice and insights gained from the many cases encountered and managed previously. Therefore, most doctors have developed an individual approach to patient management without consciously thinking about CPGs. However, CPGs are useful when dealing with uncommon conditions or diseases unfamiliar to the practitioner, as well as in controversial clinical situation. Under such circumstances, there is a high level of uncertainty as to the outcomes of clinical courses being available or considered, such as the current COVID-19 pandemic.
 
Adherence to CPGs in clinical practice is not mandatory. However, the Medical Council of Hong Kong has some guidelines to doctors in the Code of Professional Conduct, “the little red book”, with the intention to promote good clinical practice.15 There are guidelines on the proper prescription and dispensing of dangerous drugs, ethics (covering communication and dissemination of information to the public and patients), adoption of new medical procedures and human reproductive technology, as well as on practice management including signboards, service information notices, and doctors directory. In addition, legal considerations are practical issues when CPGs are not fully followed or when treatment recommended in CPGs is not offered to the patient. Following the advice found in CPGs may provide a means of protection to the doctor, as CPGs prescribe reasonable conduct expected of medical practitioners who are also expected to provide sufficient information to the patient, particularly about risks involved in a clinical decision.
 
Some CPGs contain definitive recommendations whereas others are more general, to allow for the clinical judgement of the practitioner, and therefore carry a smaller risk of liability. Generally, groups who develop CPGs, such as members of a working group, are not usually held liable for the application of CPGs. Furthermore, use of CPGs as evidence in court depends on how the guidelines are developed and whether they are up to date. Good CPGs should have a strong research evidence base, should have undergone independent review, should have built-in flexibility for adoption in different clinical situation, and should carry an expiry date.4 Practitioners should have adequate understanding of the salient points in CPGs to fully exploit the guidelines in clinical settings.
 
The purpose of CPGs is to improve the health and condition of patients, not only as individuals but also as members of the community, particularly when society is facing escalating costs of health services and medical technologies, ageing populations, increasing demands and expectations of users, inconsistent service quality of providers, and even inappropriate care. Use of CPGs by physicians in clinical practice can lead to more structured and consistent decisions and care delivery in a more objective manner, supported by the embedded evidence. The Primary Healthcare Office of the Hong Kong SAR Government has published four reference frameworks on disease management of hypertension and diabetes, and on preventive care for children and elderly patients. The frameworks aim to facilitate family doctors to provide continuing comprehensive and evidence-based care in the community.16 In the code of practice to private hospitals and clinics, the Department of Health demands that these institutions comply with guidelines and standards issued by professional and government bodies, and that CPGs must be easily accessible and available to staff for their reference.17
 
Doctors should use appropriate CPGs in their daily practice for the benefit and better quality of life of their patients. However, CPGs must not be regarded as the absolute consensus recommendations with answers to all clinical situations. Intrinsic shortcomings in the development of guidelines are not uncommon. Patients are not all the same; they vary in personal characteristics and responses to treatments. Moreover, doctors differ in their clinical judgement. Use of CPGs by physicians is still very much the core of medicine, being both an art and a science.
 
Author contributions
The author contributed to the editorial, approved the final version for publication, and takes responsibility for its accuracy and integrity.
 
Conflicts of interest
The author has disclosed no conflicts of interest.
 
References
1. World Health Organization. Clinical management of COVID-19—interim guidance. Available from: https://www.who.int/publications/i/item/clinical-management-of-covid-19. Accessed 5 Sep 2020.
2. National Institute for Health and Care Excellence. What is a NICE clinical guideline? Available from: https://www.nice.org.uk/process/pmg6/resources/how-nice-clinical-guidelines-are-developed-an-overview-for-stakeholders-the-public-and-the-nhs-2549708893/chapter/nice-clinical-guidelines#what-is-a-nice-clinical-guideline.Accessed 5 Sep 2020.
3. Brouwers MC, Kerkvliet K, Spithoff K, AGREE Next Steps Consortium. The AGREE Reporting Checklist: a tool to improve reporting of clinical practice guidelines. BMJ 2016;352:i1152. Crossref
4. National Health and Medical Research Council. A Guide to the Development, Implementation and Evaluation of Clinical Practice Guidelines. Australia: NHMRC; 1999.
5. Chong CC. Pros and cons of clinical practice based on guidelines. Hong Kong Med J 2018;24:440-1. Crossref
6. Chan KK, Szeto CC, Lum CC, et al. Hong Kong College of Physicians Position Statement and Recommendations on the 2017 American College of Cardiology/American Heart Association and the 2018 European Society of Cardiology/European Society of Hypertension Guidelines for the Management of Arterial Hypertension. Hong Kong Med J 2020;26:432-7.
7. Cancer Expert Working Group on Cancer Prevention and Screening. Recommendations on prevention and screening for colorectal cancer in Hong Kong. Hong Kong Med J 2018;24:521-6. Crossref
8. Cancer Expert Working Group on Cancer Prevention and Screening. Recommendations on prevention and screening for breast cancer in Hong Kong. Hong Kong Med J 2018;24:298-306. Crossref
9. Tomlinson B, Chan JC, Chan WB, et al. Guidance on the management of familial hypercholesterolaemia in Hong Kong: an expert panel consensus viewpoint. Hong Kong Med J 2018;24:408-15. Crossref
10. Mak LY, Lau CW, Hui YT, et al. Joint recommendations on management of anaemia in patients with gastrointestinal bleeding in Hong Kong. Hong Kong Med J 2018;24:416- 22. Crossref
11. Lim MK, Ha SC, Luk KH, et al. Update on the Hong Kong Reference Framework for Hypertension Care for Adults in Primary Care Settings—review of evidence on the definition of high blood pressure and goal of therapy. Hong Kong Med J 2019;25:64-7. Crossref
12. The Advisory Group on Antibiotic Stewardship Programme in Primary Care. Antibiotic management of acute pharyngitis in primary care. Hong Kong Med J 2019;25:58-63.
13. Wu JC, Chan AO, Cheung TK, et al. Consensus statements on diagnosis and management of chronic idiopathic constipation in adults in Hong Kong. Hong Kong Med J 2019;25:142-8. Crossref
14. Woolf SH, Grol R, Eccles M, Grimshaw J. Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ 1999;318:527-30. Crossref
15. Medical Council of Hong Kong. Code of professional conduct. Available from: https://www.mchk.org.hk/english/code/files/Code_of_Professional_Conduct_2016.pdf. Accessed 5 Sep 2020.
16. Primary Healthcare Office, Food and Health Bureau, Hong Kong SAR Government. Reference frameworks. Available from: https://www.fhb.gov.hk/pho/english/initiatives/frameworks.html. Accessed 5 Sep 2020.
17. Office for Regulation of Private Healthcare Facilities, Department of Health, Hong Kong SAR Government. Regulatory regime. Available from: https://www.orphf.gov.hk/en/regulatory_regime/index. Accessed 5 Sep 2020.

Contributions of physicians to government-subsidised disease prevention programmes: an appeal for active participation

Hong Kong Med J 2020 Oct;26(5):364–6
https://doi.org/10.12809/hkmj205105
Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
 
EDITORIAL
Contributions of physicians to government-subsidised disease prevention programmes: an appeal for active participation
Junjie Huang, MD, MSc1; Harry HX Wang, PhD1; Edmond SK Ma, MD, MMedSc2; Martin CS Wong, MD, MPH3,4
1 Editor, Hong Kong Medical Journal
2 Epidemiology Adviser, Hong Kong Medical Journal
3 Editor-in-Chief, Hong Kong Medical Journal
4 Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
 
Corresponding author: Prof Martin CS Wong (wong_martin@cuhk.edu.hk)
 
 Full paper in PDF
 
Pneumococcal infection, particularly invasive pneumococcal disease (IPD), has placed a substantial global burden of disease.1 In Hong Kong, from 2007 to 2015, the incidence rate of IPD increased from 1.7 to 2.9 per 100 000 population.2 It is one of the leading causes of disability and mortality, affecting individuals aged ≥65 years who are at higher risk of complications and premature death.3 The total number of local residents aged ≥65 years has already exceeded one million, accounting for approximately 16% of the whole population in Hong Kong.4 Due to the ageing population, the incidence of IPD is expected to rise continuously in the coming years.5
 
Evidence has shown that pneumococcal immunisation can effectively decrease the incidence and mortality of pneumococcal infection and IPD among older adults.6 7 An earlier large-scale cohort study demonstrated that immunisation was associated with a significant decrease in the risk of pneumococcal infection (hazard ratio=0.56) among patients aged >65 years.8 The pneumococcal immunisation can also lower the risks of both myocardial infarction9 and ischaemic stroke.10 Although pneumococcal immunisation is beneficial for IPD and cardiovascular disease control, the programme participation remained suboptimal worldwide.
 
The uptake rate of pneumococcal immunisation among older adults was only around 61% in the United States during 2013 to 2014.11 In England, the pneumococcal immunisation coverage among older adults was <70% during 2014 to 2015.12 In Hong Kong, only one-third of people aged ≥65 years received pneumococcal immunisation.13
 
The Hong Kong SAR Government has launched two pneumococcal immunisation programmes to eligible residents in October 2019: the Vaccination Subsidy Scheme and the Government Vaccination Programme.14 The Vaccination Subsidy Scheme provided a subsidy of HK$210 (~US$27) and HK$250 (~US$32) for influenza and pneumococcal immunisation, respectively, to eligible older individuals at enrolled private clinics as a measure to strengthen the preventive strategy for these diseases. It offers subsidies for both the 13-valent pneumococcal conjugate vaccine and the 23-valent polysaccharide pneumococcal vaccine. The Government Vaccination Programme provides eligible individuals with free pneumococcal immunisation at residential care homes for the elderly, designated centres of the Department of Health, and public clinics or hospitals managed by the Hospital Authority.14
 
In addition to pneumococcal vaccine, human papillomavirus (HPV) vaccination is currently available under the Hong Kong Childhood Immunisation Programme, wherein eligible female students may receive two doses of 9-valent HPV vaccine in their primary five and six school years.15 Other examples of Government-subsidised programmes for disease prevention include cervical cancer screening,16 colorectal cancer screening,17 and the Smoking Cessation Programme.18
 
In this issue of the Hong Kong Medical Journal, Man et al19 report an 8-year large-scale retrospective cohort study that included 792 adult patients in a major hospital. The authors found that the 30-day mortality rates were 11.5% overall and 24.5% in those patients with IPD. Among 170 patients admitted to the intensive care unit, the in-hospital mortality was 31.2%. The study results indicate that older age, the presence of chronic kidney disease, and disease severity are significantly associated with 30-day mortality. The study is limited by the absence of controls for potential confounders and its retrospective single-centre design; thus the generalisability to other settings may require cautious interpretation. This necessitates future evaluations to explore drug resistance patterns and capsular serotypes of pneumococcus. As claimed by the authors, this was the first and largest-scale investigation on pneumococcal disease in Hong Kong showing the significant burden posed by pneumococcal infection. The study exerts a significant impact on clinical care and resource planning for hospitals, given that up to 33% of IPD patients require intensive care unit care. In view of the public health impact, the role of pneumococcal vaccination in prevention should be enhanced.
 
Substantial evidence supports the effectiveness of preventive care and disease screening. A meta-analysis of 26 randomised controlled trials consisting of >73 000 individuals found that HPV immunisation can effectively protect adolescent girls and young females from cervical cancer.20 An international study conducted in eight countries by the World Health Organization found that the cumulative incidence of cervical cancer decreased by 94%, 93%, 91%, 84%, and 64% for a screening interval of 1 year, 2 years, 3 years, 5 years, and 10 years, respectively, among women who were screened before age 35 years.21 Screening is also beneficial for women aged 61 to 65 years, and is associated with a decreased risk of cervical cancer (hazard ratio=0.42), contributing to a reduction of approximately 3.3 cancer cases per 1000 women.22 Screening by faecal occult blood test and colonoscopy can effectively reduce the risk of colorectal cancer–related death by 33%23 and 68%24, respectively. Among patients who smoke ≥15 cigarettes daily, smoking reduction by 50% can significantly reduce the risk of lung cancer.25
 
The effect of physician intervention on disease prevention and screening is well documented in the literature. Participation rates of pneumococcal vaccination are associated with physician-delivered routine vaccine and promotion programmes.26 A study among Japanese primary care physicians found that patients who had pneumococcal vaccination were more likely to have received advice from physicians than those who did not receive such advice (80% vs 21%), and a strong association was shown between physician recommendation and patient participation in vaccination with an adjusted odds ratio of 8.50.27 A study in France demonstrated that patients who received recommendations from trusted family physicians were more likely to participate in HPV vaccination programme.28 In Hungary, physicians effectively motivated approximately 27% of women who initially refused to join cervical cancer screening programmes.29 Moreover, higher non-compliance rates were related to family physicians being foreign, at a younger age, and with a longer distance to the clinic from the patient’s home.30 A population-based telephone survey in Hong Kong found that people who were recommended by physicians were 23.5-fold more likely to have colorectal cancer screening uptake than those who did not.31 A recent study conducted in Canada using large administrative databases highlighted that the uptake of colorectal cancer tests by family physicians was significantly associated with greater uptake by their patients.32 Another study found that clinicians who specialised in respiratory diseases, thoracic surgery, and cardiology were more committed to encouraging patients to cease tobacco use.33
 
We believe that the study by Man et al19 acts as a call for more active participation by physicians in disease prevention and screening programmes, and appeal for your support. Physicians play an important role in both primary and secondary disease prevention for asymptomatic individuals, including promotion of lifestyle modifications, vaccination for infectious diseases, and screening for early-stage cancer lesions such as cervical cancer and colorectal cancer.
 
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 disclosed no conflicts of interest.
 
References
1. Oishi K, Suga S. Pneumococcal infection: update [in Japanese]. Nihon Naika Gakkai Zasshi 2015;104:2301- 6. Crossref
2. Centre for Health Protection, Department of Health, Hong Kong SAR Government. Updated recommendations on the use of pneumococcal vaccines for high-risk individuals. 2019. Available from: https://www.chp.gov.hk/files/pdf/updated_recommendations_on_the_use_of_pneumococcal_vaccines_amended_120116_clean_2.pdf. Accessed 3 Sep 2020.
3. Shapiro ED. Prevention of pneumococcal infection with vaccines: an evolving story. JAMA 2012;307:847-9. Crossref
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