How Hong Kong Beat SARS: Lessons Learned

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School was suspended for six weeks in Hong Kong as part of the strategy to keep SARS from spreading. On May 12, 2003, primary school children returned to class amid signs that the outbreak was coming under control. Photo by Bobby Yip - Reuters

As the new coronavirus outbreak spreads around the world, Hong Kong is bracing for a possible surge in cases. The city so far only has 18 cases but its first death from the disease was confirmed on Tuesday – a 39-year-old man who had visited Wuhan, China.

Residents are particularly on edge because many of them lived through the devastating SARS outbreak in 2003. Hong Kong suffered 299 deaths from Severe Acute Respiratory Syndrome, the most anywhere outside of China. SARS crippled the city's economy. The concern now is that this latest outbreak might do the same.

SARS: A 911 Moment

In Hong Kong, memories of SARS are surfacing in the wake of this new outbreak.

One of the key moments in the first pandemic of the 21st century came on the February 21, 2003, when Liu Jianlun arrived in Hong Kong. He'd come to the city to visit relatives. Liu was a doctor — a cardiologist from Guangdong province in China, where SARS was raging. The hotel put him in a room on the 9th floor. It might have been a sign that they gave him room 911.

Dr. Liu had been treating SARS patients in the city of Guangzhou. After checking into the Metropole Hotel in the Kowloon neighborhood, he fell ill and would end up spreading SARS to more than a dozen other guests on the 9th floor of the hotel. Those guests would check out and carry the virus around the globe. The outbreak sickened more than 8,000 people around the world and killed nearly 800 before it was snuffed out in the summer of 2003.

Liu died of SARS in a Hong Kong hospital on March 4th — less than 2 weeks after checking in to the Metropole.

Fear on the Streets, Now and Then

Catherine Chim, an accountant who lives around the corner now from the hotel that used to be the Metropole, says the panic over the new Wuhan coronavirus is worse than it was during SARS back in 2003. She says that at least the stores weren't running out of masks, hand sanitizer and staple foods like they are now.

"Now it seems like there are no more supplies," Chim says on the sidewalk just a few doors down from the former Metropole. "Every day, I need to count how many masks I still have on hand. Because I need to go to work. Every day I need to use one. Now I just have enough for only one week. I can't get any more masks at this moment."

Schools are closed for at least the next month. Her two kids are stuck at home, and she hasn't been able to buy additional masks to give to them. Chim is frustrated that the border with mainland China remains open, and she's critical of the city's response to the new outbreak. Hong Kong officials have closed more than half the border crossing points to the mainland and shut down all high-speed rail and ferry service to China. But Chim doesn't feel it's enough.

"The response is nonsense," she says. "How can they let the people with the disease go inside Hong Kong?"

Nearly everyone on the street streaming past her is also wearing face masks. Old women carrying shopping bags puff through the fabric barriers. Young kids with brightly-colored cartoon-themed ones. Teenagers with black ones. This despite many public health experts saying that masks aren't necessary for people who aren't sick and may not be effective in preventing infection.

But Chim says there could be people on the street next to her who are infected and blowing the virus toward her. "It's frightening." As if to underscore her point, a man walks by in a full gas mask with ventilators sticking out from each cheek.

"You don't know if the one next to you is a virus carrier or not," she says. "So we just can protect ourselves but they [the government] still let the disease get inside. It's horrible."

During SARS, patients were sent to nine hospitals all over Hong Kong so that no one hospital had to bear the full burden of the outbreak. Despite this effort to spread the load, the outbreak overwhelmed the city's health-care system. The Tuen Mun public hospital in the northwest of the city was one of the treatment facilities. The toll on the hospital was steep. Staff had to work long hours with the threat of a deadly virus looming over them. Non-emergency patients were turned away. Entire wards were turned into isolation zones. And the first of many casualties among health-care workers in Hong Kong occurred at Tuen Mun on April 26, 2003.

Is Hong Kong Ready?

Dr. Alfred Wong, a physician who works at Tuen Mun now, agrees with Chim that Hong Kong hasn't done enough to keep out the new coronavirus.

"We've had 17 years to prepare for this. We cannot let what happened 17 years ago happen again," he says.

But he worries that it might.

Wong and other medical professionals have been calling since early January for Hong Kong to shut down its border with mainland China but that still hasn't happened.

All of the early cases of Wuhan coronavirus outside of China have been in people who'd recently been in Hubei province.. Secondary cases have been among people who had more than casual contact with those travelers. This has also been true in Hong Kong.

Thousands of the city's medical workers have even gone on strike as of Monday, saying they'll only return to work if the border with mainland China is sealed.

In some ways Hong Kong is better prepared today to deal with an emerging outbreak than it was 17 years ago. Labs here were quickly able to start running diagnostics to screen for the newly identified virus.

"We have a lot of capacity here," says Ben Cowling, an infectious disease professor at the University of Hong Kong. "Because in Hong Kong, after the SARS epidemic, the government deliberately invested heavily in infectious disease research capacity."

Cowling says that research capacity is now focused feverishly on this new disease.

"Certainly in the universities in Hong Kong, many, many people are looking at different aspects of the outbreak," Cowling says. "Whether it's in the laboratory, in the hospitals or like me in the office, looking at the data, trying to figure out how easily is spreading, what are the dynamics of the spread. And then how effectively different kinds of control measures have been working already in China. And then as we go forward in the coming weeks, how effective measures taken in Hong Kong have been."

During SARS much of the spread was happening in hospitals. Once that became clear, public health officials put in place rigid infection control measures in medical settings; the outbreaks in Hong Kong, China, Toronto and elsewhere were brought under control. Cowling says transmission of this new coronavirus is quite different from SARS.

"Most transmission appears to be occurring in the community," he says. "We've seen a small number of infections of health-care workers, but nothing like SARS where one third of the cases were health-care workers. For the new coronavirus it's a much smaller fraction in hospitals, and probably most transmission occurring in the general community. And that's much, much more difficult for public health measures to deal with."

A Secret That's 'No Secret'

Cowling is the co-director of the World Health Organization Collaborating Centre for Infectious Disease Epidemiology and Control at the University of Hong Kong. His co-director, Wing Hong Seto, was the head of infection control at Queen Mary's Hospital during the SARS epidemic. Infections that occurred inside medical settings were a huge part of the SARS outbreak. On this front, Seto says his hospital did incredibly well.

"We had zero patients infected and only two health-care workers infected," he says proudly. "While in the whole of Hong Kong 405 health-care workers got infected and 1,700 Hong Kong people got infected."

What was the secret at the Queen Mary Hospital?

"No secret!" the 72-year-old shouts. "We just did good basic infection control. We [did] hand hygiene before and after every patient. Change the mask between every patient. If you're wearing gloves, you definitely go change after every patient."

His staff also wore protective gowns and face shields for particular procedures with SARS patients, but he says the most important measures were the infection control procedures, particularly hand washing, which was mandatory every time a doctor saw a different patient.

"It must be done religiously," he says chopping the air in front of him with his hand. "Hand hygiene. Before. After. Before. After. Before. After."

Institutional infection control was ultimately what brought an end to SARS, according to public health officials. Once it was no longer spreading in medical settings, the cases were contained and the outbreak finally came to an end. There hasn't been a case of SARS reported anywhere in the world since 2004.

Public health officials don't yet know what it will take to stop the new Wuhan coronavirus, but Seto says fanatically enforcing hand washing — at home and in hospitals — will probably be one of the keys.

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