How Hong Kong averted a major COVID-19 outbreak

Hong Kong (HK) is a special administrative region situated at the south of China. It is directly connected to mainland China via air, land and sea - allowing ease of travel between the two areas. Before containment measures were implemented, HK received tens of thousands of mainland visitors per day. Bearing in mind that HK is one of the most densely populated cities in the world with one of the best interconnected public transport systems running through its core, we were set to be the next epicentre of COVID19. Quite the opposite happened Since the first imported case of COVID 19 into Hong Kong on 23^rd Jan, 2020, we have managed to stay relatively unscathed. Out of a population of ~ 7.4 million, as of 27^th April, 2020, there were 1038 confirmed cases of COVID 19 in Hong Kong, with 4 deaths. On the contrary, COVID19 has hit hard in regions afar, such as Italy, UK and US with death tolls reaching tens of thousands. Given that the odds were against us to begin with, it is remarkable that HK has managed to flatten the curve and to protect its public health care system from collapsing.  How a major outbreak was averted  An exponential increase in COVID cases was projected, given the population flow between mainland China and HK, an epidemic was imminent. The HKSAR government acted promptly to bring about phased measures to stem the tide, including strictly limiting travel between HK and mainland China  and later to the rest of the world) with subsequent introduction of mandatory quarantine upon entering HK, school and university closures, public facility closures, restaurant restrictions and prohibition of group gatherings. Secondly, HK residents were on high alert due to the not too distant memory of SARS 2003. Our hospital was the epicentre with many lives lost in HK - including 9 healthcare workers. Lessons from the past sparked fear; and upon hearing about a novel coronavirus ‘SARS-2’ – the population promptly started wearing surgical masks and adopting hand hygiene. The is mounting evidence that universal wearing of masks is conducive to prevention of disease spread (reflected by a significant reduction in the cases of seasonal flu) - especially important in the context of asymptomatic carriers. This is especially important in densely populated urban areas since it is practically impossible to maintain socially distance at > 1 metre. Thirdly, our public healthcare system took measures to protect itself from collapse. Ever since SARS in 2003, a provision was set to ensure 3 months of PPE supply was in stock at all times. In order to further conserve critical PPE (e.g. N95 masks), non-urgent procedures requiring high level protection such as general anaesthesia were postponed (or switched to local anaesthesia), and all elective surgeries were reduced overall- and some due to patients self-rescheduling. Proper and appropriate use of different levels of PPE was reinforced and frontline staff were carefully retrained (and retested for mask fitting) to prevent self-contamination especially during removal, change of work clothes and caring of personal belongings …etc. Thanks to the implemented measures, the public healthcare system has not been paralysed by COVID19, and we are still able to maintain almost full ophthalmic services. As of today, none of the staff from our department was required to be redeployed. In order to minimise risk, a new policy was introduced in our eye theatres to keeps patients’ masks on right up until the surgical drape is about to be placed. The workflow has been reengineered to allow patients to reschedule their appointments, and minimise contact time between patients and other patients, as well as with staff. In addition, all patients entering our department must be triaged for any signs or symptoms of COVID, wear a surgical mask at all times and have their temperature checked. Hand hygiene is reinforced and hand sanitising alcohol made available at entrances. At the slit lamps, we have installed DIY plastic shields to enhance protection of staff. Unfortunately, it is likely that COVID19 will not disappear as quickly as SARS. All containment measures in place will need to be weighed against the changes in the global & community prevalence and the demands & supply of critical PPE. We are thankful to have escaped a meltdown in HK but success against COVID19 will not be achieved until it is global. Modification of practice has to be reviewed based on new evidence & evolution of local situations. We need to share and learn from each other in order to win this battle against a virus that knows no religion, race, colour or creed. *Anita LW Li     MB BCh BAO (QUB), MRes, FRCOphth, MRCSEd (Ophth);  Alvin L Young   MB BCh BAO (NUI), MMedSc (Hons), FRCOphth, FHKAM (Ophth) Department of Ophthalmology & Visual Sciences,The Chinese University of Hong Kong, Prince of Wales Hospital & Alice Ho Miu Ling Nethersole Hospital