COVID-19: where do we go from here?
27 April 2020
Without a vaccine or effective treatment, there are in essence two alternate approaches that countries or bounded territories can take to an infectious disease like COVID-19.
- The elimination approach, to achieve complete elimination within quarantined borders, contact-tracing each infection to isolate and terminate chains of transmission, and dealing with occasional leaks of the borders in the same way as and when they occur; or
- The mitigation approach, temporarily imposing harsh restrictions on civil liberties to reduce transmission while building healthcare capacity, then relaxing restrictions and managing the load placed upon that system, and possibly repeating the cycle of restrictions until most of the susceptible people are gone or have acquired immunity, if immunity can be acquired.
If and when infections have been reduced to traceable levels then a country can switch from mitigation to elimination, hunting down the remaining transmission chains. Some countries simply won't be able to afford the economic cost of elimination, and even mitigation comes at enormous economic cost to them.
As the world moves into at least it's fifth month of COVID-19, choices of approaches are becoming clear. Spain, still registering around 2,000 cases per day, is starting to relax restrictions, as is Germany. European countries generally are speaking in terms of "control" rather than elimination, so most of the contiguous EU appears headed that way. Exceptions may include Iceland, which has gone with wide testing, quarantine and has already reduced to near-zero daily cases.
The UK, at around 5,000 confirmed cases per day (but without much community testing) still talks in terms of "flattening the curve", not elimination. The USA, racking up over 30,000 confirmed cases per day, remains a patchwork of 50 different state systems (48 contiguous, plus DC) and it seems very unlikely that they will reach elimination as various social controls are already beginning to relax.
That will leave those countries/territories who have achieved internal elimination with a difficult choice:
- Maintain strict border quarantine, but gradually form a union of "clean" territories which do likewise, allowing travel between them without quarantine. We propose this could be named QUIET - the Quarantined Union for International Exempt Travel; or
- Surrender their gains and join the network of mitigating countries, adopting or reverting to similar levels of infection and death, with stop-start intervention in civil liberties to flatten the curve.
Much will depend on the relative sizes of the combined economies and populations in the clean and contaminated world. Several countries are now getting close to elimination - notably on 26-Apr Australia had just 16 new cases and New Zealand had 4. Both have closed their borders to all but returning residents and both have mandatory government quarantine. On the same day, South Korea had just 10 new cases. Arguably, mainland China is getting close to zero too (but see below).
However, maintaining quarantine on arrivals from everywhere outside the clean (or QUIET) area comes at a sharp economic price for inbound tourism and business travel. It also comes at a social cost, because citizens are in effect trapped in the clean zone. Any time they travel outside it, they will have to be quarantined on return, so a brief vacation outside the clean area becomes impractical.
The human cost of the mitigation approach
A recent antibody survey of 3,000 people in New York State indicated that about 14% had been infected and a fatality rate of between 0.5% and 1% amongst infections, allowing for uncounted deaths outside hospitals and for those who have not yet died. A stop-start approach to flatten the curve will avoid some deaths that would come from an overloaded system, but doesn't otherwise change the outcome unless a viable vaccine or treatment interrupts the process.
Taking a mid-point in the death toll and assuming some acquired immunity and/or attenuation of the virus (the stronger strains kill their hosts, the weaker strains spread more easily), we can still expect about 70% infection and 0.5% of the population of mitigating countries to die prematurely. Most fatalities are old and/or with comorbidities. In HK's case, that 0.5% would be about 38,000 premature deaths, in the UK, about 330,000, and in the USA about 1.6 million.
Mainland China currently prohibits entry to non-citizens, even prohibiting foreigners holding visas or residence permits. It has reported 11 new cases on 25-Apr of which 5 were imported (returning citizens) and 6 were domestic, including 1 in Guangdong, neighbouring HK. However, it separately reports "asymptomatic infections". Depending on the definition, most countries would regard those as cases, and some of them may go on to be symptomatic. China reported 30 asymptomatic infections on 25-Apr, including 7 imports.
One encouraging fact is that with several hundred people still entering HK from the mainland each day (mostly returning HK residents), there have been no confirmed COVID-19 cases with travel history to the mainland since early March. However, as mentioned below, not all arrivals at our land borders are tested, only those who have been in Hubei Province. Before HK considers dropping the quarantine on the land border, there should at least be a period of testing on all arrivals.
HK quarantine and testing
After several iterations, Hong Kong now has a very strict COVID-19 quarantine and testing regime at its airport. Anyone arriving at the airport since 22-Apr has to take a deep-throat saliva virus test and wait for the results, at the nearby Asia World Expo for morning arrivals, and otherwise overnight at the Regal Orient Hotel in Kowloon City, which ironically was once the Regal Airport Hotel at Kai Tak.
If the arriving passenger tests positive then he is sent to hospital; if negative then he goes to his home or designated hotel room to serve 14 days of quarantine during which no visitors are allowed. On 20-Apr, a trial began with an extra spit-test to be taken on the 12th day of quarantine, in case the disease has developed during that period. Close contacts of any person who tests positive are placed in government quarantine for 14 days.
For the land border with the mainland, there is less-strict testing regime on its 2 operating land ports, namely Shenzhen Bay and the Hong Kong-Zhuhai Macao Bridge. Arrivals are asked whether they have been in Hubei Province, and if so, they must take a saliva test. But they must still do 14 days of home quarantine. Persons arriving from the mainland with visas valid for 14 days or less are denied entry, so in practice, most arrivals are returning HK residents.
The mainland quarantine was imposed by Regulation 599C (R599C, Compulsory Quarantine of Certain Persons Arriving at Hong Kong Regulation) effective 8-Feb, and unless extended, it will expire at the end of 7-May. So far, the HKSAR Government (HKSARG) has given no indication that it will extend the land border quarantine - unlike school closures, which it has repeatedly extended several weeks in advance before announcing an indefinite closure.
At the same time as R599C, Regulation 599D was introduced to require disclosure of relevant information to health officers and make it an offence to lie or withhold required information.
Separately, section 12 of Regulation 599E (R599E, Compulsory Quarantine of Persons Arriving at Hong Kong From Foreign Places Regulation), effective 19-Mar, allows the Secretary for Food and Health (SFH) to specify "any place outside China" as a place from which arrivals must be quarantined for 14 days. By notice in the Gazette, the SFH specified "all places outside China", also effective 19-Mar. Unless extended, R599E expires at the end of 18-Jun.
If you've read that carefully, you will spot a gap. R599E doesn't allow the SFH to specify any place inside China, so she cannot specify Macao or Taiwan, and Regulation 599C originally didn't apply to Macao or Taiwan either. R599C was amended to include both places, effective 25-Mar.
Both R599C and R599E allow the Chief Secretary to make exemptions, and he has done so by several announcements, covering air crew, cross-boundary goods vehicle drivers and various others. These are obviously important to ensure that the flow of goods (including food) into HK continues. They also allow our seaport to continue acting as an entrepot to the mainland.
Click here and here for exemptions under R599C from 8-Feb and 15-Feb respectively and here for exemptions under R599E from 19-Mar. The number of persons using such exemptions have not been published. Exempted persons, if they stay in HK, are under medical surveillance by the Department of Health and have to report their temperature daily. There have been several exempt persons including flight attendants and pilots among HK's COVID-19 cases, but they are not known to have caused community infections outside their homes. Still, that's a risk we have to take if we want to avoid starvation.
So from 25-Mar, all arrivals (with exceptions) from anywhere outside HK must undergo 14 days quarantine. The effect on both inbound and outbound passenger travel was dramatic:
There's nothing we can or should do to prevent HK citizens returning to HK - it is their constitutional (Basic Law) right to enter. Since quarantines began on 8-Feb with the mainland border, there's been a "return to base" effect, with a net 119,936 HK residents, or about 1.6% of the population, returning up to 25-Apr:
Community transmission in HK
There is and will remain an erratic trickle of imported cases arriving at our airport and going either to hospital or quarantine while they incubate, but those pose almost no threat to the community. We have plenty of capacity in the hospitals to handle them as our existing cases are being rapidly discharged - today (27-Apr) only 247 remain in hospital, some of whom have other illnesses.
HK is now at or close to zero local transmissions. The latest known local transmission was probably case #1026 inside HK Airport, a 47 year-old Virgin Atlantic ground crew member, probably infected by an arriving passenger from the daily UK flight. She recalls coughing on 6-Apr but she didn't visit a doctor until 14-Apr and was confirmed on 19-Apr. There were 3 cases on the Virgin flight on 6-Apr but then none until 12-Apr, so given an incubation period, it is more likely that she was infected on 12-Apr. Not all coughs are COVID-related.
Outside of the airport, the last known transmission was case #1008 reported on 13-Apr, when he was asymptomatic but already in government quarantine, because he is the 66 year-old father of case #884, who had symptoms on 30-Mar and was confirmed on 5-Apr. That means his father caught the virus on or before 5-Apr and was then placed in quarantine.
Case #884 was already in home quarantine and awaiting transfer to a quarantine centre, because he was a close contact of case #635, a woman, confirmed on 29-Mar. The pair arrived back from Macao on 27-Mar. Case #635 had developed symptoms the day before and went to hospital on arrival. The pair went to Macao on 22-Mar. At some point prior to that, she was infected as part of the infamous "Bar & Band Cluster" (see below).
We lay out that detail because you can see that some cases like #1008 are just contracted while at home with someone who is in home quarantine, not from community transmission. One way to reduce transmissions during quarantine would be to quarantine all arrivals in single-occupancy hotel rooms or government facilities rather than at home. After all, it's not like there is much demand from anyone else for hotel rooms. Several countries have done so. However, looking at the HK data, we don't see any cases where a household member of a confirmed case in home quarantine has been able to infect others beyond the household. As soon as the home-quarantined person is confirmed positive, the other members are put into government quarantine, usually before they can begin showing symptoms themselves.
So we look back further - when was the latest known community transmission in HK, not within a home quarantine environment? That was possibly case #968, who worked at Lee Gardens One in Causeway Bay until 3-Apr, developed a fever on 4-Apr and was confirmed on 9-Apr.
So our best estimate is that there has been no community transmission since (at latest) 3-Apr, and it has now (27-Apr) been at least 24 days since the last community transmission within HK, not counting the airport.
Piecemeal approach to quarantine
While HK's quarantine measures were being gradually introduced, the global COVID-19 pandemic developed faster. At each stage, the HKSARG was slow to react; it took a strike organised by newly-formed health worker unions to push the HKSARG into imposing a quarantine on the land boundary on 8-Feb, a week after we called for it and a week after Australia, Singapore and USA had already put a block on arrivals from mainland China.
After that, the HKSARG (like most governments) was repeatedly behind the curve, reacting to increases in confirmed cases in various regions rather than projecting ahead to likely increases of infections using models.
The HKSARG has never explicitly said that it is aiming for elimination rather than mitigation, but its actions say so. If the objective is and was elimination, then a complete quarantine of borders was needed rather than a piecemeal approach. To stop a boat being inundated and sinking, you plug all the holes, not just some of them.
Inbound quarantines were imposed piece by piece as follows:
|Effective time||Arrivals from|
|08-Feb 00:00||Mainland China|
|25-Feb 06:00||Daegu and Gyeongsangbuk-do (South Korea)|
|01-Mar 00:00||Emilia-Romagna, Lombardy or Veneto (Italy), Iran|
|14-Mar 00:00||All of Italy, Bourgogne-Franche-Comte or Grand Est (France), North Rhine-Westphalia (Germany), Hokkaido (Japan), La Rioja, Madrid or Pais Vasco (Spain)|
|17-Mar 00:00||All countries in the Schengen Area in Europe|
|19-Mar 00:00||All foreign countries/territories|
|25-Mar 00:00||Taiwan and Macao (amending R599C)|
You will note that the HKSARG tried to quarantine arrivals from bits of countries in Europe, then all of Italy, ignoring the fact that there was a free-movement zone (the Schengen Area) covering 26 European states that have no passport controls, and normally no health controls, between them. It wasn't a sensible approach if the object was to prevent community spread from arrivals from anywhere in Europe, and meanwhile, arrivals from the UK, USA and rest of the World were continuing for over a week after the WHO declared COVID-19 to be a "pandemic" on 11-Mar with 118,000 confirmed cases in 114 countries. By 19-Mar when we quarantined arrivals from all foreign countries, there were already 209,839 global confirmed cases, and by 25-Mar when we quarantined arrivals from Macao and Taiwan, there were 414,179 global confirmed cases.
Cast your mind back to 7-Mar, when new cases in HK had reduced to just a handful - in fact on two days that week, 3-Mar and 5-Mar, there were no new cases. The Government announced on 7-Mar the limited reopening of some public facilities including libraries and museums, effective 11-Mar. But they had still not introduced a full border quarantine, so trouble was already on its way, as imported cases without quarantine would spread in the community, triggering a second wave. That was entirely predictable. Just the day before, 6-Mar, the Government announced that all airport arrivals would have to fill in a "health declaration form", citing at least 16,600 confirmed cases outside China in 80 countries/areas. The measure was too little, too late. Forms don't reduce transmission, quarantine does.
Since 25-Mar, with a few exceptions, anyone arriving at the airport is denied entry unless they are a "HK resident". Exceptions include the spouse or minor child of a HK resident. In practice "HK resident" means anyone with a HK Permanent ID Card, even if they live in overseas countries. If you are born in HK to a Chinese parent then you basically have that status for life even if you leave.
We've noted a number of inbound COVID-19 cases who are "resident" overseas but are entitled to return with their HKID card and enjoy HK's less congested hospitals, and a trickle of such cases will continue, but the important thing is that they either go straight to hospital or into home/hotel quarantine if tested negative. Residents of Macao and Taiwan are also allowed in, with quarantine.
This citizens-only restriction has been necessary simply to prevent medical refugees from places with high rates of infection arriving in HK and seeking treatment here. Airport transit services (connecting flights) have also been suspended.
After moving on from health declaration forms, the initial testing approach at the airport was quite relaxed. Passengers arriving from certain places, from 25-Mar including UK and Europe, and from 8-Apr from all places, were given spit-jars and asked to return them later. Not all did. The importance of the new regime, testing on entry and on day 12 of quarantine, was highlighted by case #1036 announced on 23-Apr, a 58 year-old male who had been in the UK and US, arriving back on 24-Mar. He finished his home quarantine on 7-Apr, and despite having symptoms from 26-Mar, he decided to visit his office 3 times, get a tooth extracted and get a haircut. It was only on 21-Apr that he got tested at his doctor and was subsequently sent to hospital.
As a result of the slow adoption of quarantine detailed above, several new community clusters were seeded by arrivals and grew in HK, the largest of which became known as the "Bar & Band Cluster", referring to a band which played in a chain of 4 bars, their staff and customers. Including connected cases, we count at least 92 in that cluster. Several single-digit clusters emerged from dinners and Karaoke sessions and a wedding reception. The contact-tracing efforts have now terminated all of those clusters. The peak reporting day came on 27-Mar with 65 new cases, including 41 with a travel history. For patients without a travel history, the peak was also that day, at 24 cases, of which 21 were in the Bar & Band Cluster.
Also on 27-Mar, the HKSARG announced two new sets of regulations. Regulation 599F (R599F, Prevention and Control of Disease (Requirements and Directions) (Business and Premises) Regulation), effective 28-Mar, and Regulation 599G (R599G, Prevention and Control of Disease (Prohibition on Group Gathering) Regulation), effective 29-Mar. Each lasts 3 months. Briefly, R599F empowers the SFH to order closure of food and drink catering businesses and various types of premises including fitness centres and places of entertainment or amusement. R599G empowers the SFH to prohibit gatherings of more than 4 people in public places for up to 14 days, with exceptions. It does not apply to gatherings in private places.
R599F was activated by two notices in the Gazette for 14 days starting at 18:00 on 28-Mar, closing the aforementioned premises and requiring tables of bars and other catering facilities to be spaced by 1.5 metres with a limit of 4 people per table. Click here for the directions on catering and here for the directions on premises. R599G was activated by a Gazette notice effective 29-Mar for 14 days.
On 1-Apr, HKSARG announced that R599F was amended effective 15:00 on 1-Apr to include beauty parlours, club-houses, nightclubs, karaoke establishments, mahjong-tin kau premises and massage parlours. That was activated by two Gazette notices here and here effective 18:00 on 1-Apr for 14 days: night clubs, karaoke and mahjong-tin-kau premises were ordered closed. Beauty parlours, club-houses and massage parlours continued operating but masks, hand sanitizers and temperature screening were required.
On 2-Apr, the HKSARG announced that, with the Bar & Band Cluster at 76 cases (including spread), the SFH was ordering bar closures from 18:00 on 3-Apr for 14 days.
On 8-Apr, the HKSARG announced that all the orders under R599F and R599G would continue for 14 days from 10-Apr to 23-Apr, and expanded them to order closure of beauty and massage parlours.
On 21-Apr, even though there had been no new local cases reported since 13-Apr (not counting the airport ground crew case), the HKSARG extended all the orders by 14 days to expire at the end of 7-May, which just happens to be the date on which R599C (the mainland border quarantine) is currently set to expire. Notably, although the Chief Executive is supposed to make her decisions to issue or repeal regulations "in Council" - that is, with the advice of her Executive Council, she announced this decision (technically made by the SFH) at a media briefing before the ExCo meeting. She could at least have pretended to discuss it with them first.
The only minor change was that restaurants are no longer limited to 50% of the "normal seating capacity", but in practice that makes little or no difference when they have to separate tables by 1.5 metres.
How the Regulations are made
It should not have escaped your notice that none of the Regulations, R599C to G, was subject to the scrutiny and approval of the Legislative Council. They were all made by the Chief Executive in Council (CEIC) under Section 8 of the Prevention and Control of Disease Ordinance, which states that on any occasion which the CEIC considers to be an occasion of a public health emergency (PHE), she may make regulations for the purposes of preventing, combating or alleviating the effects of the PHE and protecting public health. A PHE is defined as:
(a) the occurrence of or the imminent threat of a disease, an epidemic or a pandemic;
(b) the occurrence of a novel, or highly infectious, agent or matter; or
(c) the widespread exposure or the imminent threat of widespread exposure of human beings to an infectious agent,
that has a high probability of causing a large number of deaths in the population or a large number of serious disabilities (whether or not long-term) in the population. (our bold)
An "infections agent" is defined as "a parasite, a fungus, a bacterium, a virus, a prion or any other agent that can cause an infectious disease". Clearly, the virus SARS-CoV-2 can cause an infectious disease, COVID-19. However, when you have erected a nearly complete quarantine around HK against entry of that infectious agent, reducing it to occasional leaks from inbound arrivals that can be traced and contained, then it is hard to argue that it still has a "high probability of causing a large number of deaths". It is not enough to have a low probability of a large number of deaths, or a high probability of a small number of deaths.
For that reason alone, the social regulations R599F and R599G are now looking invalid, and any attempt to extend them further may fall subject to judicial review by those most affected. R599G in particular, banning gatherings of more than 4 people, is a gross infringement of civil rights of assembly and is starting to look like an anti-protest measure rather than an anti-epidemic measure. If there are only single-digit or zero cases in the community (not in quarantine) then your chance of encountering one of them in the wild is near-zero. Meanwhile, R599F is depriving tens of thousands of people in the services sector of their economic livelihoods.
It's also notable that even before the issue of R599F and R599G, there had only been 4 deaths in HK from COVID-19 in nearly 3 months, the latest on 13-Mar. Contact-tracing and containment were still working, and the quarantine on all arrivals, only introduced on 25-Mar, had nearly eliminated the risk of them causing local transmissions and should have been given time to work. With the full quarantine, a repeat of the Bar & Band Cluster was unlikely.
The outbreak in HK never reached the stage where there was a high probability of a large number of deaths. If anything, the social Regulations were just an imitative response to what overseas governments with far higher case-loads were doing at the time.
Time to enjoy HK
HK citizens, unable to travel without a 14-day quarantine on return, should now be allowed to enjoy the safety and security that the quarantine and testing at our borders has bought them. It's time to re-open all our public facilities, including but not limited to the theme parks, cinemas, concert halls, libraries, museums, sports facilities, bars and restaurants, schools and universities, without restrictions.
We should also begin the process of negotiating bilateral quarantine-free travel with other countries/territories that have reached sustained zero local transmission and are maintaining a quarantine against the infected parts of the world, or what we call the Quarantined Union for International Exempt Travel (QUIET) area. Limits could be agreed on what level of domestic transmission within our partner territories would trigger renewed quarantine against them.
We can start with our fellow SAR, Macao, which has had no new cases (even imported) since 8-Apr. Quarantine-free travel between Macao and HK should now be allowed. Taiwan is also getting close to zero, so quarantine against Taiwan could soon be dropped, as long as they maintain a quarantine against external infections. Australia, New Zealand and South Korea could soon join us.
The HKSARG should tread very carefully to test inbound travellers from the mainland (including HK residents) before lifting the quarantine against them when it is deemed safe to do so. At that point, we can welcome back our compatriot tourists and shoppers, and get thousands of HK people back to work. That would also allow HK residents to start travelling again within China without quarantine.
We hope that bilateral travel with other clean countries will soon follow. But until a vaccine or effective treatment becomes available, we should not drop our quarantine on arrivals from infected countries, unless HK society is collectively willing to surrender to COVID-19 and accept the consequential death toll on the aged and infirm.
© Webb-site.com, 2020