Keeping a killer out
Sars forced Hong Kong to sharpen its disease control strategy, but an overstretched health system remains its Achilles' heel, writes Ella Lee
Part 2 How hospitals fought back
On or off duty, Leung Pak-yin always keeps an ear cocked, waiting for his mobile phone to ring. Like another 20 or so health officials and experts across Hong Kong, the Hospital Authority's director of quality and safety knows he may receive alarming news at any time.
Five years after Sars crippled Hong Kong and sent shock waves through health systems around the world, Dr Leung is one of the linchpins in the city's new frontline defence system, the Notifiable Diseases and Outbreaks Reporting System (NDORS) - a network linking the Centre for Health Protection (CHP) and other relevant parties to allow Hong Kong to react rapidly to disease outbreaks.
But the picture was very different five years ago, when severe acute respiratory syndrome struck the city and claimed 299 lives. When the then unknown virus first hit ward 8A at the Prince of Wales Hospital in Sha Tin, it was a mysterious illness that overwhelmed health-care workers. By early March the disease had forced 11 of the ward's staff to go on sick leave. An influx of patients paralysed public hospitals as the infection rate soared, reaching 100 cases a day by late March. The city was soon designated an unsafe destination by the World Health Organisation.
Since those dark days, three investigations into the handling of the outbreak - one by a government-appointed Sars expert committee, another by the Legislative Council and a third by the Hospital Authority - have exposed how poorly prepared Hong Kong was for the outbreak of an unknown disease.
Five years after that painful lesson, experts say some things have changed for the better, but that other weaknesses have emerged in the health system.
The University of Hong Kong's head of microbiology, Yuen Kwok-yung, and Dr Leung agree that the infrastructure for disease surveillance and reporting has improved. They praised the setting up of the CHP in June 2004 as a milestone in disease control and prevention.
Proposed by the Sars expert committee and modelled on the US Centres for Disease Control and Prevention, the CHP has brought medical experts from various specialist areas together on its seven scientific committees.
The Hospital Authority has also improved its facilities by adding 1,400 isolation beds, 108 of which are in the new Infectious Diseases Centre at Princess Margaret Hospital.
Legal safeguards are also being introduced, with the government tabling the Prevention and Control of Disease Bill to give it more power to act swiftly in an emergency. The legislation allows officials to requisition private property, arrest anyone who escapes from detention and seize contaminated agents or articles. It also provides for compensation for such seizures and is expected to pass this year.
But frontline doctors worry that as public hospitals are still heavily overloaded, there is no 'surge capacity' to fight another epidemic. Private doctors also say they lack disease control support from the CHP. Some experts warn that a more relaxed attitude to public hygiene in Hong Kong will make the city vulnerable again if Sars returns or if bird flu becomes a pandemic.
Dr Leung, former CHP controller and deputy director of health during the Sars outbreak, said he was confident Hong Kong was much better prepared for further disease outbreaks. He said that before Sars struck, frontline doctors had to go through a many-layered reporting system for infectious diseases - first to their seniors, then to the hospital chiefs, then the Hospital Authority's head office and finally to the Health Department.
'Now frontline doctors can report to the CHP directly. The centre will instantly inform relevant parties through NDORS. The response is much quicker,' he said.
Dr Leung said five public hospitals, together with the Public Health Laboratory, could test more than 1,000 suspected Sars samples daily. A diagnosis could be made in four hours using quick tests.
The authority has one full-time infection control nurse for every 250 hospital beds. These nurses report to infection control officers and regularly audit hospital staff's compliance on good hygiene practices such as wearing masks and washing hands.
'Infection control is now deeply rooted in our clinical practice,' Dr Leung said. 'Everyone is on high alert when a patient with fever and respiratory symptoms arrives. It is different from the situation before Sars.'
He said another improvement was a closer link between Hong Kong and the mainland in disease control. Rather than being reliant on restrictive high-level communication, as they were during the Sars outbreak, health officials and experts now could communicate informally at an operational level.
Dr Leung said Sars had been a wake-up call to health officials, who had been forced to realise that openness and transparency were critical to allowing an informed public to help control any outbreak.
Experts say technology has also played a key role in strengthening response plans. Raymond Yung Wai-hung, head of the infection control branch of the CHP, who was at the helm of the design of NDORS, said the system allowed clinicians to report all 35 notifiable diseases online. At present, 95 per cent of infectious disease cases are reported through the system, allowing analysis to determine whether cases reported by different clinicians are related.
Another system, called E-Sars and E-flu, gives health officials real-time information on any outbreak.
'During Sars, the Hospital Authority took an entire morning every day to take stock of public hospitals before the 1pm cut-off time so the latest number of patients or deaths could be released at the 4.30pm press conference,' Dr Yung said. 'But with the E-Sars and E-flu system, we can update the information at any time.'
A new contact tracing system also helps hospitals to track down potential victims of an outbreak instantly. Contact tracing during the Sars outbreak was slow because it was done manually by nurses sifting through patient admission records to track down individuals who had been in contact with Sars patients during the disease's incubation period.
Professor Yuen, who is also chairman of the CHP's scientific committee on emerging and zoonotic disease (diseases transmissible from animals to humans), said the scientific committees were new forums for experts from different disciplines to exchange ideas. 'If we don't get prepared, when an outbreak arrives it will be too late,' he said.
Professor Yuen said clinicians in the past had found it difficult to communicate directly with senior health officials.
'Now clinicians just pick up a phone to contact CHP officials and communication is instant,' he said. 'Time is always the key in disease control. If we want to minimise lives lost and economic losses to the city, we have to act quickly.'
Although weaknesses in Hong Kong's public health-care system were exposed by the Sars outbreak, the city has won global recognition for its ability to detect and trace a deadly and unknown disease.
In 1997, experts in Hong Kong were the world's first to detect bird flu infections in humans and, in 2003, the source of the Sars infection - the coronavirus - was identified by Professor Yuen and his team.
Professor Yuen said Hong Kong needed to blaze its own trail in disease control rather than blindly follow overseas experience. 'Hong Kong cannot just follow the US because each place has its own situation. Hong Kong has to find its own ways, as we have with Sars and bird flu.'
But he said Hong Kong still spent too little on medical research. 'We hope the government - especially with such a big budget surplus - will put more resources into medical research,' he said.
He also warned that crowded public hospitals made the city more vulnerable to disease outbreaks.
Ho Pak-leung, vice-president of the Hong Kong Public Doctors' Association, said that apart from crowded conditions at public hospitals, the chronic manpower shortage facing the Hospital Authority would be another challenge if Sars returned.
Dr Ho, also a University of Hong Kong microbiologist, said that while the Hospital Authority had improved its hardware, its management had failed to deal with a personnel shortage and poor staff morale.
He said the reports of the three Sars investigations had all called for a surge capacity at public hospitals to deal with massive outbreaks.
'Public doctors are overworked and public hospitals are always full. How can we have a surge capacity to deal with another outbreak of Sars or bird flu? We are already fighting a war here every day. How can we fight a bigger war with no extra resources?'
Joseph Sung Jao-yiu, chair professor of the Chinese University's department of medicine and therapeutics, said: 'Hospital hardware is better now. We have more isolation facilities and medical supplies. But overall staff morale is even worse than before Sars. It is rather worrying.'
Professor Sung also said there was growing public apathy about disease prevention, with fewer people wearing masks when ill and people washing their hands less often.
Dr Yung said his team was working to improve hygiene awareness among members of the public, having compiled infection control manuals for sites including retirement homes, welfare institutions and hotels. The CHP is also publishing a new manual for households and domestic helpers.
A year ago, the Hospital Authority launched a hand hygiene programme modelled on a World Health Organisation scheme, in which it provides health-care workers with inexpensive alcohol rubs to clean their hands, reducing the time spent by doctors and nurses washing their hands every time they touch a patient.
But Choi Kin, president of the Hong Kong Medical Association, said the city's preparedness plans lacked one crucial element: adequate engagement of some 3,000 private doctors by the CHP in its disease control strategy. He said most doctors did not even know how to send patient samples to the CHP for testing.
'We don't know which number to call or who to contact. The system is not user-friendly at all,' he said. 'If a doctor faces a suspected bird flu patient in his clinic, what should he do? Will CHP or public hospital staff arrive at the door of the clinic and take samples and take care of the patient? All these questions remain unanswered.'