It's been two years since Sars caught Hong Kong unawares, and amid the increasing threat of bird flu as the chances become more real of a devastating human-to-human transmission, the question remains of Hong Kong's awareness of its own vulnerability. Although Hong Kong's health professionals are arguably the best prepared in the world to handle such a pandemic, the city's geographical position and the lack of preparedness evident in its close neighbours makes it highly vulnerable indeed. But what about our population? Are the higher levels of hygiene that were hammered home post-Sars still evident? Are the public facilities we use every day being kept clean enough to minimise risks of contamination from some new bacteria or virus? The South China Morning Post, with the help of Hong Kong Polytechnic University, conducted a series of mid-summer tests in some of the city's busiest areas to determine just how potentially dangerous are some of the things people touch during daily activities such as travelling to work, making a cash withdrawal, or talking on the phone - objects that might serve as critical means of germs being spread within the community. Following instructions from PolyU's laboratory experts, the Post collected bacteria samples with swabs. Samples included 60 escalator belts in MTR stations, the buttons of 30 non-air-conditioned lifts, 30 automatic teller machine buttons, 30 hand grips on buses, and 31 public phone mouthpieces in places such as Causeway Bay, Mongkok and Kowloon Tong. The swabs were sent to the PolyU laboratory immediately for multiplication. During the process, germs were agitated and left to grow on different agar plates so the total number of organisms and the numbers of the MRSA virus, coliform and Staphylococcus aureus bacteria present could be counted. The MRSA virus is a so-called superbug - deadly because of its high resistance to antibiotics. It is most commonly found in hospitals, but increasingly has been located in other communal areas in developed nations such as Australia and the US. Staphylococcus aureus and coliform are more commonly found, and although less serious, both are indicators of hygiene levels within the community. Staphylococcus aureus can cause disease, particularly if there is an opportunity for the bacteria to enter the body. Illnesses such as skin and wound infections, urinary tract infections, pneumonia and bacteraemia (blood stream infection) may then develop. It can also cause food poisoning and corneal infection if it enters the eyes. Coliform by itself is not usually pathogenic. Coliform resides in the intestine, and its presence on objects often indicates contamination from faeces. They are indicator organisms, which means they may indicate the presence of other pathogenic bacteria such as salmonella. The Post investigation showed a good report card for most areas tested, apart from one or two notable exceptions. But experts warned the tests were not conclusive, and residents needed to be more vigilant with their personal hygiene, and aware of how easily disease can spread in high-density areas. The results showed no trace of MRSA in the sampled locations. The overall level of organisms present was generally low, with most samples containing less than normal acceptable levels of 1,000 organisms per square centimetre. However, some places visited by a high number of Hong Kong people and tourists did show cause for concern. For instance, the buttons of a cash machine at Chek Lap Kok airport contained 10,800 organisms per square centimetre, while 9,800 organisms per square centimetre were found in a sample taken from an outdoor cash machine at Mei Foo's Broadway. On the previous day, a Sunday, an escalator belt in crowded Causeway Bay MTR exit E showed a level of 7,300 organisms per square centimetre. Margie O'Donoghue, assistant professor of the school of nursing at PolyU and a consultant for the study, said the findings demonstrated that Hong Kong remained a clean city two years after the outbreak of severe acute respiratory syndrome. During and after Sars, massive clean-up programmes were undertaken in public places and on the streets of Hong Kong. 'The hygiene condition is promising, as it reflects a low level of bacteria contamination in the crowded sites, even during summer time,' Professor O'Donoghue said. 'There were only individual instances where high contaminations were recorded, but the overall situation was quite good.' Maureen Boost, principal lecturer of PolyU's department of health technology and informatics, said that the absence of MRSA in the sample locations was encouraging. Dr Boost said that compared with countries such as the US and Australia, where the level of MRSA existing outside hospitals was rising fast, Hong Kong seemed to have done a good job in confining the resilient superbug. Although the findings indicate satisfactory hygiene levels, the results showed concerning levels of contamination at a few locations by two health-affecting germs. The study revealed that coliform existed in many tested samples, although most were below the acceptable level of 100 per square centimetre. Staphylococcus aureus, a highly antibiotic resistant germ, is carried in the noses of a quarter of the population, and hands easily become the carriers. On the buttons of a cash machine at Sha Tin's KCRC station, more than 3,000 Staphylococcus aureus were found in one square centimetre, over 30 times the acceptable level of 100 organisms per square centimetre. Professor O'Donoghue said such locations were worthy of attention, as their cleanliness might further deteriorate and the health of those who touched these areas might be at risk. 'We see that some escalators [in MTR stations] and cash machine buttons can contain as much as 7,000 organisms per square centimetre,' she said. 'That means that there are chances that things can get worse and people may be infected if they fail to wash their contaminated hands before touching food.' Gerald Dziekan, an infection control specialist with the World Health Organisation's Communicable Disease Unit, disagreed that the absence of MRSA in sampled locations was a reassuring indicator for the community. His argument was the findings were not substantial enough to conclude that the general carrier rate was low among the Hong Kong population. 'One reason is that even if we fail to find MRSA on some locations, it does not mean it is not on others,' Dr Dziekan said. He also warned that bacteria competed against each other for space, so while they might not be found on one part of a surface, they could exist on another part. 'I can't judge by the results and conclude the places are clean or not,' he said. 'A centimetre away from the swabbed site on the same object may yield totally different results. That's why we can't generalise the situation.' Although Dr Dziekan refused to comment specifically on the results of the research, he said that because it was almost predictable to see a high level of contamination from coliform and Staphylococcus aureus on public items worldwide, linking their presence with a place's cleanness might not be always be accurate. 'Their presence is a global phenomenon. Sometimes I am more surprised with the low level of contamination as shown in other surveys,' he said. 'For things which people touch regularly, such as ATM machine buttons and escalator rails, it is normal to find all sorts of bacteria. 'But the core question is not whether a high level of bacteria present on public things is health-affecting or not, but the fact that people who carry the bacteria and undergo high-risk hospital treatments such as operations or injections may have a greater chance of getting infected. 'The same [risk] is for people who prepare food and deal with children with the same polluted hands.' Dr Dziekan said that any limited-scale testing might not reflect the real hygienic condition of Hong Kong - and perhaps not even of the tested items. The Department of Health would not comment on the survey, but said there was no reason to believe Hong Kong's hygiene levels had worsened, because no previous research was available for comparison. A spokesman for the Department of Health cited a survey it conducted on the habit of mask wearing among Hong Kong people last April, and said the preliminary results showed that 59.2 per cent of interviewees put on masks when they developed symptoms of respiratory infection or fever. 'We find the results positive, although there is always room for improvement,' the spokesman said. Legislator Kwok Ka-ki, deputy chairman of the Legislative Council health services panel, said he was not surprised with the results of the test. 'It is expected that no MRSA would be found in public places, as they are more common in hospitals,' he said. 'And I think the presence of bacteria [such as coliform and Staphylococcus aureus] is a hard fact.' However, Dr Kwok said he believed that compared with efforts two years ago to promote personal and public hygiene, Hong Kong people now seemed more relaxed. 'I have the impression that many people have forgotten [the precautions] we strictly observed when Sars hit us. Fewer people use serving chopsticks and wear masks when they are sick. They also wash their hands less frequently.' He advised the government to take more action to encourage people to keep themselves, and especially their hands, clean. One improvement would be erecting more public toilet facilities. 'The principle of not getting harmed by germs involves always washing our hands before touching food or wounds,' he said. 'But there simply just aren't enough public toilets and hand-washing facilities around.' Hygiene hot spots Although areas tested by the Post indicated a general level of cleanliness, the places below showed higher bacteria levels than the rest. The figures show organism counts per square centimetre. Generally acceptable total levels of organisms per square centimetre are less than 1,000, whereas a count for coliform or Staphylococcus aureus that approaches or exceeds 100 per square centimetre is cause for concern.