What Hong Kong Has Done Right

Despite a crowded, aging population and thousands of Mainland Chinese and Western visitors, Hong Kong has only had four COVID-19 deaths.

While substantial risk of spread remains, Hong Kong has until now had more limited COVID-19 growth than nearly anywhere in the world.

Hong Kong was vulnerable to COVID-19

In many ways, Hong Kong’s success containing the virus is against the odds.

1. Hong Kong has the fourth highest population density in the world and 90% of the population uses public transportation.
2. Hong Kong was affected early, with the first confirmed case on January 22. By end-January, there were already 13 confirmed cases.
3. There were multiple daily direct flights from Wuhan and tens of thousands of daily Mainland Chinese visitors in January and thousands of European visitors in February.
4. Hong Kong is among the world’s most elderly countries, with a median age of 44.4.

Despite this, as of April 8, Hong Kong has only had 4 deaths due to COVID-19 and fewer than 1000 confirmed positive cases. The majority (59%) of the cases have been imported, i.e. patients who likely contracted the virus before arriving in Hong Kong. This suggests that Hong Kong has successfully staved off exponential local transmission during the first three months of the crisis.

Source: https://www.worldometers.info/coronavirus/ Data as of April 8, 2020

Local transmissions rose when people returned to HK from the USA and Europe but recently leveled off as returnees have been required to quarantine. Source: https://chp-dashboard.geodata.gov.hk/covid-19/en.html

Four keys to Hong Kong’s limited COVID-19 growth:

1. Hong Kong began shutting down public facilities when there were fewer than 10 confirmed cases. The government acted with urgency as soon as the first cases began to appear. Hong Kong shut down all schools, parks, and public museums on January 29th when there were just 9 confirmed cases and zero deaths. The Hong Kong Marathon was canceled on February 8, when the city had only 36 confirmed cases. This stands in stark contrast with governments elsewhere who were quick to administer travel bans but slow to encourage, much less mandate, social distancing. Examples include President Trump suggesting the threat from COVID-19 was exaggerated and Bill DiBlasio recommending New Yorkers go out on the town in early March. Other examples include the mayor of Los Angeles allowing a 27,000-person LA marathon when there were hundreds of cases in California and Madrid holding the International Women’s March in early March. According to Professor Yanzhong Huang at Seton Hall University, “Hong Kong chose in the very beginning to move toward maximizing protection, while [other countries] seemed focused on minimizing disruption to the economy and society.”
2. Hong Kong isolates ALL positive cases and quarantines close contacts in government facilities. Every person who tests positive, even if symptom-free, is put into the public hospital system. Patients are then required to remain at hospitals until they produce two consecutive negative tests. Should hospitals run out of beds, the government will isolate patients in other facilities. Details about every case are made public through government websites. All known contacts of the positive cases must spend 14 days in government quarantine. The importance of isolating positives cannot be understated. A study of one China province showed that 80% of cluster infections originated from people who tested positive and were told to rest at home. Wuhan began quarantining all mild cases in makeshift hospitals converted from offices, stadiums, and gymnasiums in early February, a move that helped dramatically slow the spread of the virus. Doctor Aaron E. Carroll wrote in the New York Times that a robust system of contact tracing and isolation is necessary to prevent further outbreak and lockdown.
3. Hong Kong’s population has broad virus awareness, largely a result of SARS. The memories and lessons of SARS linger in Hong Kong. Since well before COVID-19, masks have been commonly used by individuals who harbor a common cold. Buttons on elevators are frequently sterilized once if not more times each day. It is customary not to wear shoes within the home and gel sanitizer is widely available throughout shared facilities such as office buildings. The population quickly tapped into virus-prevention mode as soon as the news of the virus circulated from Mainland China. Not wearing a mask is shunned in Hong Kong, and the population takes pride in responsible, virus-preventative everyday behavior. According to a poll by SCMP, the majority of Hong Kong residents believe they have only themselves to thank rather than the government if the city wins its battle against COVID-19.
4. Hong Kong tests all people entering the country and requires them to home quarantine for 14 days. Hong Kong only recently implemented severe travel bans, denying entry to non-residents on March 25. There was, however, a 14-day required home quarantine for people arriving from Mainland China, which was then expanded to arrivals from nearly anywhere in the world. While a delay in requiring home quarantine for European and American visitors led to a second wave of cases, that surge has already begun to flatten. People in home-quarantine wear electronic bracelets that track location. While there were initial glitches with the technology, the spirit of the law is broadly respected and violations are enforced. Three people have already been sentenced to jail time for breaking the quarantine.

Hong Kong has used a required 14-day home quarantine to limit visitors and prevent infected returnees from spreading the virus

What has Hong Kong NOT done?

Hong Kong has not undertaken certain tactics more commonly employed in other parts of the world. Some of these tactics could potentially slow the spread of COVID-19 even further. Such restraint may arguably have helped the economy — already suffering from the preceding months of political protest — to avoid a full shut down. But it may also be limiting a more accurate and comprehensive understanding of the virus’ spread, including the risk posed by asymptomatic people.

1. There has not been mass-testing of the public. While home-testing is available via private health clinics and on-site testing is available at public hospitals, there has not been testing of the broad population. There is even a potential disincentive to get tested, as a positive test will lead to the required hospitalization of the patient and government quarantine of his or her family members. In worst-case scenarios, parents and children are even sometimes separated, which further disincentivizes testing. Some health experts still are calling for more widespread public testing.
2. There has not been a total economic shutdown. While the economy has slowed substantially, restaurants remain open and businesses are still allowed to have employees work from the office. Central Hong Kong, the city’s primary business district, has substantial foot traffic with people standing close to one another. Over the past four weeks, more establishments have been closed, and both lawmakers and academics have suggested a potential for further shutdowns, but a shelter-in-place or safer-at-home order has not been implemented.

Hong Kong has not gotten this crisis perfect and is still a long way from being rid of the virus. Many of the measures have only been possible because of Hong Kong’s unique positioning as a city-state, and the public’s wide acceptance of the government’s role in defeating a pandemic. Nevertheless, it does provide an example of an extremely dense city that has, until now, avoided exponential COVID-19 case growth. The steps Hong Kong has taken could potentially help limit future waves or be used as a model for future pandemics.