4.7.2003

Press Release

Hong Kong Doctors Union with 1,700 private and public doctor members has written the enclosed Submission on the Government's handling of SARS with comments and recommendations.  For your information, it has been sent to the following parties:-

  1. SARS Expert Committee
  2. Review Panel on SARS Outbreak of Hospital Authority
  3. Mr. C.H. Tung

Contact person: Dr. Yeung Chiu Fat, President, Hong Kong Doctors Union

Pager - 7838 2831

28.6.2003

Position paper of Hong Kong Doctors Union on SARS saga

INTRODUCTION

In just over 3 months, we witnessed the aftermath of SARS epidemic in Hong Kong. SARS not only took away the lives of 297 innocent people; it has a far damaging effect on the economy and the morale of people in Hong Kong. At one time, SARS stretched the potential of our high standard public health care system to the limit and caused panic in the whole community. When we look around the world, there is no place like Hong Kong where SARS has caused such high mortality and morbidity rate.

Are the front line health care workers at fault? No. Those health care workers in the Prince of Wales Hospital were even praised as heroes in the Time Magazine. They deserved our utmost respect. Some even have sacrificed their own lives in saving the lives of SARS patients.

Are the health administrators at fault? Is the health care system in Hong Kong wrong in the very first beginning? This paper attempts to review the SARS incident from the perspective of Hong Kong Doctors Union and to contribute to guard the citizens of Hong Kong from further outbreak of highly contagious infectious diseases like SARS.

 

FACTS

13th March 2003

Hong Kong Doctors Union is the First Medical Organisation who gave the warning signal to Front Line Doctors to wear masks as a preventive measure against the SARS. This was the result of collective wisdom from our members from both the public and private sectors. The recommendation of mask wearing to Front Line Doctors through our rapid communication system by the Union came on 13th March 2003 as a result of painstaking evidence collection and logical thinking, especially when we knew that one of our members got infected after a TWO MINUTE consultation with a patient with SARS.

We circulated by rapid communication system among members reminding them the importance of wearing masks on 13th March 2003 even though Dr. the Hon. Lo Wing Lok announced in RTHK on 12th March 2003 that masks were ineffective and were not required.

Subsequently, our warning was eventually affirmed by the HKSAR Government on 18th March 2003, supported by microbiologists in the University of Hong Kong, proven by the Chinese University on 12th April 2003 and evidenced by the fact that none of all the private colleagues suffering from this deadly disease worn mask before contracting it (except Dr. Thomas Cheung who was an ENT surgeon). However, we feel extremely sorry to lose one of our members who did not wear mask in treating SARS patients, Dr. Lau Tai Kwan, in this mysterious virus war.

16th March 2003

On 16th March 2003, we held a seminar on Atypical Pneumonia. In the seminar, Dr. Lau Tai Kwan complained that after two suspected cases of Atypical Pneumonia he referred to public hospitals were refused, he had to admit them into private hospitals under his care. Subsequently he was admitted to Princess Margaret Hospital on 23rd March 2003 and died of SARS.  Many Hong Kong Doctors Union doctors started wearing masks on the 17th March 2003 disregard of reassurance from the Government that there was no community outbreak

17th March 2003

Dr. Lai Wing Lun, one of our members, was admitted into Princess Margaret Hospital on 14th March 2003, our President spoke to the media about a community outbreak since the Government did not admit it, but he was told by the Director of Health that Dr. Lai・s case was not related to SARS on 17th March 2003.

Actually, Dr. Lai Wing Lun of Yau Ma Tei was infected by a SARS patient who later died in Queen Elizabeth Hospital. Dr. Lai was infected after a TWO MINUTE consultation with that patient suffering from SARS. Subsequently his wife and his 4 nurses and another private doctor (Dr. Lee) got infected too by 18th March 2003. In the beginning, the Government selected only to trace contacts of confirmed cases and refused to trace contacts of unconfirmed cases as in the case of family members of Dr. Lai Wing Lun, allowing the virus to spread undeterred and the health authorities became led by the virus instead of containing it.

If the Government had realised the importance of Dr. Lai・s case in the beginning as another source of SARS apart from Prof. Lau of The Metropole Hotel and if only there was earlier and more stringent health alerts, there would have been much less morbidity especially in the community and doctors in the community would not need to die.

20th March 2003 to 27th March 2003

During a public forum screened in Television in March 2003, Dr. the Hon Lo Wing Lok asked the public to trust the Government in handling of SARS, when people suspected something serious is happening and wanted the Government to do more. Even in the days following finally on the 18th March 2003 when the Government did ask the public to wear masks, she did it only half-heartedly.

We have challenged the authority・s statement of SARS confining to the hospital in the very beginning and we have even stepped up our suggestions to the HKSAR Government in our two press statements to combat community outbreaks on 20th and 24th March 2003 (Appendix I and II). The measures we suggested were enforcing mask wearing in crowded areas, strict isolation measures for close contacts, close schools for two weeks and health checks in the border.

When our President called for schools to be closed for two weeks on 23rd March 2003, we were criticized by Dr. Leung Pak Yin in the afternoon of 23rd March 2003 as creating panic in the community and the Hong Kong Medical Association representatives as being hysterical in a meeting with Dr. E K Yeoh on 25th March 2003. Our advice was not taken seriously even after our meeting with Dr. E K Yeoh on 25th March 2003 in the Health, Welfare and Food Bureau until there was an outbreak of SARS cases in Amoy Garden on 26th March 2003 and then the Chief Executive announced on 27th March 2003 to implement the measures which we had suggested.

10th April 2003 to 12th April 2003

Noting there was an increasing number of new cases and mortalities from the SARS even after the implementation of the above mentioned measures by the Government, we held a press conference on 12th April 2003 to suggest further step up control measures to be taken by the HKSAR Government to attack and contain the mysterious virus then confirmed to be coronavirus, possibly originated from animals. Please refer to the HKDU Press Statement on 10th April 2003 as reproduced in the Appendix III. The measures we suggested included compulsory mask wearing, quarantine and isolate close contacts and hospital staff caring SARS patients, :close; border between Hong Kong and Mainland China for travelers in leisure or home visits, surveillance and quarantine of visitors in the ports, posting lists of SARS affected resident areas and private doctors (on a voluntary basis).

23rd June 2003

However, on the day when Hong Kong was taken off areas of epidemic, there were already 1,755 patients who suffered from SARS with a high percentage from health care workers. Moreover, the mortality rate was over 16.9%, which was the highest in the world.

REVIEW

In the review, we are of the opinion that there were a lot of shortcomings in the Government.s handling of the SARS saga and need to be improved. 

It is our belief that the SARS outbreak could have been contained a lot earlier, and we have identified problems in the following areas:

  1. Repeated and gross underestimation on the whole situation against SARS;
  2. Blind and deaf of health administrators to advices and suggestions from the profession;
  3. Unacceptably slow reaction V always behind the virus;
  4. Delayed health alerts, giving false reassuring remarks and allege warnings from the Medical Profession as mass hysteria;
  5. Lack of transparency;
  6. Indecisive on issues such as suspension of schools, quarantine measures, etc;
  7. Over saturation of the Public health sector V Hospital Authority (HA) is overloaded and lacks flexibility to react to crisis;
  8. Poor co-ordination with the private sector V refusal of admission of cases, delay to inform colleagues of private sector, bought all supplies in market without taking private colleagues into consideration;
  9. Lack of resources in infectious diseases control including an infectious disease hospital;
  10. Fail to protect Health Care Workers;
  11. Unacceptable high mortality rate of SARS patients in Hong Kong.
Repeated and gross underestimation on the whole situation against SARS

In late February 2003, there was already a deep concern of something dreadful coming to Hong Kong by many doctors, first with the return of Avian flu, then a rumour of mysterious fatal Atypical Pneumonia epidemic in Guangzhou. But China then Hong Kong Government stepped in to reassure us nothing was to be concerned.  Then we knew now among some senior doctors there was a real knowledge of such being happening in China but somehow authorities on both sides of the border did not openly admit.  Hong Kong Doctors Union held two seminars in a fortnight to hear specialists reporting on the latest development of Atypical Pneumonia.  The Government however when asked by the media reassured everyone nothing is amiss. Then one Hong Kong Doctors Union member was admitted with SARS and soon involved a total of six cases in his clinic and one private doctor after servicing a SARS patient.  We sounded the alarm that there is a community outbreak on 13th March 2003. But Dr. Yeoh said openly there was no community outbreak and Dr. Margaret Chan said then Hong Kong was not a city with an epidemic.

Blind and deaf of health administrators on advices and suggestions from the profession V concern more on economy than healthcare of citizens

It was obvious that Dr EK Yeoh and Margaret Chan were trying to minimize the problem and had issued false reassurance to the public repeatedly.  They were trying to suppress panic in the hope that SARS would not affect the economy of Hong Kong.   We do not understand why health administrators chose to worry more on economy of Hong Kong at the expense of public health, including lives of Hong Kong citizens.

It was not until the news of Dr William Ho being admitted into hospital that the public realized the truth and panicked. 

Unacceptably slow reaction V always behind the virus

Measures such as more vigilant detection of fever in travelers were only instituted too late and had been well criticized.  When frontline doctors and nurses fell from SARS one after another and panic was rife there was a call to close one hospital but initially rejected.  Many measures were justly criticized as instituted too late so that finally the SARS outbreak went out of hand with second and perhaps third waves. 

In the early stages, there was an overestimate of the ability to control SARS in the hospital so that when one patient rapidly infected Dr. Lai Wing Lun of Yau Ma Tei then his family and his nurses by the 14th March 2003. Even so the Government still did not issue appropriate alerts to the community doctors particularly on the importance of wearing masks. In the beginning, the Government selected only to trace contacts of confirmed cases and refused to trace contacts of unconfirmed cases as in the case of family members of Dr. Lai Wing Lun, allowing the virus to spread undeterred. The health authorities became led by the virus instead of containing it.

On 25th March 2003, Hong Kong Doctors Union sought a meeting with Dr. Yeoh and asked him to introduce more stringent measures, he said to go slow since the matter needs further debates. The virus, however, did not wait.

As mentioned earlier, the health alerts came too late so that private doctors could not adequately protect themselves or their patients in time and Government could not coordinate public and private medical personnel.  Again calling for wearing of masks and other protective gear came too late.

Delayed health alerts, giving false reassuring remarks, allege warnings from the Medical Profession as mass hysteria

Dr. Lai Wing Lun, one of our members, was admitted into Princess Margaret Hospital on 14th March 2003, our President spoke to the media about a community outbreak since the Government did not admit it, but he was told by the Director of Health that Dr. Lai・s case was not related to SARS on 17th March 2003. When our President called for schools to be closed for two weeks on 23rd March 2003, we were criticized by Dr. Leung Pak Yin in the afternoon of 23rd March 2003 as creating panic in the community and the Hong Kong Medical Association representatives as being hysterical in a meeting with Dr. E K Yeoh on 25th March 2003. On 27th March 2003, the Chief Executive announced all schools and kindergartens be closed

Lack of transparency

Overconfidence was shown by adamantly denying the existence of outbreak and the repeated reassurance by some senior officials that everything was under control just as China claimed in January and February 2003.

Denying the presence of many instances of serious implications and refusing to disclose exact figures of SARS in public hospitals and information passed on by the Chinese authorities showed a lack of transparency.

Indecisive on issues such as suspension of schools, quarantine measures, etc.

After individual headmasters closed schools and some wished a unified action and more positive action, a call for a closure of all schools was initially rejected but only to be reversed a few days later by promulgating closure of schools. A call for more vigilant scrutiny of contacts including home contacts was made by Hong Kong Doctors Union but refused by the Government on humanitarian grounds. Finally it took some 18 days before Hong Kong decided to isolate contacts by home confining and then putting a whole buildings・ inhabitants in camps. This was indeed too late as shown by the outbreak in Amoy Gardens.

Surveillance at borders and ports, similar to closure of schools, was installed too late.

Over saturation of the Public health sector V HA is overloaded and lacks flexibility to react to crisis

Nearly all public hospitals under HA were paralyzed within a few weeks after SARS outbreak.  Wards were closed or converted to other specialties.  Patients failed to receive proper treatment in hospitals, and most patients in specialist outpatients were deprived of medical attention.   All these revealed that our over-burdened public medical sector was not able to cope with extra workload, and it had lost its flexibility and had no reserve in managing crisis.

Poor co-ordination with the private sectorV refusal of admission of cases, delay to inform colleagues of private sector, bought all supplies in market without taking private colleagues into consideration

The refusal of admission of suspected SARS cases as complained by Dr. Lau Tai Kwan and he himself by Queen Mary Hospital; the lack of protective supplies to the private sector and the unwillingness of the Government to communicate with the private sector in the course of the war against the SARS showed the Government poor co-ordination with the private sector.

Lack of resources in infectious diseases control including an infectious disease hospital

The public resources allotted to the Department of Health for public health is far too minimal as compared to that for the Hospital Authority. This is the reason why the measures could not be implemented early to contain the virus. Lack of an infectious disease hospital is another obvious problem in combating highly infectious diseases which are said to prevail in Hong Kong from time to time.

Fail to protect Health Care Workers

Preventive medical supplies were scarce so that public health care staff suffered while private doctors were hard hit because of the inability to find masks and protective gowns. A Government with adequate foresight would have coordinated and prepared for such contingencies on time. In a meeting of Hong Kong Doctors Union with Dr. E K Yeoh on 25th March 2003, Dr. Yeoh talked about possible coordination of resources and such supplies but ultimately nothing happened.

Unacceptable high mortality rate of SARS patients in Hong Kong

As compared with other areas or countries, Hong Kong is number one in the mortality rate of SARS patients.

Table showing Mortality Rate of SARS Patients against area or country

#

Area or country

Mortality rate of SARS patients (No. of deaths / No. of confirmed SARS patients)

1

China, Hong Kong

16.9%

(297 / 1,755)

2

Singapore

15.5%

(32 / 206)

3

Canada

14.7%

(37 / 251)

4

China, Taiwan

12.3%

(84 / 682)

5

Vietnam

7.9%

(5 / 63)

6

China

6.5%

(348 / 5,327)

 

Global

9.6%

(809 / 8,456)

(Information from Cumulative Number of Reported Probable Cases of SARS in WHO site at http://www.who.int/csr/sars/country on 28.6.2003)

The use and efficacy of steroids is almost unknown and is potentially dangerous in infectious diseases like SARS. Some public hospitals noted that the use of pulse steroids is associated with more ICU admissions, more intubations and more deaths in SARS. Some SARS patients indeed died of secondary infections instead of SARS. After all, the recovered patients suffered a lot of side effects including psychosis and proximal myopathy. Since some cases of SARS were relatively mild and recovered without any treatment, the empirical use of high dose steroids in these cases is unnecessary and possibly detrimental.

Secondly, Ribavirin does not appear to alter the course of SARS and there is no evidence that it affects the outcome. Patients given Ribavirin were still very infectious and those who succumbed were found to be harbouring numerous virus particles at post mortem. At the same time, there are a lot of side effects of Ribavirin including haemolytic anaemia, bradycardia, tachycardia which are detrimental to a dyspnoeic SARS patient. Similarly, there are also a lot of side effects in SARS patients taking Kaletra which was introduced later in SARS patients but without obvious curative effects.

We wonder whether the widely use of Steroids, Ribavirin and Kaletra in the treatment of nearly all SARS patients is scientifically proven. We wonder whether such use of empirical regimes to nearly all SARS patients can stand the test of good reasons based on previous knowledge of drug effect on similar diseases, evaluation with a well-designed protocol which is subject to scrutiny by scientific and ethics committees. Above all, such regimes should be made known to the Government, the Profession and most important of all, the Public, that they are just experimental without committed results as advocated by Dr. E K Yeoh in the very beginning that the regimes are effective and would result in 95% cure rate.

RECOMMENDATIONS

1. Independent review committee on SARS outbreak in Hong Kong

An Independent Review Committee, as suggested by Hong Kong Doctors Union to the Chief Executive, is more desirable.  This would facilitate a more objective review of the whole incident.  Like Audit of all kinds, it is best done and should always be carried out by third parties outside the Health, Welfare and Food Bureau.

2. Public Private Interface

This topic has been under discussion ever since the days of the Harvard・s report which commented that our healthcare system in Hong Kong was heavily compartmentalized. Surely, there has been inadequate communications and collaborations between the two sectors of our healthcare system.  Regrettably, there had not been any improvement since. We strongly suggest a proper and strong communication infrastructure be established between the two sectors to enhance flow of patient information, flow of medical education materials, flow of patients and flow of manpower which are lacking in the SARS incident.

3. Hospital Authority should look after mainly tertiary health care

The over expanding public health sector has been a concern especially when our Government is facing a huge budget deficit recently. The Hospital Authority was over-stretched with 50% of the Hong Kong doctors looking after 93% of medical care of the population of Hong Kong The recent SARS incident exposed the weakness of such comprehensive care by the Hospital Authority. Actually, there are a lot of functions of the Hospital Authority, particularly those involving primary health care, which could be outsourced to the private sector. Even the primary health care for Civil Servants should also be out sourced to the private sector which we are sure could be run in a more cost-effective manner than by the Hospital Authority.

4. Cross-departmental Crisis Intervention

Schools and the border were identified as the most vulnerable channels in the spread of SARS.  A cross departmental crisis intervention engine should be established to escalate the education and awareness of the epidemic, and to take the right measures to prevent the spread e.g. suspension of schools, preventive measures in the borders which could be implemented at an earlier stage.

5. Protection of Health Care Workers (HCW)

One of the reasons why so many HCW got infected in the SARS war was that the isolation ward training might be inadequate.  Hong Kong Doctors Union recommends that we should look into how effective the HCW are doing in isolation procedures.

Protection of HCW should receive top priority in epidemics.  HCW risk their lives in going to work despite of HA squeezing on them on their job securities and pay in the past few years.  Emphasis should be put on having adequate rest time for HCW, and even extra allowances according to the risk level the HCW is facing.

Ventilation systems in public hospitals should be reviewed and see how it could have been related to the spread of SARS within hospitals.

6. Infectious Disease hospital

The SARS war could have been ended a lot earlier if all patients are centralized in one or two infectious disease hospitals like what Beijing was doing. The distribution of SARS patients to different regional hospitals has ended up in small outbreaks in different parts of Hong Kong. This is most obvious in Tai Po where the HCW spread SARS from the hospital back into the community. More and more people criticize the Government・s slow and inadequate response and cite the low incidence of mortality and morbidity in Vietnam and Singapore. If more stringent measures were introduced and introduced earlier against SARS, many lives could have been saved.

7. Centre for Disease Control & Prevention (CDC)

Inexperienced health administrators have turned things get out of control in the SARS epidemic.  In the long run, a CDC-equivalent organization should be set up in Hong Kong to ensure that all measures taken at the time of an epidemic is well co-ordinated, and that adequate professionals on Infectious Diseases should be in place to take care of the situation. Hong Kong could not afford another SARS which killed hundreds of people, paralysed our economy for three months, and left tens of thousands of people jobless.

8. Communication with Guangdong and surrounding areas on Infectious diseases

This cannot be overemphasized as the traffic between Guangdong and Hong Kong is increasing exponentially in the past few years. Infection follows population flow, and Hong Kong is prone to develop new outbreaks of infectious disease.  An effective channel of communication on Infectious diseases between the two places should be set up without further delay.

Surveillance of infectious diseases should be expanded to all nearby countries and districts with good communication channels including China, Taiwan and South East Asia.

9. Develop a well-designed protocol to treat SARS

We should develop regimes to treat SARS patients based on previous knowledge of drug effect on similar diseases and evaluation with a well-designed protocol which is subject to scrutiny by scientific and ethics committees. The Government should never promise results to the public unless she is scientifically certain or else the promise would introduce hardship to the front line doctors and even to the whole profession.

Conclusion - Can we eradicate SARS?

The total eradication of SARS depends on the cooperation of the Government, the Profession and the Public. To this end, effective and factual communication is vital among all parties. While diagnostic tool to quickly and correctly identify infectious cases of SARS is badly needed, the Government should invest to assist prompt development of effective vaccine and drug against SARS. Even though the singling out and eradication of reservoir of SARS is unsuccessful, the above measures should be implemented and assisted by the Government and an Independent Committee to look into the incident of SARS saga in Hong Kong is vitally important in preparation for the next onslaught.

Will the Government learn much out of the bitter experience of mortality and morbidity of her people and their financial loss?  Will the Government realize the importance of good Family Medicine as a gate-keeper for the whole Health Care System? Will the Government revoluntionise infection control concept in the future health care system? It is vital to the future health of Hong Kong that she does all of the above.

Press Release on 4.7.2003/outgoing13