Letter to the Editor

Namrata Arora

Dear Editor,

COVID-19: A family physician’s perspective

Following SARS in 2003, Hong Kong is now battling a new strain of coronavirus: the COVID-19 virus. There is no question that COVID-19 is a severe disease in certain circumstances. Characteristics of the virus, inparticular the infectivity in the incubation and early symptomatic stage in addition to the immunological storm in the later stages in some individuals, mean that this disease has spread widely and overwhelmed some health systems. When looking from the population-based point of view, the epidemiological curves tells us a lot about how the disease spreads, but also our social and community response to the condition. Hong Kong compared to most places, has been doing comparatively well. Despite having 1038 cases of COVID-19 by April 27 (1037 confirmed cases, and 1 suspected case), at the time of me writing this article, we are currently seeing a downward trend of cases after the second wave. ¹

Hong Kong learned lessons after SARS and this may explain the enhanced public health preparedness and willingness to respond quickly to COVID-19. ² A survey of the general population in Hong Kong conducted hours after the first COVID-19 case was announced showed that more than 95% of respondents reported washing their hands frequently and 99% wore face masks. ² The US Centres for Disease Control and Prevention originally advised the public against wearing masks during the Covid-19 pandemic. This advice was updated on April 4 and they now recommend that members of the public wear face coverings in crowded areas to prevent shedding of the virus. (Cloth masks if surgical masks are not available, since these should be saved for health professionals first). ³

Hong Kong closed schools early and many workplaces encouraged remote working. Public health measures such as border controls, social distancing, high volume testing and contact tracing have likely contributed to the control of the disease in Hong Kong. ² Studies show that a combination of quarantine with other prevention and control measures such as school closings, travel restrictions, social distancing, and others had a greater effect on the reduction of transmission, cases that required critical care beds, and deaths than individual measures alone. Studies on SARS and MERS seem to be consistent with findings from the modelling studies on COVID-19 so far. ⁴ Rapid contact tracing by the Department of Health, selfless service by front line health professionals and the commitment of delivery workers, supermarket workers, cleaners and all Hong Kong citizens are commendable and have been instrumental in our fight against COVID-19.

COVID-19 has not only strained our healthcare facilities, it is starting to take a toll on the mental and physical health of people. Individuals are facing many challenges and inherent uncertainty. Some parents are working from home while juggling their children’s online schooling, some are being laid off work and having financial problems, while others are falling into the trap of negative thinking and anxiety. My patients often complain of low mood, anxiety and many are having increasingly sedentary lifestyles. In a British survey, it was found that a major adverse consequence of COVID-19 is likely an increase in social isolation and loneliness, which have been associated with anxiety, depression, self-harm, and suicide attempts. ⁵ It is not unlikely that the mental health consequences of COVID-19 will be present for longer and peak later than the actual pandemic. ⁶

In many places, including Hong Kong and the UK ⁷ , non-urgent cases and operations have been put on hold during this time. A local study by Queen Mary Hospital, showed there were delays in patients seeking care, even for emergency conditions like myocardial infarctions, which could be because people are reluctant to go to a hospital during the outbreak. ⁸ In Australia, there has been a drop in cancer and heart at tack patients attending hospitals and some propose that a delayed diagnosis and treatment of these conditions due to coronavirus anxiety could cause problems when the pandemic is over. ⁹

While Hong Kong has been working hard to contain the virus, the health, educational, social and economic implications will likely be more longstanding. We must, as a community, come together to help each other at this difficult time. While some businesses have been unable to deal with the challenges that COVID-19 has brought, others have found innovative ways and developed infrastructure to work from home, educate students at home, shop online and even do medical tele-consults or workout sessions from home. There will be some damage control and some health issues that will have to be taken care of, that we should start addressing now. Governments need to provide safety nets, such as food, housing and financial support for their citizens undergoing hardships and for those who are unemployed. ⁹ As family physicians, we must actively reach out to our patients and support their physical and mental wellbeing at this challenging time.

While Hong Kong has done well in containing the virus , the real challenge is how to slowly raise restrictions. On April 13th, the World Health Organization released in its press conference , six criteria for countries as they consider lifting restrictions, including ¹⁰:

1. Transmission is under control
2. Systems are in place to detect, test, isolate and trace cases and contacts
3. Outbreak risks are minimised in specialised settings (for example, healthcare facilities and old aged homes)
4. Protective measures have been incorporated to places of essential travel (for example, workplaces and schools)
5. Importation risks can be managed
6. Communities are educated and empowered to adjust to the‘new norm’

Population studies can show us the true community prevalence of the condition and help us understand how many people in our community have been exposed and formed antibodies. It will also be interesting to see how other countries fare as they start lowering restrictions. These factors will help us understand more about COVID-19, how life in Hong Kong can slowly return to a new norm and how we can better face the challenges that continue to lie ahead of us.

Yours sincerely,