SARS-related perceptions in Hong Kong

To understand different aspects of community responses related to severe acute respiratory syndrome (SARS), 2 population-based, random telephone surveys were conducted in June 2003 and January 2004 in Hong Kong. More than 70% of respondents would avoid visiting hospitals or mainland China to avoid contracting SARS. Most respondents believed that SARS could be transmitted through droplets, fomites, sewage, and animals. More than 90% believed that public health measures were efficacious means of prevention; 40.4% believed that SARS would resurge in Hong Kong; and approximately equals 70% would then wear masks in public places. High percentages of respondents felt helpless, horrified, and apprehensive because of SARS. Approximately 16% showed signs of posttraumatic symptoms, and approximately equals 40% perceived increased stress in family or work settings. The general public in Hong Kong has been very vigilant about SARS but needs to be more psychologically prepared to face a resurgence of the epidemic.     

The SARS-associated stigma of SARS victims in the post-SARS era of Hong Kong

This article explores the disease-associated stigma attached to the SARS victims in the post-SARS era of Hong Kong. I argue that the SARS-associated stigma did not decrease over time. Based on the ethnographic data obtained from 16 months of participant observation in a SARS victims' self-help group and semistructured interviews, I argue that the SARS-associated stigma was maintained, revived, and reconstructed by the biomedical encounters, government institutions, and public perception. I also provide new insight on how the SARS-associated stigma could create problems for public health development in Hong Kong. As communicable diseases will be a continuing threat for the human society, understanding how the disease-associated stigma affects the outcomes of epidemic control measures will be crucial in developing a more responsive public health policy as well as medical follow-up and social support service to the diseased social groups of future epidemic outbreaks.     

Monitoring the severe acute respiratory syndrome epidemic and assessing effectiveness of interventions in Hong Kong Special Administrative Region

OBJECTIVE: To estimate the infection curve of severe acute respiratory syndrome (SARS) using the back projection method and to assess the effectiveness of interventions. DESIGN: Statistical method. DATA: The daily reported number of SARS and interventions taken by Hong Kong Special Administrative Region (HKSAR) up to 24 June 2003 are used. METHOD: To use a back projection technique to construct the infection curve of SARS in Hong Kong. The estimated epidemic curve is studied to identify the major events and to assess the effectiveness of interventions over the course of the epidemic. RESULTS: The SARS infection curve in Hong Kong is constructed for the period 1 March 2003 to 24 June 2003. Some interventions seem to be effective while others apparently have little or no effect. The infections among the medical and health workers are high. CONCLUSIONS: Quarantine of the close contacts of confirmed and suspected SARS cases seems to be the most effective intervention against spread of SARS in the community. Thorough disinfection of the infected area against environmental hazards is helpful. Infections within hospitals can be reduced by better isolation measures and protective equipments.     

Monitoring community responses to the SARS epidemic in Hong Kong: from day 10 to day 62

STUDY OBJECTIVE: To report the evolution in perceptions and behaviours of the general public in response to the severe acute respiratory syndrome (SARS) epidemic in Hong Kong. DESIGN: Ten similar and sequential telephone surveys were conducted during outbreak of SARS, which are classified as belonging to the first and second phases of the epidemic. SETTING: Hong Kong, China. PARTICIPANTS: 1397 Hong Kong residents between 18 and 60 years of age. MAIN OUTCOME MEASURES: Perceptions and behaviours to SARS and its prevention. RESULTS: Most of the respondents believed that SARS could be transmitted via direct body contact and droplets. About half of respondents believed that SARS was curable, which increased in the initial phase and decreased in the second phase. Perceived chance of infection was low (9%) but fear of infection in public places was high (48%). Perceived efficacy of hygiene measures (wearing a mask: 82%, hand washing: 93%, and home disinfection: 75%) remained high in both phases and the perceived efficacy of avoiding crowded place, and using public transportation, etc, increased initially and decreased in the second phase. In parallel, use of the three hygiene measures increased significantly in the first phase and remained high for wearing a mask and washing hands in the second phase. Percentages of people avoiding crowded place and public transportation significantly increased initially and decreased in the second phase. CONCLUSION: SARS related perceptions and behaviours evolved rapidly during the epidemic and Hong Kong residents quickly adopted appropriate SARS prevention measures. Timely dissemination of information seems effective in public health crises management.     

A tale of two cities: community psychobehavioral surveillance and related impact on outbreak control in Hong Kong and Singapore during the severe acute respiratory syndrome epidemic.

OBJECTIVES: To compare the public's knowledge and perception of SARS and the extent to which various precautionary measures were adopted in Hong Kong and Singapore. DESIGN: Cross-sectional telephone survey of 705 Hong Kong and 1,201 Singapore adults selected by random-digit dialing. RESULTS: Hong Kong respondents had significantly higher anxiety than Singapore respondents (State Trait Anxiety Inventory [STAI] score, 2.06 vs 1.77; P < .001). The former group also reported more frequent headaches, difficulty breathing, dizziness, rhinorrhea, and sore throat. More than 90% in both cities were willing to be quarantined if they had close contact with a SARS case, and 70% or more would be compliant for social contacts. Most respondents (86.7% in Hong Kong vs 71.4% in Singapore; P < .001) knew that SARS could be transmitted via respiratory droplets, although fewer (75.8% in Hong Kong vs 62.1% in Singapore; P < .001) knew that fomites were also a possible transmission source. Twenty-three percent of Hong Kong and 11.9% of Singapore respondents believed that they were "very likely" or "somewhat likely" to contract SARS during the current outbreak (P < .001). There were large differences between Hong Kong and Singapore in the adoption of personal precautionary measures. Respondents with higher levels of anxiety, better knowledge about SARS, and greater risk perceptions were more likely to take comprehensive precautionary measures against the infection, as were older, female, and more educated individuals. CONCLUSION: Comparative psychobehavioral surveillance and analysis could yield important insights into generic versus population-specific issues that could be used to inform, design, and evaluate public health infection control policy measures.     

Health-seeking behaviors and social change: the experience of the Hong Kong Chinese elderly

In this article, the author outlines how the Hong Kong Chinese elderly revise, shift, and modify their health-seeking behaviors to adapt to rapid social change, presenting data drawn from three studies undertaken with elderly Chinese conducted in Hong Kong during the period 1993 to 1998. The primary data source is a qualitative survey involving interviews with 47 elderly Hong Kong Chinese men and women to ascertain their health-seeking beliefs and behaviors. The author analyzes how public policy and Confucian rhetoric constitute social guidelines, which are perceived in light of an individual's resources, gender and generational experiences and are manifest in health-seeking behaviors: seeking religious solace, preparing special food, visiting formal and informal healers, and shifting expectations of what constitutes family support. The article highlights the interface between public interpretations of old age, morality, religion, filial support, and personalized meaning as manifest in health behaviors.     

"Exposing the cracks": Severe Acute Respiratory Syndrome and the Hong Kong health system

PURPOSE: Hong Kong was particularly affected by the 2003 outbreak of Severe Acute Respiratory Syndrome (SARS). During the epidemic, it seemed as if the Hong Kong government and health system were barely coping, leading to calls of mismanagement and governance incapacity. In the wake of the SARS outbreak, two inquiries were conducted. The purpose of this article is to review the Hong Kong's response to SARS from the perspective of two inquiries. DESIGN/METHODOLOGY/APPROACH: An historical analysis of the institutional arrangements for health care delivery in Hong Kong is undertaken, followed by a chronology of developments in the SARS outbreak. The article then reviews outbreak management and the findings of the two inquiries. Finally, it considers whether the Hong Kong health system can be reformed to manage any future infectious disease epidemic better. FINDINGS: Both leadership and coherency were lacking in Hong Kong's response to SARS. These are age-old problems in the Hong Kong health sector. The prospects for mending the health system appear limited, given that leadership and coherency have been consistently absent features of post-1997 governance in Hong Kong. RESEARCH LIMITATIONS/IMPLICATIONS: This article reviews events in the immediate period following the SARS outbreak. A future follow-up study of the Hong Kong government and health system's capacity to respond to infectious disease outbreaks would be useful. PRACTICAL IMPLICATIONS: This article provides a review that will be useful to policymakers and researchers. ORIGINALITY/VALUE: No other article reviews the Hong Kong health system's SARS response.     

SARS related preventive and risk behaviours practised by Hong Kong-mainland China cross border travellers during the outbreak of the SARS epidemic in Hong Kong

OBJECTIVES: To investigate patterns of behaviours and attitudes related to SARS prevention in the Hong Kong cross border traveller population.Settings: A survey was carried out at the Hong Kong-China cross border checkpoint in the middle of the epidemic. PARTICIPANTS: A total of 839 Hong Kong adult residents returning to Hong Kong from mainland China were surveyed. MAIN OUTCOME MEASURES: Practice of preventive measures and relevant behaviours and attitudes. RESULTS: Around 40% of the respondents were using masks all or most of the time in public places or washing their hands frequently (>10 times per day) and about one third avoided visiting crowded places in mainland China. Such figures were however lower than those practised by the general public in Hong Kong. SARS related perceptions, such as perceived risk of transmission and efficacy, etc, were associated with mask use and not visiting crowded places, but not with hand washing, which was associated with duration of stay. Gender differences were also observed. Around 70% of the travellers would have delayed medical consultation for influenza-like illness in China; 12.7% would not wear masks during such episodes of illness. Furthermore, about 30% of the respondents used to wear masks in Hong Kong but not in mainland China. CONCLUSIONS: The findings have implications on cross border prevention of SARS. It seems that those travelling during the SARS epidemic were a "self selected" group, and they were using less preventive measures. Special attention and intervention need to be provided to travellers to prevent a second wave cross border transmission of the disease.     

Prevalence and factors associated with social avoidance of recovered SARS patients in the Hong Kong general population

The study investigated the general population's perceived infectivity of asymptomatic and recovered severe acute respiratory syndrome (SARS) patients and factors associated with avoidance and discriminatory attitudes, including demographic background, SARS-related perceptions and emotional response to the SARS epidemic. A population-based survey was conducted in Hong Kong during 3 December 2003 through 4 January 2004; 475 Hong Kong Chinese adults participated in the survey. Perceptions of the infectivity and health conditions of recovered SARS patients and avoidance and discrimination towards them were measured. Of the respondents, 75.7% and 16.2%, respectively, believed that SARS could be transmitted via asymptomatic SARS patients and those patients who have recovered from SARS for 18 months; 72.7% of the respondents believed that the health of SARS patients would severely and permanently be damaged; 16.6% showed some tendency of avoiding recovered SARS patients and 35.7% expressed some sort of job-related discriminatory attitudes. Perceived infectivity of asymptomatic and recovered SARS patients, health sequelae and emotional distress from SARS were independently associated with avoidance and discriminatory attitudes. The study showed that misconceptions about the infectivity of asymptomatic and recovered SARS patients were common. Recovered SARS patients may also be facing avoidance and discrimination.     

Alternative methods of estimating an incubation distribution: examples from severe acute respiratory syndrome

BACKGROUND: Accurate and precise estimates of the incubation distribution of novel, emerging infectious diseases are vital to inform public health policy and to parameterize mathematical models. METHODS: We discuss and compare different methods of estimating the incubation distribution allowing for interval censoring of exposures, using data from the severe acute respiratory syndrome (SARS) epidemic in 2003 as an example. RESULTS: Combining data on unselected samples of 149 and 168 patients with defined exposure intervals from Toronto and Hong Kong, respectively, we estimated the mean and variance of the incubation period to be 5.1 day and 18.3 days and the 95th percentile to be 12.9 days. We conducted multiple linear regression on the log incubation times and found that incubation was significantly longer in Toronto than in Hong Kong and in older compared with younger patients, while it was significantly shorter in healthcare workers than in other patients. CONCLUSIONS: Our findings suggest subtle but important heterogeneities in the incubation period of SARS among different strata of patients. Robust estimation of the incubation period should be independently carried out in different settings and subgroups for novel human pathogens using valid statistical methods.     

SARS preventive and risk behaviours of Hong Kong air travellers

This study aims to investigate Severe Acute Respiratory Syndrome (SARS)-related behaviours of travellers returning to Hong Kong by air. A total of 820 travellers returning to Hong Kong by air were interviewed about their SARS-related behaviours in April 2003. Three quarters of the respondents wore a mask most/all of the time on board, 15% did so in public places at the travel destination. Perceived susceptibility to SARS at the destination predicted mask-wearing in public places and avoidance of crowded places, and perceived efficacy was a predictor for mask-wearing during flight. Approximately 16% of the respondents stated that they would delay their medical consultation for flu-like symptoms until returning to Hong Kong. Nearly 18.2% stated that they would not wear a mask in public places at the destination if they had flu-like symptoms. Education programmes, special services and effective thermal screening are required to minimize the chance of the spread of SARS by air travellers.     

Primary care physicians in Hong Kong and Canada--how did their practices differ during the SARS epidemic?

BACKGROUND: Hong Kong and Canada have very different primary health care systems. We thus hypothesized family physicians between the two places would be different in how they protected themselves, their staff and families during the epidemic. OBJECTIVE: The purpose of this study was to explore and contrast the impact of SARS on family physicians in Hong Kong and Toronto. METHODS: A postal questionnaire was designed and sent to 183 tutors affiliated with the Chinese University of Hong Kong with 137 replies (74.8%). In Toronto, 150 questionnaires were sent to academic family physicians affiliated with the University of Toronto with 51 replies (34%). RESULTS: All agreed SARS had changed their clinical behaviour. For public health measures in the control of SARS, Hong Kong physicians were less likely to quarantined themselves (77.1% versus 19.4%, P < 0.01) or gave quarantine leave to staff (95% versus 59.7%, P < 0.01) after exposure to probable or suspected SARS. However, they were more likely to wear a mask (52.7% versus 97.7%, P = 0) during consultation, having support staff to wear masks (68.6% versus 97.8%, P = 0) and test patient's temperature (47.1% versus 68.1%, P < 0.01). CONCLUSION: There were noticeable differences in how family physicians deal with SARS between the two cities. As SARS emerged as a global disease, better understanding of practice differences among physicians from different countries would facilitate globalization of public health.     

Factors influencing the wearing of facemasks to prevent the severe acute respiratory syndrome among adult Chinese in Hong Kong

BACKGROUND: The global outbreak of the severe acute respiratory syndrome (SARS) in 2003 has been an international public health threat. Quick diagnostic tests and specific treatments for SARS are not yet available; thus, prevention is of paramount importance to contain its global spread. This study aimed to determine factors associating with individuals' practice of the target SARS preventive behavior (facemask wearing). METHODS: A total of 1329 adult Chinese residing in Hong Kong were surveyed. The survey instrument included demographic data, measures on the five components of the Health Belief Model, and the practice of the target SARS preventive behavior. Logistic regression analyses were conducted to determine rates and predictors of facemask wearing. RESULTS: Overall, 61.2% of the respondents reported consistent use of facemasks to prevent SARS. Women, the 50-59 age group, and married respondents were more likely to wear facemasks. Three of the five components of the Health Belief Model, namely, perceived susceptibility, cues to action, and perceived benefits, were significant predictors of facemask-wearing even after considering effects of demographic characteristics. CONCLUSIONS: The Health Belief Model is useful in identifying determinants of facemask wearing. Findings have significant implications in enhancing the effectiveness of SARS prevention programs.     

山东省6县（区）部分人群预防SARS行为调查分析

目的了解山东省不同地域居民SARS流行期生活行为及流行前后行为变化情况。方法选择城市和乡镇社区对于SARS传播和控制意义较重要的具有代表性的7个人群进行入户式现场调查。结果人们从个人卫生、公共卫生、提高身体素质、减少接触机会、维护生态平衡等多个方面约束或改进了个人行为。92.0%的被调查者认为非典流行促使自己改进了生活习惯。结论山东省人群非典期间采取预防行为的比率很高,为今后SARS、禽流感及其他呼吸道传染病的预防奠定了良好的基础。     

Do men have a higher case fatality rate of severe acute respiratory syndrome than women do?

Severe acute respiratory syndrome (SARS) has been reported in 30 countries and regions, with a cumulative total of 8,099 probable cases and 774 deaths as of July 31, 2003, according to the World Health Organization. In Hong Kong, People's Republic of China, 1,755 SARS cases and 299 deaths had occurred as of September 22, 2003. The authors analyzed data from the Department of Health, Hong Kong SAR. The data series includes details regarding sex, age, and chronic disease history. Using data from early March to September 22, 2003, the authors found that males had a significantly (p < 0.0001) higher case fatality rate than females did, 21.9% versus 13.2%; the relative risk was 1.66 (95% confidence interval (CI): 1.35, 2.05), and it was 1.62 (95% CI: 1.21, 2.16) after adjustment for age. Subgroup analysis was conducted by excluding health care workers (n = 386) from the analysis. The overall crude relative risk of mortality was 1.41 (95% CI: 1.15, 1.74), and the adjusted relative risk was 1.48 (95% CI: 1.10, 2.00). Thus, among SARS patients, males may be more severely affected by the disease than females are. This finding could be related to a nonuniform case definition of SARS disease, a different treatment regimen, a past smoking history, work-environment factors, or gender-specific immune-defense factors, for instance.     

Understanding the spatial clustering of severe acute respiratory syndrome (SARS) in Hong Kong

We applied cartographic and geostatistical methods in analyzing the patterns of disease spread during the 2003 severe acute respiratory syndrome (SARS) outbreak in Hong Kong using geographic information system (GIS) technology. We analyzed an integrated database that contained clinical and personal details on all 1,755 patients confirmed to have SARS from 15 February to 22 June 2003. Elementary mapping of disease occurrences in space and time simultaneously revealed the geographic extent of spread throughout the territory. Statistical surfaces created by the kernel method confirmed that SARS cases were highly clustered and identified distinct disease "hot spots." Contextual analysis of mean and standard deviation of different density classes indicated that the period from day 1 (18 February) through day 16 (6 March) was the prodrome of the epidemic, whereas days 86 (15 May) to 106 (4 June) marked the declining phase of the outbreak. Origin-and-destination plots showed the directional bias and radius of spread of superspreading events. Integration of GIS technology into routine field epidemiologic surveillance can offer a real-time quantitative method for identifying and tracking the geospatial spread of infectious diseases, as our experience with SARS has demonstrated.     

SARS transmission, risk factors, and prevention in Hong Kong

We analyzed information obtained from 1,192 patients with probable severe acute respiratory syndrome (SARS) reported in Hong Kong. Among them, 26.6% were hospital workers, 16.1% were members of the same household as SARS patients and had probable secondary infections, 14.3% were Amoy Gardens residents, 4.9% were inpatients, and 9.9% were contacts of SARS patients who were not family members. The remaining 347 case-patients (29.1%) had undefined sources of infection. Excluding those <16 years of age, 330 patients with cases from "undefined" sources were used in a 1:2 matched case-control study. Multivariate analysis of this case-control study showed that having visited mainland China, hospitals, or the Amoy Gardens were risk factors (odds ratio [OR] 1.95 to 7.63). In addition, frequent mask use in public venues, frequent hand washing, and disinfecting the living quarters were significant protective factors (OR 0.36 to 0.58). In Hong Kong, therefore, community-acquired infection did not make up most transmissions, and public health measures have contributed substantially to the control of the SARS epidemic.     

How did general practitioners protect themselves, their family, and staff during the SARS epidemic in Hong Kong?

CONTEXT: Severe acute respiratory syndrome (SARS) is a newly emerging infectious disease and how the frontline community doctors respond to it is not known. OBJECTIVES: To explore the impact of SARS on general practitioners (GPs) in Hong Kong. DESIGN: A cross sectional survey. SETTING: Community based primary care clinics. PARTICIPANTS: 183 family medicine tutors affiliated with a local university. Postal survey sent to all tutors with a 74.8% response rate. MAIN OUTCOME MEASURES: Change of clinical behaviour and practices during the epidemic; anxiety level of primary care doctors. RESULTS: All agreed SARS had changed their clinical practices. Significant anxiety was found in family doctors. Three quarters of respondents recalled requesting more investigations while a quarter believed they had over-prescribed antibiotics. GPs who were exposed to SARS or who had worked in high infection districts were less likely to quarantine themselves (10.8% versus 33.3%; p<0.01; 6.5% versus 27.5%; p<0.01 respectively). Exposure to SARS, the infection rates in their working district, and anxiety levels had significant impact on the level of protection or prescribing behaviour. CONCLUSION: The clinical practice of GPs changed significantly as a result of SARS. Yet, those did not quarantine themselves suggesting other factors may have some part to play. As failure to apply isolation precautions to suspected cases of SARS was one major reason for its spread, a contingency plan from the government to support family doctors is of utmost importance. Interface between private and public sectors are needed in Hong Kong to prepare for any future epidemics.     

SARS-CoV antibody prevalence in all Hong Kong patient contacts

A total of 1,068 asymptomatic close contacts of patients with severe acute respiratory (SARS) from the 2003 epidemic in Hong Kong were serologically tested, and 2 (0.19%) were positive for SARS coronavirus immunoglobulin G antibody. SARS rarely manifests as a subclinical infection, and at present, wild animal species are the only important natural reservoirs of the virus.     

The 2003 SARS outbreak and its impact on infection control practices

Severe Acute Respiratory Syndrome (SARS) emerged recently as a new infectious disease that was transmitted efficiently in the healthcare setting and particularly affected healthcare workers (HCWs), patients and visitors. The efficiency of transmission within healthcare facilities was recognised following significant hospital outbreaks of SARS in Canada, China, Hong Kong, Singapore, Taiwan and Vietnam. The causative agent of SARS was identified as a novel coronavirus, the SARS coronavirus. This was largely spread by direct or indirect contact with large respiratory droplets, although airborne transmission has also been reported. High infection rates among HCWs led initially to the theory that SARS was highly contagious and the concept of 'super-spreading events'. Such events illustrated that lack of infection control (IC) measures or failure to comply with IC precautions could lead to large-scale hospital outbreaks. SARS was eventually contained by the stringent application of IC measures that limited exposure of HCWs to potentially infectious individuals. As the 'global village' becomes smaller and other microbial threats to health emerge, or re-emerge, there is an urgent need to develop a global strategy for infection control in hospitals. This paper provides an overview of the main IC practices employed during the 2003 SARS outbreak, including management measures, dedicated SARS hospitals, personal protective equipment, isolation, handwashing, environmental decontamination, education and training. The psychological and psychosocial impact on HCWs during the outbreak are also discussed. Requirements for IC programmes in the post-SARS period are proposed based on the major lessons learnt from the SARS outbreak.