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.     

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.     

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.     

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.     

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.     

Impacts of SARS on health-seeking behaviors in general population in Hong Kong

BACKGROUND: The severe acute respiratory syndrome (SARS) epidemic that occurred in Hong Kong in 2003 caused serious public health consequences. Its impacts on health-seeking behaviors of the general public have not been assessed. METHODS: Two cross-sectional, random telephone surveys interviewed 1603 Hong Kong adult residents in the post-SARS epidemic period, June and September 2003 to investigate changes in the post-SARS period. RESULTS: Noteworthy percentages of the respondents self-reported increased frequencies of practicing favorable health-seeking behaviors in June 2003, as compared with the pre-SARS period. Few respondents reported the opposite. This was observed in different dimensions: health services seeking, adoption of healthier lifestyle, spending more resources on health, adoption of good personal hygiene, mask use when ill with influenza, and avoidance of risk behaviors. The frequencies of practicing most of these health-seeking behaviors, as measured in June and September 2003, were comparable. Further increases in healthy diet and weight control, etc., were observed during that period. Those who worried about contracting SARS were more likely to have improved health-seeking behaviors. CONCLUSIONS: The community in Hong Kong responded to the SARS epidemic by practicing more favorable health-seeking behaviors. Public health workers should utilize these opportunities to foster favorable changes.     

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.     

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.     

医院门诊就诊者流感相关知识及行为状况调查

目的了解医院就诊者流感传播和预防知识认识及行为状况。方法采用开放式调查方法 ,用自行设计的调查表对来北京大学第一医院就诊的患者进行问卷调查。结果认为流感是通过飞沫传染他人的占98.1%,认为戴口罩可以在很大程度上阻断传播的占96.3%,认为身边流感患者通过打喷嚏、咳嗽传染自己的占75.0%,关注公共场所空气污染的占96.5%。家庭中感冒患者戴口罩的占21.4%,感冒者外出戴口罩的占42.8%,退热后有较重感冒症状但坚持上班(上学)的占82.1%,不同年龄段和不同受教育程度人员感冒在家中戴口罩的比例存在统计学差异;不同年龄段人员感冒时外出戴口罩的比例存在统计学差异。结论被调查者中了解流感相关知识与传播途径的人员所占比例较大,但采取预防行为的人较少。应加大力度强化感冒患者戴口罩意识和行为;对流感患者应有相应隔离政策;强化预防流感宣传教育。     

"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.     

An uphill struggle: effects of a point-of-choice stair climbing intervention in a non-English speaking population

BACKGROUND: Increases in lifestyle physical activity are a current public health target. Interventions that encourage pedestrians to choose the stairs rather than the escalator are uniformly successful in English speaking populations. Here we report the first test of a similar intervention in a non-English speaking sample, namely the Hong Kong Chinese. METHODS: Travellers on the Mid-Levels escalator system in Hong Kong were encouraged to take the stairs for their health by a point-of-choice prompt with text in Chinese positioned at the junction between the stairs and the travelator. Gender, age, ethnic origin, and walking on the travelator were coded by observers. A 2 week intervention period followed 2 weeks of baseline monitoring with 57 801 choices coded. Specificity of the intervention was determined by contrasting effects in Asian and non-Asian travellers. RESULTS: There was no effect of the intervention on stair climbing and baseline rates (0.4%) were much lower than previous studies in Western populations (5.4%). Nonetheless, a modest increase in walking up the travelator, confined to the Asian population (OR = 1.12), confirmed that the intervention materials could change behaviour. CONCLUSIONS: It would be unwise to assume that lifestyle physical activity interventions have universal application. The contexts in which the behaviours occur, e.g. climate, may act as a barrier to successful behaviour change.     

The impact of community psychological responses on outbreak control for severe acute respiratory syndrome in Hong Kong

OBJECTIVE: To examine the public's knowledge and perception of SARS and the extent to which various precautionary measures have been adopted. DESIGN: Cross sectional survey. SETTING: General population of Hong Kong at the height of the SARS outbreak (29 March to 6 April 2003). PARTICIPANTS: 1115 ethnic Chinese adults. Main results: Forty per cent did not recognise fomites as a possible mode of transmission whereas 55.1% believed that the infection could be transmitted airborne. A large proportion (30.1%) believed they were very or somewhat likely to contract SARS while only one quarter believed they were very likely to survive if they contracted the disease, benchmarked against an actual case fatality ratio of 2.8% at the time of the survey and 15%-20% according to current best estimates. Precautionary measures directed against person to person droplet spread were generally adopted by most while the prevention of transmission through fomites was not practised as frequently. Respondents with higher risk perceptions and a moderate level of anxiety were most likely to take comprehensive precautionary measures against the infection, as were older, female, more educated people as well as those with a positive contact history and SARS-like symptoms. CONCLUSIONS: The findings demonstrate that the promotion of protective personal health practices to interrupt the self sustaining transmission of the SARS virus in the community must take into account background perceptions of risk and anxiety levels of the public at large. Continuing public education about preventive measures should be targeted at the identified groups with low current uptake of precautions.     

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.     

Probable secondary infections in households of SARS patients in Hong Kong

Although severe acute respiratory syndrome (SARS) is highly infectious in clinical settings, SARS has not been well examined in household settings. The household and household member attack rates were calculated for 1,214 SARS case-patients and their household members, stratified by two phases of the epidemic. A case-control analysis identified risk factors for secondary infection. Secondary infection occurred in 14.9% (22.1% versus 11% in earlier and later phases) of all households and 8% (11.7% versus 5.9% in the earlier and later phases) of all household members. Healthcare workers' households were less likely to be affected. Risk factors from the multivariate analysis included at-home duration before hospitalization, hospital visitation to the SARS patient (and mask use during the visit), and frequency of close contact. SARS transmission at the household level was not negligible in Hong Kong. Transmission rates may be greatly reduced with precautionary measures taken by household members of SARS patients.     

Screening international travellers in China for SARS

Faced with the spread of SARS through international travel, the World Health Organisation (WHO) advised against inessential travel to certain areas with local SARS transmission, and also the screening of travellers from such areas. This report looks at the steps taken in China for the screening of travellers. Travellers were asked about contact with SARS and possible symptoms, were screened for high fever, provided with health information and observed for any clinical signs. Arrangements were in place for dealing with ill travellers and for contact tracing of fellow travellers. There were also extra measures that could only be justified by the reassurance they provided. The overall impact of these measures in preventing international spread of SARS is unknown, but the experience could contribute to the control of future epidemics.     

Lessons from the severe acute respiratory syndrome outbreak in Hong Kong

Severe acute respiratory syndrome (SARS) is now a global public health threat with many medical, ethical, social, economic, political, and legal implications. The nonspecific signs and symptoms of this disease, coupled with a relatively long incubation period and the initial absence of a reliable diagnostic test, limited the understanding of the magnitude of the outbreak. This paper outlines our experience with public health issues that have arisen during this outbreak of SARS in Hong Kong. We confirmed that case detection, reporting, clear and timely dissemination of information, and strict infection control measures are essential in handling such an infectious disease outbreak. The need for an outbreak response unit is crucial to combat any future outbreak.     

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.     

Intention to receive influenza vaccination prior to the summer influenza season in adults of Hong Kong, 2015

Following a severe winter epidemic of drifted influenza A(H3N2) during January–March 2015, the Hong Kong government purchased vaccines of southern hemisphere formulation for administration prior to the anticipated summer influenza epidemic. This is the first time that seasonal influenza vaccines will be delivered twice within the same year in Hong Kong. We conducted a household telephone survey to investigate the acceptance of Hong Kong adults to pre-summer influenza vaccination. We found that the proportion of people reporting intention to receive vaccination was 37.8, 24.0, 31.4, and 34.4% in the age groups of 18–39, 40–59, 60–69, and 70 years or above. Only 31.3% of respondents who claimed they were parents or guardians said they would take their children to receive vaccination if the new vaccine was available. These findings suggested that intention to receive pre-summer vaccination was low even among the priority group of older people.