Questions going forward
- What should be Hong Kong’s border policy?
Our border policy should prioritize opening with the rest of the world as the mainland continues its zero covid-19 policy. We should gradually shorten the quarantine period to home quarantine with a RT-PCR test at arrival, the first three days and the tenth day and daily self-administered RATs. The home and hotel quarantine could eventually be replaced by daily RT-PCR testing with a bracelet tracker for seven days and another test on the tenth day. Inbound travelers would be forbidden by the modified government’s LeaveHomeSafe vaccine pass app from visiting restaurants and pubs for the first seven days. Cross infections do occur in quarantine hotels since they are not hospital isolation rooms.
Imported cases from travelers does not make a difference to the local epidemic situation. As all returning travelers are required to be fully vaccinated, they would not place undue burden on our hospital system even if they have Covid.
- What are the best antigen and RT-PCR testing strategies?
Antigen and/or RT-PCR testing should be deployed in clinically/epidemiologically sensitive settings such as dedicated border facilities, hospitals, clinics and elderly homes. The public should be encouraged to self-administer an RAT whenever they suspect they may have Covid-19. Higher risk individuals can procure antivirals from designated clinics and private-sector outlets and can self-isolate at home.
The use of restriction testing declarations (RTD), or the issuance of compulsory testing notices, is expensive, disruptive and wasteful. They should now be abandoned because we DO want a low level of virus circulation to boost our airway mucosal immunity.
Existing influenza surveillance mechanisms can be easily modified for Covid-19 in schools, childcare facilities and kindergartens. The daily Covid antigen testing for schools should be cancelled. Parents should know the risks if they do not vaccinate their children for Covid or flu. People will make decisions after weighing the amount of risk they would like to take.
- When should genome sequencing of positive Covid-19 tests be indicated from now on?
RT-PCR testing for known variants is generally sufficient. Genome sequencing should be limited to infected incoming travelers, outbreaks or academic settings to detect for emerging variants or subvariants.
- What should be our contact-tracing strategy?
Contact tracing should be limited to epidemiologically sensitive settings such as inpatient facilities, kindergartens, playgroups and elderly homes. The purpose of outbreak investigation is to prescribe antivirals quickly to newly diagnosed cases with risk factors. Contact tracing in restaurants and bars are just ways to maintain training of the contact tracing team, keep up public vigilance, and identify premises with poor ventilation.
- When should people be isolated and quarantined?
Hospital isolation should only apply to epidemiologically sensitive settings or for new variants when their epidemiological or clinical significance are still uncertain. Patients who acquire Covid-19 in the community should be encouraged to self-isolate at home. Isolation in community isolation facilities should be offered to cases who have close contacts who are at-risk for severe Covid and those living in cramped conditions. The same principle should apply to quarantine. We should not have different rules for different variants. The variants BA 2.12.1, BA.2.75, BA.4, and BA.5 may cause more cases but their impact on the healthcare system is going to be much milder than during the fifth wave. As noted earlier, we should stop hotel quarantine for incoming travelers soon.
- How should we modify our social distancing measures?
We have to admit that the social distancing measures that we have adopted in the first two years of the pandemic were not as effective during the fifth wave. These social distancing measures (except universal masking unless exercising outdoors) are therefore no longer necessary unless there are sharp increases in the number of hospitalizations, ICU admissions or deaths, irrespective of variants or viruses. We should gradually relax all these measures, following the example of Singapore.
- What should be our vaccination strategy?
We should refocus our vaccination and booster campaigns on the elderly and those with chronic medical conditions. The use of the vaccine pass should only be relaxed after the coming sixth wave. By then, close to 100 percent of the population will be either infected, fully vaccinated ,or both.
- How should we modify our pandemic control strategy, given new data?
When new variants come in from other places, if most of the population is either infected or vaccinated or both, these new strains are unlikely to have an impact. Even an antigenically distinct variant such as Omicron did not change the hospitalization rates in South Africa, India and Europe. Case counts will continue to fluctuate, but the situation will be manageable. We should not go back to imposing a 14/21-day quarantine. A growing number of positive tests should not a cause for concern. Increasing hospitalizations, ICU admissions and deaths will occur in the beginning of the sixth wave but will be far lower than fifth-wave levels.
- What should we expect after next winter?
New variants with varying degree of immune escape will continue to emerge but the disease should be mild as the full vaccination rate would hopefully be over 95 percent and hybrid immunity over 70 percent. By that time, large-scale RT-PCR testing for case finding and surveillance should be abandoned, reserving it only for guiding clinical management. Testing would only be indicated in symptomatic individuals who have risk factors for severe disease or require hospitalization so that antiviral treatment can be administered rapidly. Accommodating infected cases in wards by cohort would be sufficient, and infection control requirements should be relaxed further as the vaccination rates would be high enough and the population would have a sufficient level of hybrid immunity. This will help free up hospital bed space and allow staff in public hospitals to clear the long queue of patients that built up as a result of the suspension of non-urgent services in the past three years.
Contact tracing should be limited to cases infected by new variants with uncertain behavior. Even now, we should let healthcare workers with a history of contact and who test negative to be on duty to avoid the vicious cycle of decreasing hospital manpower amid rising cases in the community. There should be yearly vaccine boosting against the latest variant for the elderly and chronically ill, on top of the administration of the seasonal flu vaccine.
Then, life should almost be back to normal.