CME INDIA Presentation by Dr. S. K. Gupta, MD (Med), FICP, CFM (France) Clinical Asst. Professor GS Medical College, CCSU, Uttar Pradesh, India. Visiting Consultant, Max Super Specialty Hospital, New Delhi.

Hong Kong long had an enviable record in suppressing the coronavirus with a “dynamic zero” Covid policy, in line with that on mainland China, but as an Omicron wave now overwhelms the city, the steps that saved lives are making life unbearable for many of its 7.4 million people. -Reuters.

What is Zero Covid?

  • Zero-COVID, is an elimination or eradication strategy.
  • “Zero-COVID” aims to completely stop the spread of the virus within the community. In comparison with mitigation strategies, elimination involves stricter short-term measures, followed by milder long-term measures to prevent a return of the virus.
  • The zero-COVID approach aims to prevent viral transmission, using a number of different measures, including contact-tracing and quarantine and pharmaceutical interventions such as vaccination.   Successful containment or suppression reduces the basic reproduction number of the virus below the critical threshold.

Living with Covid or Jio Covid

  • Also called mitigation or Control strategy which attempts to lessen the effects of the virus on society, still tolerating some level of transmission within the community. Mitigation strategies (also commonly known as “flattening the curve”) aim to reduce the growth of an epidemic and to prevent the healthcare system from becoming overburdened.

Zero-COVID strategy consists of two phases:

  1. An initial suppression phase in which the virus is eliminated locally using aggressive public health measures like lockdowns curfews tracking tracing isolation and treatment,
  2. A sustained containment phase, wherein public health measures are utilized to contain new outbreaks before they spread widely so that normal economic and social activities can resume in most places.

Which Countries pursued Zero Covid?

  • Australia, Canada, mainland China, Hong Kong, Macau, New Zealand, Singapore, Scotland, South Korea, Taiwan, Tonga, and Vietnam utilized Zero Covid strategy to varying degrees.

Advantages of Zero Covid:

  • Zero-COVID leads to:
    • Far lower death rates
    • Faster return to normal life
    • Short term costs may be pinching but long-term economic growth is higher as exemplified by China

Challenges with Zero-Covid

  • To achieve zero-COVID in an area with high infection rates, one review estimated that it takes three months of strict lockdowns leading to disruption of life and economy in a localised area.
  • It may not be realistic to eliminate a respiratory virus such as SARS-CoV-2 which has high transmission rates.
  • After elimination of COVID-19 from a region, Zero-COVID strategies require stricter border controls in order to prevent reintroduction of the virus, more rapid identification of new outbreaks and better contact tracing.

Why Zero Covid is falling out of favour?

  • Of late, in 2022 it is becoming difficult to pursue Zero Covid after the emergence of Omicron.  Transmission of Omicron is so quick and widespread that health resources are not able keep pace tracing and tracking the contacts. It’s like Bullock cart chasing a train. 
  • Secondly with arrival of vaccines which are effective in curtailing hospitalization, ICU admissions and mortality chasing a tamed virus appears futile.
  • Some countries such as Vietnam, Singapore, and Australia pursued zero-COVID but later decided to discontinue it.
  • However, Mainland China, Hong Kong, Taiwan, Tonga and Western Australia are still pursuing a zero-COVID strategy.

How China successfully implemented Zero Covid?

  • There is a lot to learn from China provided one is ready to peep out of the window of the Anit China castle crafted by the Western media.
  • China’s data may not be 100% reliable but the prompt and glittering revival from Economic slump has lot more to say. How China fought the Virus?

1. Lockdowns

  • Lockdown measures are commonly used to achieve initial containment of the virus
  • Lockdowns encompass measures such as closure of non-essential businesses, stay-at-home orders and movement restrictions. During lockdowns, governments must often supply basic necessities to households. In China, lockdowns of specific high-risk communities are also sometimes used to suppress new outbreaks. China implemented strict lockdowns.

2. Quarantine for travellers:

  • In order to prevent reintroduction of the virus into zero-COVID regions after initial containment, quarantine for incoming travellers is essential. As each infected traveller could seed a new outbreak, the goal of travel quarantine is to intercept as large a percentage of infected travellers as possible speeders.
  • International flights to China are heavily restricted, and incoming travellers are required to undergo PCR testing and quarantine in designated hotels and facilities. In order to facilitate quarantine for travellers, China has constructed specialized facilities at its busiest ports of entry, including Guangzhou and Xiamen.
  • Through November 2020, border quarantine measures prevented nearly 4,000 infected international travellers from entering the wider community within China. Each month, hundreds of travellers who test negative before flying to China subsequently test positive while undergoing quarantine after arrival.

3. Contact tracing, quarantine and isolation            

  • When an infected person is identified, public health workers attempt to locate the people with whom they have come into close contact, and to quarantine and test them. Various studies have argued that early detection and isolation of infected people is the single most effective measure for preventing transmission of SARS-CoV-2.
  • In China, when an infected person is identified, all close contacts are required to undergo a 14-day quarantine, with multiple rounds of PCR testing. In order to minimize the risk that infected people will transmit the virus to family members, China has implemented quarantine in centralized facilities for those close contacts deemed to be at the highest-risk of infection. Secondary close contacts (contacts of close contacts) are sometimes required to quarantine at home.
  • Digital Contact Tracing:
    • The widespread use of smartphones has enabled more rapid “digital” contact tracing. In China, “health code” applications are used to facilitate the identification of close contacts. Taiwan has made use of digital contact tracing, notably to locate close contacts of passengers who disembarked from the Diamond Princess cruise ship, the site of an early outbreak in February 2020.

4. Routine testing of key populations             

  • Community-wide screening.
  • An additional tool for identifying cases outside of known transmission chains is community-wide screening, in which populations of specific neighbourhoods or cities are PCR tested.
  • In China, community-wide PCR testing is carried out during outbreaks in order to identify infected people, including those without symptoms or known contact with infected people.
  • Community-wide screening is intended to rapidly isolate infected people from the general population, and to allow a quicker return to normal economic activity. China first carried out community-wide screening from 14 May to 1 June 2020 in Wuhan, and has used this technique in subsequent outbreaks.
  • In outbreaks in June 2020 in Beijing and July 2020 in Dalian, community screening identified 26% and 22% of infections, respectively.
  • In order to test large populations quickly, China commonly uses pooled testing, combining 5 to 10 samples before testing, and retesting all individuals in each batch that tests positive.

5. Effective Mass Vaccination:

  • China has already given more than 3.1 billion doses of indigenous vaccines to its population. 219 doses per 100 people is one of the highest in the world.
  • China model is one of the best, to learn from.  Some countries such as Vietnam, Singapore, and Australia also pursued zero-COVID but later decided to discontinue it.
  • China model can be implemented by an Iron Hand and a Silver Spoon keeping in view the long-term interests of citizens and the Nation. Emotionally surcharged verdicts counting to care for Citizens Rights including Antivaxxers may serve cheap publicity but harm the mankind in long term.

Why Hong Kong failed in Zero-Covid in this wave?

Zero Covid Versus Jio Covid (Living with Covid)

Why Hong Kong failed in Zero-Covid in Omicron wave?

  • Hong Kong was a poster boy of pandemic control success in the past two years. Having gone thru SARS it oozed confidence in managing pandemics. By the end of 2021, the city of 7.5 million had recorded only 12,650 cases and fewer than 220 deaths.
  • The success justified the government’s adherence to the mainland’s “dynamic zero Covid” strategy.
  • But the city has been brought to its knees with the arrival of the highly transmissible Omicron variant. The number of reported cases has soared to more than 66,000 in just a couple of months. Complacent poor vaccination and highly transmissible Omicron turned tables and cases started rising exponentially.
  • Hong Kong recorded a new high of nearly 22,000 Covid-19 infections reported on 24 Feb 2022 (too high for nation of 7.5 million Population) in a single day.

How did it start?

  • The first local Omicron cases linked to two Cathay Pacific flight attendants who breached Covid rules in late December. Then a larger cluster emerged in a quarantine hotel and then it became a community transmission.

Policy Change

  • Earlier, Hong Kong was pursuing Zero-Covid and made it mandatory for all the infected regardless of symptoms to get admitted in Govt Hospital for 14 days but this soon overwhelmed the health infra. Long Queues could be seen outside hospital with people waiting on open grass in cold. Strike by front-line workers further added to woes.
  • Situation came at a time when most countries, were reducing restrictions and allowing people with mild or no symptoms to remain at home.
  • “The whole world knows we have to live with the virus, only the Hong Kong government does not know,” were the kind of satire in circulation.
  • Rising case load with imploding health facilities, growing public unrest and frowning forced Hong Kong government to drastically change its tracking testing strategy and govt started relying on self-test kit results, and home quarantine rather than pushing Govt Nose everywhere.
  • According to projections by the University of Hong Kong (HKU), the city will see a peak of more than 180,000 new cases daily by mid or late March.

What led to current explosion of cases?

  • Key problem of the low vaccination rate among the elderly. Some 76.2% of those aged above 11 are fully vaccinated – but fewer than one-third of people aged 80 and above have had two jabs.
  • Very little Covid in Hong Kong all along, made people complacent. Very few people knew people who had Covid or had died of Covid. So, the most important fear driven force for vaccination was missing.
  • Vaccine hesitancy also took root in Hong Kong, in part driven by low trust in the authorities following the political unrest in recent years.
  • Hong Kong scored lowest in vaccine acceptance and effectiveness compared to five other territories, including Singapore, UK and the US.
  • Also, for months, authorities provided little incentive for people to get vaccinated, with little difference in the way they treated vaccinated and unvaccinated people.
  • Now Officials are rolling out a vaccine pass, allowing vaccinated people to enter venues like restaurants and shopping malls.
  • Imploding health infra might have made Govt to buckle in for now.  Strategy change having brought public outcry in control Govt seems to be working on long term strategy to make Zero Covid a success.
  • Govt announced cash relief measures which include a handout of $10,000 Hong Kong dollars ($1,282) in consumption vouchers for 6.6 million residents, as well as loans, tax breaks and subsidies for struggling businesses. Property rate concessions, rental relief and electricity subsidies are also on offer.
  • Schools have already switched to online learning and summer holidays are being moved forward so that the buildings can be used as facilities for testing, isolation and vaccination. Hong Kong plans to go ahead with the plan to test every one of its 7.5 million residents three times in March.
  • With hospitals in Hong Kong already overwhelmed, construction crews from mainland China are being sent to build new isolation units and the city was moving to convert hotels, halls, indoor stadiums and other quarantine locations.
  • Chinese medical teams were also building mobile testing laboratories to help prepare Hong Kong for the launch of the mass testing.
  • There is paradigm shift in policy and resource allocation to most needy. Stable patients are being discharged from hospitals to homes. Medical teams have been called in from China, state of emergency declared.
  • Hong Kong Govt might have buckled but not broken. However, Hong Kong experience once again brings into focus the importance of vaccination. It further reaffirms that complacency can be costly and overconfidence fatal, while dealing with virus.

Suggested Reading


  3. China’s zero covid policy

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