To the Editor—We refer to the multicentre review in Hong Kong Medical Journal about respiratory syncytial virus (RSV) and children with heart disease in Hong Kong.1 There is no universal guideline in Hong Kong regarding RSV immunoprophylaxis for children with heart disease because of a lack of local data on RSV infection. The authors found predictors of severe RSV infection in patients with heart disease were heart failure, pulmonary hypertension, and severe airway abnormalities associated with congenital heart disease, and conclude RSV infection poses a heavy disease burden on children with heart disease. There is no vaccine for the prevention of RSV disease, but prophylaxis is possible with palivizumab, which is available in Hong Kong.2 Indications for palivizumab are well established and include prematurity (under 35 weeks’ gestation), certain congenital heart defects, bronchopulmonary dysplasia, and infants with congenital malformations of the airway.2 However, the lack of distinct RSV seasonality in the subtropical city of Hong Kong can potentially affect the cost-effectiveness of prophylaxis immunisation.2 3 We recently managed a 4-month-old infant with Noonan syndrome and hypertrophic obstructive cardiomyopathy, who contracted RSV and developed respiratory failure, requiring venovenous extracorporeal membrane oxygenation support. Noonan syndrome is an autosomal dominant genetic disorder that may present with mildly unusual facial features, short height and skeletal malformations, and a very common syndromic cause of congenital heart disease, including pulmonary valvular stenosis, atrial septal defects, ventricular septal defects and hypertrophic cardiomyopathy.1 3 4 The mother also had Noonan syndrome and hypertrophic obstructive cardiomyopathy. Children aged ≤12 months with haemodynamically significant cardiomyopathy are at a higher risk for RSV infections and may benefit from palivizumab prophylaxis. Therefore, if resources are available, palivizumab prophylaxis should be advocated.1 5 6

Both authors contributed to the drafting of the letter and critical revision for important intellectual content. Both authors approved the final version for publication and take responsibility for its accuracy and integrity.

The authors have no conflicts of interest to disclose.

This Letter received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

1. Lee SH, Hon KL, Chiu WK, Ting YW, Lam SY. Epidemiology of respiratory syncytial virus infection and its effect on children with heart disease in Hong Kong: A multicentre review. Hong Kong Med J 2019;25:363-71. Crossref

2. Lee SY, Kwok KL, Ng DK, Hon KL. Palivizumab for infants <29 weeks in Hong Kong without a clear-cut season for respiratory syncytial virus infection-a cost-effectiveness analysis. J Trop Pediatr 2018;64:418-25. Crossref

3. Hon KL, Leung TF, Cheng WY, et al. Respiratory syncytial virus morbidity, premorbid factors, seasonality, and implications for prophylaxis. J Crit Care 2012;27:464-8. Crossref

4. Yu KP, Luk HM, Leung GK, et al. Genetic landscape of RASopathies in Chinese: three decades’ experience in Hong Kong. Am J Med Genet C Semin Med Genet 2019;181:208-17. Crossref

5. Kim AY, Jung SY, Choi JY, et al. Retrospective multicenter study of respiratory syncytial virus prophylaxis in Korean children with congenital heart diseases. Korean Circ J 2016;46:719-26. Crossref

6. American Academy of Pediatrics Committee on Infectious Diseases, American Academy of Pediatrics Bronchiolitis Guidelines Committee. Updated guidance for palivizumab prophylaxis among infants and young children at increased risk of hospitalization for respiratory syncytial virus infection. Pediatrics 2014;134:415-20. Crossref

To the Editor—Children and infants initially appeared to be largely spared from the coronavirus disease 2019 (COVID-19) pandemic. However, the United Kingdom and United States have recently reported an apparent rise in the number of children presenting with multisystem inflammatory disease, some of whom also tested positive for COVID-19.1

A multisystem inflammatory syndrome in children potentially associated with COVID-19 has been reported, with the following suggested definition: persistent fever, inflammation, evidence of single or multi-organ dysfunction; may fulfil full or partial criteria for Kawasaki disease; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction testing maybe positive or negative and other microbial causes excluded.2

About 50% of these patients have no microbiological evidence of COVID-19 infection, which fits into one of the hypothetical scenarios in our epidemiological analysis based on early data from the United Kingdom, suggesting a statistically significant correlation between COVID-19 and Kawasaki disease (P=0.0048) [Table].3 4 The pathophysiology of COVID-19 is likely to be a hyperinflammatory process of a massive cytokine storm; however, this clinical presentation can also be vasculitic in nature as there is evidence of SARS-CoV leading to vasculitis.4 5 This apparent link could also be due to the similarities in clinical presentation between COVID-19 and other sepsis syndromes including systemic inflammatory response syndrome, severe acute respiratory syndrome, toxic shock syndrome, Kawasaki disease shock syndrome, and multi-organ dysfunction syndrome.

Although this phenomenon is reported in Western countries, the majority of cases are non-Caucasians.6 As the incidence of Kawasaki disease is up to 10 times higher in Asian than in Western populations, it is inconceivable that this phenomenon could only be observed in Western countries, unless there is an underlying genetic, environment predisposition, presentation of a new variant of the SARS-CoV-2 virus, or misinterpretation of data.3

We postulate that SARS-CoV-2 may just happen to be one of the many respiratory viruses that can cause a multisystem inflammatory syndrome in children. The ‘novel phenomenon’ is in fact septic or toxic shock syndrome associated with viral triggered inflammation, potentially attributed to a new variant of SARS-CoV-2. However, we shall remain sceptical before any definitive conclusions can be drawn. Meanwhile, we caution the loose coining of too many confusing abbreviations or syndromes associated with SARS-CoV diseases, such as SARS, MERS (Middle East respiratory syndrome), COVID-19, MIS-C (multisystem inflammatory syndrome in children), PIMS/PIMS-TS (paediatric inflammatory multisystem syndrome), COVID toe syndrome, and COVID skin syndrome.7

All authors contributed to the drafting of the letter and critical revision for important intellectual content. All authors approved the final version for publication and take responsibility for its accuracy and integrity.

As the editor of the journal, KL Hon was not involved in the peer review process. Other authors have disclosed no conflicts of interest.

This letter received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

1. Paediatric Intensive Care Society. PICS Statement: Increased number of reported cases of novel presentation of multi system inflammatory disease. 2020. Available from: https://picsociety.uk/wp-content/uploads/2020/04/PICS-statement-re-novel-KD-C19-presentation-v2-27042020. pdf. Accessed 30 Apr 2020.

2. Royal College of Paediatrics and Child Health. Guidance: Paediatric multisystem inflammatory syndrome temporally associated with COVID-19. Available from: https://www.rcpch.ac.uk/sites/default/files/2020-05/COVID-19-Paediatric-multisystem- inflammatory syndrome-20200501.pdf. Accessed 14 May 2020.

3. Campbell D, Sample I. At least 12 UK children have needed intensive care due to illness linked to Covid-19. The Guardian [newspaper on the internet]. 27 Apr 2020: Health. Available from: https://www.theguardian.com/world/2020/apr/27/nhs-warns-of-rise-in-children-with-new- illness-that-may-be-linked-to-coronavirus. Accessed 30 Apr 2020.

4. Riphagen S, Gomez X, Gonzalez-Martinez C, Wilkinson N, Theocharis P. Hyperinflammatory shock in children during COVID-19 pandemic. Lancet 2020;395:1607-8. Crossref

5. Ding Y, Wang H, Shen H, et al. The clinical pathology of severe acute respiratory syndrome (SARS): A report from China. J Pathol 2003;200:282-9. Crossref

6. Public Health England. The weekly surveillance report in England (Week 16 April 2020 to 22 April 2020). Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/880848/COVID19_Weekly_Report_22_April.pdf. Accessed 28 Apr 2020.

7. Hon KL, Leung AK, Wong JC. Proliferation of syndromes and acronyms in paediatric critical care: are we more or less confused? Hong Kong Med J 2020;26:260-2.Crossref

To the Editor—We have previously reviewed a number of issues and challenges associated with in-flight medical emergencies.1 Recently, during a short flight from Hong Kong to Kaohsiung, one author (KLH) encountered a male passenger who summoned the flight attendants for medicine as he was having stomach cramps. The flight attendants rightly enquired about his history of drug allergy. Both antacids and paracetamol were available but only one should be offered; the man opted to take the paracetamol, and he seemed to feel better within a few minutes of taking it.

The man claimed that his stomach pain was triggered by eating and he was fine when empty-stomached. He denied any consumption of alcohol, tobacco, or over-the-counter medications. He claimed that the pain recurred approximately every month, but he had not seen any doctor about it. The author took this opportunity to provide health promotion education, noting the possibility of peptic ulcer disease and helicobacter infection, and recommending him to consult a doctor to follow up on the issue. The male passenger and his female companion appeared to be mistrustful at first but were at the end grateful for the health advice provided.

This episode exposed one of the fundamental health issues among Hong Kong citizens: living in a ‘sub-health’ state without seeking medical advice.2 This phenomenon is often due to people having a fear of doctors, antibiotics, steroids, or Western medicine.3 4 A sub-health state is characterised by some disturbances in psychological behaviours or physical characteristics, or in some indices of medical examination, with no typical pathologic features.5 A survey conducted by The University of Hong Kong in 2013 revealed that 97% of the surveyed Hong Kong citizens have experienced at least one sub-health symptom, and the most affected were aged 30 to 49 years, with an average of more than nine symptoms each.2 The impact should not be underestimated as 64% of the respondents reported that their daily lives were adversely affected.2

Public health promotion should target this sub-health state population, to prevent the potential development of chronic diseases. Health authorities should consider validated questionnaires to measure sub-health status in the primary care setting, so that interventions can be provided before it is too late.6

The authors had full access to the data, contributed to the letter, approved the final version for publication, and take responsibility for its accuracy and integrity.

As an editor of the journal, KL Hon was excluded from the review process for this letter. The other author has disclosed no conflicts of interest.

1. Hon KL, Leung KK. Review of issues and challenges of practicing emergency medicine above 30,000-feet altitude: 2 anonymized cases. Air Med J 2017;36:67-70. Crossref

2. Public Opinion Programme, The University of Hong Kong. Survey on Hong Kong Citizens’ knowledge and opinions on sub-health. 2013. Available from: https://www.hkupop.hku.hk/english/report/subhealth/index.html. Accessed 24 Dec 2019.

3. Chen J, Xiang H, Jiang P, et al. The role of healthy lifestyle in the implementation of regressing suboptimal health status among college students in China: A nested case-control study. Int J Environ Res Public Health 2017;14. pii: E240. Crossref

4. Wu S, Xuan Z, Li F, et al. Work-recreation balance, healthpromoting lifestyles and suboptimal health status in southern china: a cross-sectional study. Int J Environ Res Public Health 2016;13. pii: E339. Crossref

5. Li G, Xie F, Yan S, et al. Subhealth: definition, criteria for diagnosis and potential prevalence in the central region of China. BMC Public Health 2013;13:446. Crossref

6. Yan YX, Liu YQ, Li M, et al. Development and evaluation of a questionnaire for measuring suboptimal health status in urban Chinese. J Epidemiol 2009;19:333-41. Crossref

To the Editor—Measles outbreaks have been reported in the Hong Kong Medical Journal in the past 2 years.1 2 Such outbreaks occur worldwide, including in countries where measles was previously considered eliminated. In March 2019, there was a measles outbreak at Hong Kong International Airport involving airport workers, some with documented evidence of at least two doses of measles vaccinations.3 Fortunately, the patients were all relatively young adults who experienced with mild symptoms, and the basic reproduction number of these cases was not high. In response to this outbreak, control measures at the airport included a vaccination programme and measles antibody testing for airport staff. The Hong Kong childhood immunisation schedule was also revised, so that the second dose of the MMRV (measles, mumps, rubella and varicella) vaccination is given at age 18 months (previously given at age 6 years) to enhance protection against measles.

Measles vaccination uptake rate is declining due to pockets of unvaccinated communities and anti-vaccination movements, both of which might have contributed to the recent outbreaks. To eliminate measles, a continuously high (>95%) level of vaccination coverage is required in all areas. Most recent outbreaks of measles in developed countries have been imported cases; thus, they are closely linked to the aviation industry. Early recognition of disease outbreak could prevent a global pandemic. Therefore, it is crucial to have contingency plans at every airport to prevent the spreading of contagious diseases. Travellers should ensure their vaccination status is up-to-date with two doses of measles vaccination; infants from 6 months of age should receive a supplementary dose of measles vaccine if they are travelling to areas with measles outbreaks.4 Affected patients, especially school-age children, should be isolated and quarantined at home for at least 4 days from the appearance of rash.

The 2019 measles outbreak saw a substantial increase in the number of measles cases reported worldwide relative to 2018. Such outbreaks will occur again if we do not learn from the past. The only hope to truly defeat measles is for humankind to work together.

The authors had full access to the data, contributed to the study, approved the final version for publication, and takes responsibility for its accuracy and integrity.

As an Editor of the Journal, KL Hon was excluded from the review process for this letter. The other author has disclosed no conflicts of interest.

1. Hon KL, Leung AK, Leung K, Chan GC. Measles outbreak at an international airport: a Hong Kong perspective. Hong Kong Med J 2019;25:331-3. Crossref

2. Leung AK, Hon KL, Leong KF, Sergi CM. Measles: a disease often forgotten but not gone. Hong Kong Med J 2018;24:512-20. Crossref

3. Centre for Health Protection, Hong Kong SAR Government. Daily update on measles situation in Hong Kong. Available from: https://www.chp.gov.hk/files/pdf/daily_update_on_measles_cases_in_2019_eng.pdf. Accessed 6 Dec 2019.

4. World Health Organization. WHO advice for international travel in relation to measles. 2019. Available from: https://www.who.int/ith/WHO-advice-for-international-travel-in-relation-to-measles.pdf?ua=1. Accessed 6 Dec 2019.

To the Editor—With large number of deaths in many countries owing to the coronavirus disease 2019 (COVID-19) pandemic, there is a place for palliative care to alleviate suffering and uphold dignity for these patients.1 However, the small number of deaths and the primary goal to save lives has limited the referral of patients with COVID-19 in Hong Kong for palliative care. Nevertheless, medical professionals should be well prepared to serve those who would die of COVID-19 as well as from unrelated causes.2

Without palliative care units, although patients with advanced life-limiting illnesses could be admitted to acute medical beds with support from the palliative consultative service, the aggressiveness of medical treatment and provision of compassionate care might not be appropriate in acute settings. This can jeopardise the quality of care, especially for patients with complex needs, challenging symptom burden, and complicated grieving families. Thus, both palliative in-patient and consultative services are complementary and both are needed in acute hospitals.3 There is ample evidence that palliative care provides good outcomes, including better quality of life, shortened length of stay in hospital, increased home death, and more cost-effective acute care.4 5 6 Deprioritising palliative care would imply that the local health authority overlooks the holistic needs of people with life-limiting illnesses.

The initial strategy adopted by the Hospital Authority for quarantining all patients with COVID-19 in acute hospitals, regardless of their disease severity, was successful in containing the spread of virus. However, for patients with COVID-19 and only minor or no symptoms, compulsory home or camp quarantine with ambulatory medical support may achieve equal success, sparing the well-equipped cohort wards and intensive care units for those in serious and critical conditions, without sacrificing patients with other medical conditions.

A blanket method of rationing in which individuals are categorised according to factors such as age, physical or mental disability, or those under palliative care, should not be adopted during a pandemic.7 8 Categorical exclusions may be interpreted by the public to mean that certain groups of patient are “not worth treating”, leading to the perception of unfairness and distrust. Palliative care patients are often the most vulnerable and neglected group in the medical field. Nevertheless, palliative care is about more than medical treatment. A case-by-case approach is a better and more humane way to preserve the dignity of all groups of patients.

The author drafted the letter. The author approved the final version for publication and takes responsibility for its accuracy and integrity.

The author declared no conflicts of interest for the authorship and publication of this letter.

This letter received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

1. Humanitarian Health Ethics Research Group. Alleviating suffering and upholding dignity in the midst of CoViD-19 response: a place for palliative care. 31 Mar 2020. Available from: https://www.phpc.cam.ac.uk/pcu/files/2020/04/PallcareCovid_Recommendations_FINAL.pdf. Accessed 30 Apr 2020.

2. Downar J, Seccareccia D, Associated Medical Services Inc. Educational Fellows in Care at the End of Life. Palliating a pandemic: “All patients must be cared for”. J Pain Symptom Manage 2010;39:291-5. Crossref

3. Gaertner J, Frechen S, Sladek M, Ostgathe C, Voltz R. Palliative care consultation service and palliative care unit: why do we need both? Oncologist 2012;17:428-35. Crossref

4. Eti S, O’Mahony S, McHugh M, Guilbe R, Blank A, Selwyn P. Outcomes of the acute palliative care unit in an academic medical center. Am J Hosp Palliat Care 2014;31:380-4. Crossref

5. Grogan E, Paes P, Peel T. Excellence in cost-effective inpatient specialist palliative care in NHS—a new model. Clin Med (Lond) 2016;16:7-11. Crossref

6. Hui D, Elsayem A, Palla S, et al. Discharge outcomes and survival of patients with advanced cancer admitted to an acute palliative care unit at a comprehensive cancer center. J Palliat Med 2010;13:49-57. Crossref

7. Daly DJ. Guidelines for rationing treatment during the COVID-19 crisis: a catholic approach. Health Prog 2020;101. Available from: https://www.chausa.org/publications/health-progress/current-issue. Accessed 30 Apr 2020.

8. Emanuel EJ, Persad G, Upshur R, et al. Fair allocation of scarce medical resources in the time of COVID-19. N Engl J Med 2020;382:2049-55. Crossref