Faculty development for postgraduate medical education in Hong Kong

© Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
 
EDITORIAL
Faculty development for postgraduate medical education in Hong Kong
HY So, FHKAM (Anaesthesiology)1; Philip KT Li, FHKAM (Medicine)2; Benny CP Cheng, FHKAM (Anaesthesiology)3; Faculty Development Workgroup, Hong Kong Jockey Club Innovative Learning Centre for Medicine#; Gilberto KK Leung, FHKAM (Surgery)4
1 Educationist, Hong Kong Academy of Medicine, Hong Kong SAR, China
2 Vice-President (Education and Examinations), Hong Kong Academy of Medicine, Hong Kong SAR, China
3 Honorary Director, Hong Kong Jockey Club Innovative Learning Centre for Medicine, Hong Kong SAR, China
4 President, Hong Kong Academy of Medicine, Hong Kong SAR, China
# Members of Faculty Development Workgroup:
Albert KM Chan (The Hong Kong College of Anaesthesiologists),
Dominic KL Ho (The College of Dental Surgeons of Hong Kong),
Franklin TT She (The College of Dental Surgeons of Hong Kong),
YF Choi (Hong Kong College of Emergency Medicine),
Peter Anthony Fok (The Hong Kong College of Family Physicians),
KK Tang (The Hong Kong College of Obstetricians and Gynaecologists),
Jason CS Yam (The College of Ophthalmologists of Hong Kong),
PT Chan (The Hong Kong College of Orthopaedic Surgeons),
KC Wong (The Hong Kong College of Otorhinolaryngologists),
SP Wu (Hong Kong College of Paediatricians),
Rock YY Leung (The Hong Kong College of Pathologists),
YM Kan (Hong Kong College of Physicians),
CW Law (The Hong Kong College of Psychiatrists),
Kevin KF Fung (Hong Kong College of Radiologists),
Skyi YC Pang (The College of Surgeons of Hong Kong)
 
Corresponding author: Dr HY So (sohingyu59@gmail.com)
 
 Full paper in PDF
 
Competency-based medical education and faculty development
By the late 20th century, traditional teaching methods in postgraduate medical education were considered inadequate for preparing doctors to navigate modern healthcare systems, thereby posing risks to patient safety. This realisation led to a global shift towards competency-based medical education.1 2 3 The Hong Kong Academy of Medicine (HKAM) identifies seven key competencies essential for contemporary medical practitioners, namely, professional expertise, interpersonal communication, teamwork, leadership, professionalism, academia, and health promotion. The achievement of proficiency in these areas requires novel approaches to teaching and learning.
 
Traditional postgraduate medical education is often centred around two main principles: the transmission of knowledge and the ‘see one, do one, teach one’ model. Although knowledge acquisition is essential, mere memorisation of facts and information does not lead to excellence in medical practice. Effective education requires more than the delivery of information. It involves selecting content aligned with learning objectives, organising and presenting material in ways that reflect how people learn, and fostering motivation to engage with the material.4 It had been demonstrated that knowledge acquisition alone does not result in expertise.5 Individuals may successfully recall information and perform well on examinations, but they often encounter difficulties when addressing real-life clinical problems. The application of knowledge is critical, and hands-on clinical experience is invaluable. However, the tasks encountered in postgraduate medicine are more complex and challenging than those in traditional apprenticeships, rendering the ‘see one, do one, teach one’ method insufficient. Teaching methods that provide support and promote a deeper understanding of material are necessary to develop true expertise in medicine.6 The importance of such teaching methods underscores the critical need for faculty development—commonly referred to as training for trainers—which involves acquiring new skills and knowledge while undergoing a shift in mindset.
 
The Faculty Development Workgroup
Faculty development is central to the successful implementation of competency-based medical education. It includes activities undertaken by healthcare professionals to enhance teaching, leadership, research, and scholarly abilities in both individual and group contexts.7 This emphasis on faculty development was highlighted in the Position Paper on Postgraduate Medical Education, published in 2023.8 The Hong Kong Jockey Club Innovative Learning Centre for Medicine (ILCM), established by HKAM, was created to modernise postgraduate medical education in Hong Kong. Initially focused on simulation-based medical education, the ILCM has since broadened its scope to address all aspects of postgraduate medical education.9 Recognising the importance of faculty development, the ILCM has assumed a leading role in advocating for this concept within the medical community. To advance these efforts, the ILCM formed the Faculty Development Workgroup (the ‘Workgroup’), which includes representatives from all 15 Colleges under HKAM, to collaborate on faculty development initiatives.
 
To ensure that faculty development in postgraduate medical education is competency-based, the Workgroup conducted a literature review to identify existing frameworks and identified seven relevant models.10 11 12 13 14 15 16 After careful deliberation, the frameworks proposed by Hesketh et al12 and the Academy of Medical Educators16 were deemed the most comprehensive and appropriate for adaptation to the local context in Hong Kong.
 
The Faculty Development Framework of the Academy
Steinert7 defines faculty as all individuals involved in teaching and educating learners across the educational continuum (eg, undergraduate, graduate, postgraduate, and continuing professional development), leadership and management within universities, hospitals, and the community, as well as research and scholarship in the health professions (eg, communication sciences, dentistry, nursing, and rehabilitation sciences). Based on this definition, the Workgroup delineated four categories of faculty within the framework: trainers, examiners, supervisors of training, and collegial leads in medical education within each College of HKAM. The initial phase of development focused on creating the Framework for Faculty Development of Trainers, which outlines the key competencies required for trainers. This framework facilitates the identification of individual learning needs, supports effective delivery of course content, and guides the evaluation of outcomes of the faculty development programme.17
 
The Workgroup adopted the three-circle model to classify learning outcomes proposed by Simpson et al.18 This model categorises competencies into core tasks, approaches to tasks, and professional identity, ensuring that trainers perform their roles effectively while approaching these roles with appropriate attitudes and professionalism (Fig).18
 

Figure. Faculty Development Framework for Trainers based on the three-circle model18
 
Workshops and beyond for faculty development
The Framework for Faculty Development of Trainers17 was approved earlier this year by the Education Committee and the Council of HKAM (Fig). In the future, the ILCM will design and implement training workshops guided by the following principles19:
  • Evidence-informed educational design
  • Relevant content
  • Experiential learning with opportunities for practice and application
  • Opportunities for feedback and reflection
  • Intentional community building
  •  
    Moreover, a recent systematic review has highlighted key principles for effective faculty development that extend beyond workshops and individual teaching effectiveness. These principles include strengthening participants’ identities as educators, promoting recognition of educational excellence and leadership development, and fostering communities of practice to support ongoing learning and skill refinement.20 This comprehensive approach reflects the learning process for clinical skills, which requires practice, feedback, and continuous development in the workplace. Therefore, effective faculty development will require sustained support from HKAM and collaboration with stakeholders across all Colleges to ensure that faculty continue to advance their skills after completing workshops.
     
    Conclusion
    Faculty development is essential for the advancement of postgraduate medical education in Hong Kong. By equipping trainers with the appropriate competencies and skills, the framework ensures that doctors in training receive high-quality education and mentorship, ultimately enhancing patient care and outcomes within the healthcare system.6
     
    Author contributions
    All authors have contributed equally to the concept, development and critical revision of the manuscript. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.
     
    Conflicts of interest
    All authors have declared no conflicts of interest.
     
    Funding/support
    This editorial received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
     
    References
    1. Kohn LT, Corrigan JM, Donaldson MS, editors. To Err Is Human: Building a Safer Health System. Washington (DC): National Academies Press; 2000.
    2. Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington (DC): National Academies Press (US); 2001.
    3. Whitehead CR, Austin Z, Hodges BD. Flower power: the armoured expert in the CanMEDS competency framework? Adv Health Sci Educ Theory Pract 2011;16:681-94. Crossref
    4. Swanwick T, Forrest K, O’Brien BC, editors. Understanding Medical Education: Evidence, Theory, and Practice. The Association for the Study of Medical Education (ASME); 2019. Crossref
    5. Dreyfus SE, Dreyfus HL. A five-stage model of the mental activities involved in direct skill acquisition. Operations Research Center, University of California, Berkeley; 1980.
    6. So HY. Postgraduate medical education: see one, do one, teach one…and what else? Hong Kong Med J 2023;29:104. Crossref
    7. Steinert Y. Faculty development: core concepts and principles. In: Steinert Y, editor. Faculty Development in the Health Professions: A Focus on Research and Practice. Innovation and Change in Professional Education, 11. Dordrecht [NY]: Springer; 2014: 3-25. Crossref
    8. So HY, Li PK, Lai PB, et al. Hong Kong Academy of Medicine position paper on postgraduate medical education 2023. Hong Kong Med J 2023;29:448-52. Crossref
    9. Chen PP, So HY, Lo JS, Cheng BC. Modernising postgraduate medical education: evolving roles of the Hong Kong Jockey Club Innovative Learning Centre for Medicine in the Hong Kong Academy of Medicine. Hong Kong Med J 2023;29:480-3. Crossref
    10. Skeff KM, Stratos GA, Bergen MR, Regula DP Jr. A pilot study of faculty development for basic science teachers. Acad Med 1998;73:701-4. Crossref
    11. Harden RM, Crosby J. AMEE Guide No. 20: The good teacher is more than a lecturer—the twelve roles of the teacher. Med Teach 2000;22:334-47. Crossref
    12. Hesketh EA, Bagnall G, Buckley EG, et al. A framework for developing excellence as a clinical educator. Med Educ 2001;35:555-64. Crossref
    13. Molenaar WM, Zanting A, van Beukelen P, et al. A framework of teaching competencies across the medical education continuum. Med Teach 2009;31:390-6. Crossref
    14. Milner RJ, Gusic ME, Thorndyke LE. Perspective: toward a competency framework for faculty. Acad Med 2011;86:1204-10. Crossref
    15. Srinivasan M, Li ST, Meyers FJ, et al. “Teaching as a Competency”: competencies for medical educators. Acad Med 2011;86:1211-20. Crossref
    16. Academy of Medical Educators. Professional standards for medical, dental and veterinary educators (fourth edition). 2022. Available from: https://www.medicaleducators.org/write/MediaManager/Documents/AoME_Professional_Standards_4th_edition_1.0_(web_full_single_page_spreads).pdf. Accessed 1 Nov 2024.
    17. Hong Kong Academy of Medicine. Framework for Faculty Development Part 1: Trainers. September 2024. Available from: https://www.hkam.org.hk/sites/default/files/PDFs/2024/HKAM_Faculty%20Development%20Framework_Part%201.pdf?v=1729586789500. Accessed 20 Sep 2024.
    18. Simpson JG, Furnace J, Crosby J, et al. The Scottish doctor—learning outcomes for the medical undergraduate in Scotland: a foundation for competent and reflective practitioners. Med Teach 2002;24:136-43. Crossref
    19. Steinert Y, Mann K, Centeno A, et al. A systematic review of faculty development initiatives designed to improve teaching effectiveness in medical education: BEME Guide No. 8. Med Teach 2006;28:497-526. Crossref
    20. Steinert Y, Mann K, Anderson B, et al. A systematic review of faculty development initiatives designed to enhance teaching effectiveness: a 10-year update: BEME Guide No. 40. Med Teach 2016;38:769-86. Crossref

    Medical-social collaboration at Siu Lam Integrated Rehabilitation Services Complex

    © Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
     
    EDITORIAL
    Medical-social collaboration at Siu Lam Integrated Rehabilitation Services Complex
    Karen KY Ho, MB, BS, FHKAM (Psychiatry)1; Winson CT Chan, MB, BS, MRCPsych1; Eric SK Lai, MSocSc2; Bonnie WM Siu, MB, ChB, FHKAM (Psychiatry)3; YS Ng, MB, ChB, FHKAM (Family Medicine)4; CL Lau, MB, BS, FHKAM (Emergency Medicine)5; Queenie Leung, MNurs (Clinical Leadership)1; YC Wong, MB, BS, FHKAM (Radiology)6
    1 Department of Psychiatry, Castle Peak Hospital, Hong Kong SAR, China
    2 Occupational Therapy Department, Castle Peak Hospital, Hong Kong SAR, China
    3 Castle Peak Hospital and Siu Lam Hospital, Hong Kong SAR, China
    4 Department of Family Medicine and Primary Health Care, Tuen Mun Hospital, Hong Kong SAR, China
    5 Department of Accident and Emergency, Pok Oi Hospital, Hong Kong SAR, China
    6 New Territories West Cluster, Hospital Authority, Hong Kong SAR, China
     
    Corresponding author: Dr Winson CT Chan (cct762@ha.org.hk)
     
     Full paper in PDF
     
    Background
    The Siu Lam Integrated Rehabilitation Services Complex (SLIRSC) is a newly established rehabilitation facility developed by the Social Welfare Department (SWD) on the former site of Siu Lam Hospital in Tuen Mun. It was created as part of the Chief Executive’s 2013 Policy Address initiatives for increasing subvented day and residential care placements for persons with disabilities.1 As the largest purpose-built rehabilitation facility in Hong Kong, the SLIRSC provides 1150 residential placements and 560 day-training placements for individuals in mental recovery, as well as those with intellectual and/or physical disabilities. It includes five residential care homes for persons with disabilities, which are operated by three non-governmental organisations (NGOs), namely, SAHK, Tung Wah Group of Hospitals, and New Life Psychiatric Rehabilitation Association.
     
    Challenges in medical service delivery
    The SLIRSC accommodates a large population of relatively advanced-age residents with multiple co-morbidities. As of 31 August 2024, the SLIRSC houses 567 residents, approximately one-third of whom are aged ≥60 years. Many residents require follow-up by various specialties, including 329 (58%) who require medical follow-up and 421 (74%) who require psychiatric follow-up. Despite its scenic natural landscape, the relatively remote location of the SLIRSC creates challenges when transporting residents to hospitals for medical care. Moreover, a substantial proportion of residents display mobility problems—more than one-fifth (21%) are either chairbound or bedbound. Some residents experience difficulty in adjusting to unfamiliar environments while they receive medical care outside the facility, leading to a need for more intensive care and supervision. These challenges emphasise the importance of an innovative medical-social collaboration model tailored to the unique requirements of the SLIRSC.
     
    Medical-social collaboration
    The World Health Organization has suggested that an integrated health service model, based on strong primary care and public health functions, can improve the distribution of health outcomes, enhance well-being, and increase quality of life.2 3 There is growing recognition of the need to integrate various health services to provide coordinated, patient-centred care.4 This integration can improve care quality, expand patient access to services, and reduce wait times for outpatient appointments.5 Notably, medical-social collaboration is one of the core strategies outlined in the World Health Organization Framework on integrated, people-centred health services.2 Collaboration is defined in various ways throughout the literature. Generally, it represents processes intended to improve efficiency and quality via synergistic combinations of resources and expertise from different organisations.6 7 This approach reduces duplication and facilitates the sharing of expertise and resources, enabling organisations to explore solutions beyond the limitations of their own perspectives.8 Medical-social collaboration is especially beneficial for populations with needs encompassing physical, mental, and social domains.9 Partnerships between the Hospital Authority (HA) and local NGOs are not new. As early as 2012, integrated medical and social support initiatives were already targeting and serving older adults in Hong Kong.10 Additional collaborative efforts include the Integrated Discharge Support Programme for high-risk older patients and the District Health Centres led by the Health Bureau.11 12
     
    The Committee for Service Implementation of the SLIRSC was established in 2023. The Committee is led by Dr YC Wong, Cluster Chief Executive of the New Territories West Cluster (NTWC) of the HA and Ms Maggie Leung, Assistant Director (Rehabilitation and Medical Social Services) of the SWD. It consists of stakeholders from the HA, SWD, and NGOs, which provides strategic direction and guidance regarding medical-social collaboration and support for the SLIRSC. A medical-social collaboration task force for the SLIRSC was created under the Committee to serve as a working platform for key stakeholders and facilitate collaboration among parties. Our medical-social collaboration model has three primary objectives: (1) streamline delivery of care, (2) enhance quality of care and services, and (3) improve backend efficiency.
     
    Streamlining delivery of care
    Considering the relatively remote location of the SLIRSC, our medical-social collaboration strives to facilitate on-site management, minimising the need for patient transport and admissions. To provide additional medical support, Yan Oi General Out-patient Clinic (GOPC), the clinic closest to the SLIRSC, has reserved appointment times for SLIRSC residents to manage episodic and chronic illnesses. The SLIRSC can make prior arrangements with the Yan Oi GOPC. Unused appointment times are released back to the general pool. The utilisation of these reserved appointment times increased from 2% in January 2024 to 24% in July 2024.
     
    Clustering follow-up appointments for residents through telehealth can mitigate distance barriers, conserve manpower, and reduce the time required for travel and transport.13 14 Specific telehealth workflows have been established by the Yan Oi GOPC and Tuen Mun Mental Health Centre, the psychiatric specialist out-patient clinic of Castle Peak Hospital, to facilitate case selection and delivery of care via telehealth. Telehealth has been used in the treatment of minor ailments, protocol-driven management, and follow-up of stable chronic illnesses. It is also utilised for initial case triage to reduce unnecessary attendance at the accident and emergency departments.
     
    Outbreak containment is important in any large-scale residential complex.15 The NTWC has collaborated with NGO operators to develop specific management guidelines for infectious disease outbreaks. Close surveillance is performed by the SLIRSC and NTWC, enabling early detection of infectious disease clusters and triggering necessary responses. Several communication platforms have been established between the NTWC and SLIRSC. Timely infection control guidance is provided by NTWC infection control team; face-to-face or telehealth consultations are arranged based on disease severity and symptomatology. In the event of a large-scale outbreak, the NTWC coordinates necessary medical support, admissions, and bed assignments in wards. This workflow has been activated twice (July 2024 and August 2024) to manage two coronavirus disease 2019 outbreaks, both of which were contained within a small area and for a limited duration.
     
    Enhancing quality of care and services
    A substantial number of SLIRSC residents require specialised nursing care. Our medical-social collaboration enhances the quality of care through the train-the-trainer programmes for new staff. These programmes focus on specialised nursing care, including management of the unique needs of residents with mental and intellectual disabilities and stoma care. Physiotherapists and occupational therapists from the NTWC also provide services through a hybrid mode, assisting local allied health professionals in delivering specialised on-site rehabilitation programmes.
     
    Due to the extensive impact of methicillin-resistant Staphylococcus aureus (MRSA) colonisation on the daily operations of the SLIRSC and provision of rehabilitation to residents, the NTWC has arranged MRSA decolonisation therapy for the SLIRSC. Prior training was provided to SLIRSC staff to enhance compliance. The programme began in June 2024 and the first group showed a success rate of 76% (16 of 21 MRSA carriers completed decolonisation and tested negative for MRSA upon re-evaluation). Successful cases will be de-labelled in the HA system. This training allows SLIRSC staff to continue on-site MRSA decolonisation therapy for carriers.
     
    Improving backend efficiency
    Increased efficiency is another primary goal of our collaboration. The SLIRSC is equipped with a state-of-the-art in-house medication management system. The NTWC facilitates the electronic transfer of dispensing data by supporting the input of dispensed medication information into their system. This system reduces administrative and medication errors, improves dispensing efficiency and medication safety, enhances productivity, and reduces the required manpower, saving both time and costs. A dedicated telehealth workflow for the SLIRSC further increases efficiency in medication collection after telehealth consultations, shortening wait times and conserving manpower within the SLIRSC.
     
    Summary
    As the largest purpose-built rehabilitation facility in Hong Kong, the SLIRSC offers a unique opportunity to re-orient our service model for residential homes by strengthening local medical-social collaboration. Thus far, outcomes have been promising; continuous review with collaborative efforts will further refine our service model, with the aim of promoting holistic care for persons with disabilities.
     
    Author contributions
    All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.
     
    Conflicts of interest
    All authors have disclosed no conflicts of interest.
     
    Acknowledgement
    The authors thank the following individuals and parties for their contributions to this article:
    1. Mr CC Law, Dr KM Cheng, Dr Jessica Wong and Mr WM Chung from Department of Psychiatry, Castle Peak Hospital;
    2. Dr Steve Tso from Department of Psychiatry, Siu Lam Hospital;
    3. Ms Mandy Mak from Department of Physiotherapy, Tuen Mun Hospital;
    4. Ms Pauline Chu from Department of Pharmacy, Tuen Mun Hospital;
    5. Ms Maggie Leung, Assistant Director (Rehabilitation and Medical Social Services) of Social Welfare Department;
    6. SAHK;
    7. Tung Wah Group of Hospitals; and
    8. New Life Psychiatric Rehabilitation Association.
     
    Funding/support
    This editorial received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
     
    References
    1. Panel on Welfare Services, Legislative Council. Setting up of an Integrated Rehabilitation Services Complex at the site of ex–Siu Lam Hospital, Tuen Mun. 2014 Dec 8. Available from: https://www.legco.gov.hk/yr14-15/english/panels/ws/papers/ws20141208cb2-381-7-e.pdf. Accessed 2 Dec 2024.
    2. World Health Organization. Continuity and coordination of care: a practice brief to support implementation of the WHO Framework on integrated people-centred health services. World Health Organization; 2018.
    3. World Health Organization. Integrating health services: brief. World Health Organization; 2018.
    4. He AJ, Tang VF. Integration of health services for the elderly in Asia: a scoping review of Hong Kong, Singapore, Malaysia, Indonesia. Health Policy 2021;125:351-62. Crossref
    5. Baxter S, Johnson M, Chambers D, Sutton A, Goyder E, Booth A. The effects of integrated care: a systematic review of UK and international evidence. BMC Health Serv Res 2018;18:350. Crossref
    6. Axelsson R, Axelsson SB. Integration and collaboration in public health—a conceptual framework. Int J Health Plann Manage 2006;21:75-88. Crossref
    7. Woulfe J, Oliver TR, Zahner SJ, Siemering KQ. Multisector partnerships in population health improvement. Prev Chronic Dis 2010;7:A119.
    8. Huxham C, Vangen S. Managing to Collaborate: The Theory and Practice of Collaborative Advantage. Routledge; 2013. Crossref
    9. Fisher MP, Elnitsky C. Health and social services integration: a review of concepts and models. Soc Work Public Health 2012;27:441-68. Crossref
    10. Maw KC, Lo SV, Leung PY. Integrating medical and social support for elderly in Hong Kong—system and technology enabled service innovations. World Hosp Health Serv 2017;53:7-10.
    11. Lin FO, Luk JK, Chan TC, Mok WW, Chan FH. Effectiveness of a discharge planning and community support programme in preventing readmission of high-risk older patients. Hong Kong Med J 2015;21:208-16. Crossref
    12. Lin AF, Cunliffe C, Chu VK, et al. Prevention-focused care: the potential role of chiropractors in Hong Kong’s primary healthcare transformation. Cureus 2023;15:e36950. Crossref
    13. Groom LL, McCarthy MM, Stimpfel AW, Brody AA. Telemedicine and telehealth in nursing homes: an integrative review. J Am Med Dir Assoc 2021;22:1784-801.e7. Crossref
    14. Shigekawa E, Fix M, Corbett G, Roby DH, Coffman J. The current state of telehealth evidence: a rapid review. Health Aff (Millwood) 2018;37:1975-82. Crossref
    15. Lee MH, Lee GA, Lee SH, Park YH. Effectiveness and core components of infection prevention and control programmes in long-term care facilities: a systematic review. J Hosp Infect 2019;102:377-93. Crossref

    Empowering women’s health: a rising priority

    © Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
     
    EDITORIAL
    Empowering women’s health: a rising priority
    Claire Chenwen Zhong, PhD, MPhil1,2 #; Junjie Huang, PhD, MSc1,2,3 #; Mellissa Withers, PhD, MHS4; Martin CS Wong, MD, MPH1,2,5
    1 Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
    2 Centre for Health Education and Health Promotion, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
    3 Editor, Hong Kong Medical Journal
    4 Department of Population and Health Sciences, Institute for Global Health, University of Southern California, Los Angeles, United States
    5 Editor-in-Chief, Hong Kong Medical Journal
    # Equal contribution
     
    Corresponding author: Prof Martin CS Wong (wong_martin@cuhk.edu.hk)
     
     Full paper in PDF
     
    Introduction
    Women’s health differs from men’s health not only in biological and gender-specific aspects but also in societal and psychological dimensions, making it a crucial component of public health. The health of women and girls is particularly important because they often face disadvantages and vulnerabilities due to discrimination in many societies. In recent years, increased awareness of gender-specific health issues has underscored the need for comprehensive strategies to address women’s health concerns, including reproductive health, cancer prevention, and care for elderly women. This editorial provides an overview of the unique health challenges faced by women in Hong Kong throughout various stages of life and examines interventions designed to improve health outcomes for women.
     
    Reproductive health
    Reproductive health is fundamental to women’s overall well-being, encompassing all aspects of the reproductive system and its functions.1 Health issues may arise at any stage of life, from menarche (the onset of the first menstrual period) to menopause. Multiple pregnancies, defined as the simultaneous presence of more than one fetus (eg, twins, triplets, or higher-order multiples), involve serious health risks.2 3 The perinatal mortality risk can be up to 7 times higher in twin pregnancies than in singleton pregnancies; risks increase further in triplet and quadruplet pregnancies.2 Since the introduction of assisted reproductive technology in 1978, the prevalence of multiple pregnancies has risen worldwide.2 A retrospective study analysing medical records from a university tertiary obstetric unit in Hong Kong showed that the prevalence of multiple pregnancies increased from 1.41% in the first decade (2000-2010) to 1.91% in the second decade (2010-2019).2 Despite this increase, the total mortality rate for multiple births significantly decreased, from 25.32 per 1000 births to 13.82 per 1000 births. This improvement has been attributed to advancements in antenatal care, enhanced treatment options, and reductions in preterm births.2 These findings highlight the importance of continued research and targeted interventions in reproductive health to achieve better outcomes for women and infants.
     
    Additionally, postpartum haemorrhage (PPH), a life-threatening condition characterised by excessive bleeding, is significantly more common in women with multiple pregnancies than in those with singleton pregnancies.4 A retrospective cohort study revealed a substantially elevated risk of severe PPH among women with twin pregnancies, particularly those who were obese, had conceived via in vitro fertilisation, or presented with placenta previa.4 Special attention must be given to pregnant women with these risk factors, including proactive preparations for the management of severe PPH to mitigate the risk of mortality. Enhanced monitoring and targeted interventions are essential for efforts to improve outcomes in this vulnerable population. Psychological morbidity is also frequently observed in pregnant women, particularly those experiencing threatened miscarriage.5 In a cross-sectional study of women in their first trimester, 48.4% to 76.7% reported distress.5 Notably, women with a history of miscarriage exhibited higher stress scores relative to those without such a history.5 6 Thus, early identification of women requiring additional psychological support, facilitated through psychometric instruments, is critical for improvements to maternal psychological well-being, which is also associated with better fetal outcomes.5
     
    Moreover, pregnant women tend to be more vulnerable to communicable diseases such as coronavirus disease 2019 (COVID-19), more concerned about severe complications, and more fearful of vertical transmission to neonates; these tendencies impose additional psychological stress.7 8 According to a cross-sectional survey conducted in Hong Kong from 28 July 2020 to 13 August 2020, 83.1% of pregnant women expressed substantial concern about contracting COVID-19 during pregnancy, 70.5% feared intrauterine viral infection of their fetuses due to maternal COVID-19, and 84.3% opposed the ban on husbands accompanying their wives during labour and delivery.7 Governments and healthcare professionals should enhance public education to increase awareness of COVID-19—related complications during pregnancy, enabling women to approach the situation with informed perspectives and reducing unnecessary stress.7 The provision of universal screening for pregnant women, a widely supported approach, represents another intervention to alleviate the burden of disease.7
     
    In addition to health concerns during pregnancy, infertility remains a major reproductive health issue for women, affecting nearly one in six adult women worldwide.9 Although advancements in fertility preservation technologies have enabled many patients to conceive their own biological children, some individuals have been unable to undergo the ovarian stimulation required for oocyte or embryo freezing, including prepubertal girls who are ineligible for the procedure.10 Ovarian tissue cryopreservation serves as an ideal option for preserving fertility in these cases.11 An in vivo study of nude mice demonstrated that grafted ovarian tissues remained viable after ovarian tissue cryopreservation and subsequent transplantation, supporting the implementation of this approach in Hong Kong.11
     
    Cancer and ageing
    Cancer is a leading cause of death among women, and breast cancer is the most prevalent type in Hong Kong.12 13 Early detection through risk-based screening programmes is essential for reducing breast cancer–related morbidity and mortality.14 15 In Hong Kong, the Cancer Expert Working Group on Cancer Prevention and Screening has reviewed and updated its breast cancer screening recommendations, introducing slight changes for women at moderate risk.12 Women aged 44 to 69 years with increased breast cancer risk (eg, family history, benign breast disease, reproductive history, early menarche, high body mass index, and physical inactivity) are advised to consider biennial mammography screening after consulting their physicians.12
     
    Advanced treatment plays an equally important role in managing breast cancer.16 Neoadjuvant chemotherapy (NAC), administered before definitive breast cancer surgery, reduces tumour size and facilitates surgery for patients.17 Insights from a 12-year review of the Hong Kong Breast Cancer Registry demonstrated the effectiveness of NAC, supporting its application in patients with stage II or higher disease, as well as those with human epidermal growth factor receptor 2–positive (non-luminal) or triple-negative breast cancers.16 The use of NAC in Hong Kong nearly doubled during the 12-year period, increasing from 5.6% in 2006-2011 to 10.3% in 2012-2017.16
     
    Early prevention of cancer through human papillomavirus (HPV) vaccination plays an indispensable role in women’s health. Human papillomavirus vaccination is a safe and effective method for preventing cervical cancer, as well as other HPV-related cancers, including cancers of the anus, vulva, vagina, penis, and oropharynx.18 To improve vaccine coverage, the promotion of a gender-neutral vaccination programme within the school-based childhood immunisation framework is essential. A cross-sectional online survey in Hong Kong revealed that only 12.5% (63/503) of parents had consented to vaccination for their daughters.18 Parental misconceptions regarding vaccine safety and the ideal vaccination age represent major barriers that must be addressed to increase HPV vaccination coverage among children.18
     
    As women age, they encounter unique health challenges, including an increased risk of osteoporosis, cardiovascular disease, and cognitive decline. Pelvic organ prolapse (POP) is a common health issue, reported by nearly 10% of the Chinese population.19 Increasing evidence supports surgical treatment over vaginal pessaries as a definitive intervention for POP. A recent multicentre retrospective study showed that POP surgeries were safe and effective for women aged ≥75 years in Hong Kong.20 Additionally, there is a need to emphasise the importance of the Hong Kong Reference Frameworks in managing chronic diseases among elderly women.21 These frameworks provide evidence-based, standardised guidelines for primary healthcare professionals to assist patients in preventing and managing conditions such as diabetes mellitus, hypertension, and common musculoskeletal disorders.21
     
    In summary, the growing recognition of women’s health as a critical component of public health requires a comprehensive, evidence-based approach to implementing effective interventions that address the unique challenges faced by women at various life stages. This editorial has outlined prevalent health issues among women in Hong Kong and worldwide, emphasising the need for a multidimensional framework that integrates prevention, early detection, and effective treatment. Such an approach is essential to improve women’s health outcomes in the future.
     
    Author contributions
    All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.
     
    Conflicts of interest
    All authors have disclosed no conflicts of interest.
     
    Acknowledgement
    The authors acknowledge the literature search and review assistance of Mr Zehuan Yang, Research Assistant at the Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong.
     
    References
    1. Global Perspectives on Women’s Sexual and Reproductive Health Across the Lifecourse. Cambridge International Law Journal; 2018.
    2. Lau SL, Wong ST, Tse WT, et al. Perinatal mortality rate in multiple pregnancies: a 20-year retrospective study from a tertiary obstetric unit in Hong Kong. Hong Kong Med J 2022;28:347-56. Crossref
    3. Sherer DM. Adverse perinatal outcome of twin pregnancies according to chorionicity: review of the literature. Am J Perinatol 2001;18:23-37. Crossref
    4. Kong CW, To WW. Risk factors for postpartum haemorrhage in twin pregnancies and haemorrhage severity. Hong Kong Med J 2023;29:295-300. Crossref
    5. Ip PN, Ng K, Wan OY, Kwok JW, Chung JP, Chan SS. Cross-sectional study to assess the psychological morbidity of women facing possible miscarriage. Hong Kong Med J 2023;29:498-505. Crossref
    6. Farren J, Jalmbrant M, Ameye L, et al. Post-traumatic stress, anxiety and depression following miscarriage or ectopic pregnancy: a prospective cohort study. BMJ Open 2016;6:e011864. Crossref
    7. Lok WY, Chow CY, Kong CW, To WW. Knowledge, attitudes, and behaviours of pregnant women towards COVID-19: a cross-sectional survey. Hong Kong Med J 2022;28:124-32. Crossref
    8. Dashraath P, Wong JL, Lim MX, et al. Coronavirus disease 2019 (COVID-19) pandemic and pregnancy. Am J Obstet Gynecol 2020;222:521-31. Crossref
    9. World Health Organization. 1 in 6 people globally affected by infertility: WHO. Last modified April 4, 2023. Available from: https://www.who.int/news/item/04-04-2023-1-in-6-people-globally-affected-by-infertility. Accessed 12 Dec 2024.
    10. Dolmans MM, Donnez J. Fertility preservation in women for medical and social reasons: oocytes vs ovarian tissue. Best Pract Res Clin Obstet Gynaecol 2021;70:63-80. Crossref
    11. Chung JP, Chan DY, Song Y, et al. Implementation of ovarian tissue cryopreservation in Hong Kong. Hong Kong Med J 2023;29:121-31. Crossref
    12. Tsang TH, Wong KH, Allen K, et al. Update on the Recommendations on Breast Cancer Screening by the Cancer Expert Working Group on Cancer Prevention and Screening. Hong Kong Med J 2022;28:161-8. Crossref
    13. Huang J, Chan PS, Lok V, et al. Global incidence and mortality of breast cancer: a trend analysis. Aging (Albany NY) 2021;13:5748-803. Crossref
    14. Duffy S, Vulkan D, Cuckle H, et al. Annual mammographic screening to reduce breast cancer mortality in women from age 40 years: long-term follow-up of the UK Age RCT. Health Technol Assess 2020;24:1-24. Crossref
    15. Henderson JT, Webber EM, Weyrich MS, et al. Screening for breast cancer: evidence report and systematic review for the US Preventive Services Task Force. JAMA 2024;331:1931-46. Crossref
    16. Chan YH, Kwok CC, Tse DM, Lee HM, Tam PY, Cheung PS. Preoperative considerations and benefits of neoadjuvant chemotherapy: insights from a 12-year review of the Hong Kong Breast Cancer Registry. Hong Kong Med J 2023;29:198-207. Crossref
    17. Shien T, Iwata H. Adjuvant and neoadjuvant therapy for breast cancer. Jpn J Clin Oncol 2020;50:225-9. Crossref
    18. Lam EW, Ngan HY, Kun KY, Li DF, Wan WY, Chan PK. Awareness, perceptions, and acceptance of human papillomavirus vaccination among parents in Hong Kong. Hong Kong Med J 2023;29:287-94. Crossref
    19. Pang H, Zhang L, Han S, et al. A nationwide population-based survey on the prevalence and risk factors of symptomatic pelvic organ prolapse in adult women in China—a pelvic organ prolapse quantification system-based study. BJOG 2021;128:1313-23. Crossref
    20. Wong D, Lee YT, Tang GP, Chan SS. Surgical treatment of pelvic organ prolapse in women aged ≥75 years in Hong Kong: a multicentre retrospective study. Hong Kong Med J 2022;28:107-15. Crossref
    21. Health Bureau, Primary Healthcare Commission. Reference Frameworks. Available from: https://www.healthbureau.gov.hk/phcc/main/frameworks.html?lang=2. Accessed 24 Nov 2024.

    Hepatitis B screening to reduce liver cancer burden

    © Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
     
    EDITORIAL
    Hepatitis B screening to reduce liver cancer burden
    Claire Chenwen Zhong, MPhil, PhD1,2; Wanghong Xu, MD, PhD3,4; Junjie Huang, MSc, PhD1,2,5; Martin CS Wong, MD, MPH1,2,5,6
    1 The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
    2 Centre for Health Education and Health Promotion, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
    3 International Editorial Advisory Board, Hong Kong Medical Journal
    4 School of Public Health, Fudan University, Shanghai, China
    5 Editor, Hong Kong Medical Journal
    6 Editor-in-Chief, Hong Kong Medical Journal
     
    Corresponding author: Prof Martin CS Wong (wong_martin@cuhk.edu.hk)
     
     Full paper in PDF
     
    Epidemiology of liver cancer and hepatitis B infection
    According to the 2021 statistics from the Hong Kong Cancer Registry, liver cancer is the fifth most commonly diagnosed cancer and the third leading cause of cancer-related mortality in Hong Kong.1 Over the past few decades, the incidence of liver cancer in Hong Kong has exhibited an exceptionally declining trend, consistent with the overall decrease observed across Eastern Asia.2 3 4 5 However, the number of new liver cancer cases in Hong Kong has been increasing, primarily due to the ageing population.2 3 In addition to the heightened risk of liver cancer among older individuals, prognosis is often worsened by increased liver fragility and the presence of co-morbidities.6
     
    Hepatocellular carcinoma (HCC) is the predominant histological type of liver cancer, causing the majority of liver cancer diagnoses and deaths.7 8 Cirrhosis of the liver precedes HCC development in most cases, acting as a driver through hepatocyte regeneration.9 10 Among the various causes of cirrhosis, chronic hepatitis B infection is the leading contributor to HCC.11 The hepatitis B virus (HBV) infects only primates and can cause hepatocellular injury by damaging infected hepatocytes.12 Moreover, HBV exhibits oncogenic potential by inducing genomic instability through its integration into the host genome.12 Other risk factors for HCC include chronic hepatitis C virus (HCV) infection, dietary exposure to aflatoxin, excessive alcohol consumption, obesity, type 2 diabetes, and smoking.2 However, the burden of liver cancer in Hong Kong is unlikely to be linked to HCV or aflatoxin exposure, considering the low prevalence of HCV and the rarity of aflatoxin contamination over the past decade.13 14
     
    The endemicity of hepatitis B in Hong Kong has declined from high-intermediate to intermediate-low, with a significant reduction in seroprevalence of hepatitis B surface antigen (HBsAg) among various populations, including new blood donors and pregnant women.15 This success can be attributed to the implementation of a universal hepatitis B vaccination programme in 1988 for all newborns and the availability of antiviral treatments. Since the initiation of the vaccination programme, coverage of the third dose of the hepatitis B vaccine in children aged 3 to 5 years has consistently exceeded 99%.16 However, adults over the age of 30 years were not included in the universal neonatal hepatitis B vaccination programme; these individuals remain at high risk of hepatitis B infection because they lack immunological protection.2 A recent study estimated that the overall HBsAg seroprevalence in Hong Kong remains as high as 7.2%.13 Therefore, a subsidised screening programme is urgently needed to protect the unvaccinated population from the risks of hepatitis B infection and liver cancer.
     
    Existing screening practices and their challenges
    Worldwide, the epidemiology of liver cancer is shifting due to expanded vaccination coverage for HBV and HCV, increasing prevalences of chronic diseases, and growing numbers of smokers and individuals consuming excessive amounts of alcohol.17 18 According to a global analysis,18 liver cancer was responsible for 529 202 new cases, 483 875 deaths, and 12.9 million disability-adjusted life years in 2021. These figures represent approximately 26% and 25% increases in liver cancer incidence and mortality, respectively, from 2010 to 2021.18 In 2021, the majority of liver cancer deaths were attributed to HBV (38%), followed by HCV (30%), alcohol (19%), metabolic dysfunction–associated steatotic liver disease (9%), and other causes (4%).18
     
    The global burden of HBV remains substantial, with an estimated HBsAg prevalence of 3.9% in 2016, corresponding to nearly 291 million infections.19 However, only 10% (29 million) of these infections were diagnosed, and just 5% (4.8 million of 94 million eligible individuals) received antiviral therapy.19 The absolute number of liver cancer cases due to hepatitis B increased by 21%, and associated deaths rose by 17% from 2010 to 2021 globally.20 The global age-standardised incidence rate for liver cancer due to hepatitis B declined, with an annual percentage change of -0.60% (95% uncertainty interval: -0.69% to -0.51%); the age-standardised death rate also decreased, with an annual percentage change of -0.98% (95% uncertainty interval: -1.24% to -0.72%).18
     
    To reduce the prevalence and burden of HBV infection, two primary screening strategies have been proposed and implemented in various countries: universal screening and screening in higher-prevalence settings. In the United States, the Centers for Disease Control and Prevention updated its guidelines in 2023, recommending hepatitis B screening using three laboratory tests at least once in a lifetime for adults aged ≥18 years.21 Prior to this update, hepatitis B screening was recommended only for pregnant women and populations at increased risk of chronic HBV infection.21 This policy change was informed by a study demonstrating the cost-effectiveness of universal screening, particularly in settings with an undiagnosed chronic hepatitis B prevalence of 0.24% and annual antiviral treatment costs below US$894.22 Universal screening also simplifies implementation by eliminating complex risk stratification, which is challenging for healthcare workers to effectively implement in real-world settings.22 Conversely, targeted screening may be more cost-effective in settings where the prevalence of undiagnosed HBsAg is very low (<0.026%), often achievable through universal neonatal vaccination and high screening coverage.22 Targeted screening also requires fewer resources, making it more feasible in resource-limited contexts.22
     
    Proposed programme overview
    In the 2024 Policy Address, the Hong Kong Government announced plans to introduce a subsidised hepatitis B screening programme to prevent liver cancer.23 Under this programme, District Health Centres and family doctors will provide risk-based hepatitis B screening and management through strategic purchasing.23 The initiative aims to support Hong Kong in achieving the World Health Organization’s viral hepatitis elimination goals24 by increasing awareness among individuals unaware of their HBV infection. The programme will involve Hong Kong’s 18 District Health Centres, which will offer simple blood tests. Family doctors will follow up with hepatitis B carriers, ensuring consistent monitoring for this chronic and often asymptomatic condition, which can persist for 20 to 30 years.23 The programme will adopt a risk-based screening approach, initially offering free screening to individuals with elevated risk of HBV infection, such as family members of hepatitis B patients, and subsequently expanding to other adults.25 Additional high-risk groups, including people who inject drugs, individuals with human immunodeficiency virus, men who have sex with men, sex workers, and prison inmates, will be prioritised for testing.25 Screening may also target specific age-groups to more effectively reduce severe morbidity and mortality.
     
    Benefits of the proposed programme
    The proposed programme offers several advantages. First, it will improve access to screening for individuals at high risk of HBV infection, addressing resource constraints in Hong Kong’s healthcare system while enhancing clinical outcomes by prioritising vulnerable populations. Second, the programme has the potential to reduce liver cancer rates through early detection and intervention. Considering the strong association between HBV infection and liver cancer, this initiative could significantly alleviate the burden of both conditions. Finally, the programme will strengthen community healthcare by identifying at-risk individuals early, preventing progression to more severe disease, and reducing strain on the healthcare system.
     
    Implementation considerations
    Before implementing the proposed hepatitis B screening programme, three critical aspects must be carefully addressed and optimised to ensure its success.
     
    First, it is essential to assess and address the training needs of healthcare providers. The shortage of healthcare professionals in Hong Kong, combined with increasing healthcare demand, has led to prolonged waiting times for medical services.26 To enhance implementation readiness, targeted and comprehensive training programmes should be developed and delivered to healthcare providers prior to the programme’s launch. This training should focus on equipping providers with the necessary knowledge, skills, and workflows to ensure the programme’s efficiency and effectiveness while minimising disruptions to existing services.
     
    Second, increased public awareness of hepatitis B is vital for efforts to achieve high participation rates in the screening programme. A 2010 telephone survey revealed suboptimal public awareness of hepatitis B in Hong Kong; approximately 45% of respondents were unaware that hepatitis B is the leading cause of chronic viral hepatitis, and 73% mistakenly believed that the virus could be transmitted by consuming contaminated seafood.27 Similarly, a 2020 study identified persistent deficiencies in knowledge, attitudes and behaviours regarding viral hepatitis, as well as low screening rates, highlighting the need for comprehensive educational initiatives.28 These initiatives should utilise evidence-based strategies to correct misconceptions, enhance risk awareness, and promote positive health-seeking behaviours, consistent with the World Health Organization’s viral hepatitis elimination targets.28
     
    Finally, robust evaluation mechanisms should be established to monitor and assess the programme’s implementation and outcomes. Key metrics can include the proportion of the target population screened relative to the estimated need and the programme’s cost-effectiveness, measured by comparing cost savings from early detection and treatment with total programme expenditures. Implementation science frameworks, such as process evaluation and logic models, can be established to identify barriers, facilitators, and contextual factors influencing outcomes. This approach facilitates ongoing refinement and scalability of the programme. A structured three-phase approach is recommended to develop effective implementation strategies. In the first phase, qualitative studies using the Consolidated Framework for Implementation Research can identify obstacles and facilitators to implementation.29 The second phase involves designing tailored strategies based on the Consolidated Framework for Implementation Research-linked Expert Recommendations for Implementing Change to address barriers and enhance facilitators.30 In the third phase, these strategies can be evaluated and refined through consensus-building methods, such as Delphi techniques.31
     
    Conclusion
    The rising burden of liver cancer, largely attributable to chronic hepatitis B infection, emphasises the pressing need for robust screening and prevention strategies. The proposed subsidised hepatitis B screening programme aims to identify at-risk individuals and facilitate early detection, ultimately reducing the community’s liver cancer burden. By leveraging the resources of District Health Centres and family doctors, the programme seeks to enhance public awareness and expand access to screening, particularly for high-risk populations. Efforts to ensure adequate training for healthcare providers and improve public education regarding hepatitis B will be central to the programme’s success. Based on careful planning, implementation, and evaluation, this initiative has the potential to substantially advance Hong Kong’s progress toward achieving the World Health Organization’s viral hepatitis elimination targets.
     
    Author contributions
    All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.
     
    Conflicts of interest
    All authors have disclosed no conflicts of interest.
     
    Funding/support
    This editorial received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
     
    Acknowledgement
    The authors acknowledge the assistance of Mr Zehuan Yang, Research Assistant at The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, for his support with the literature search and review.
     
    References
    1. Hong Kong Cancer Registry, Hospital Authority. Top ten cancers. 2021. Available from: https://www3.ha.org.hk/cancereg/topten.html. Accessed 6 Nov 2024.
    2. Ma T, Wei X, Wu X, Du J. Trends and future projections of liver cancer incidence in Hong Kong: a population-based study. Arch Public Health 2023;81:179. Crossref
    3. Huang J, Lok V, Ngai CH, et al. Disease burden, risk factors, and recent trends of liver cancer: a global country-level analysis. Liver Cancer 2021;10:330-45. Crossref
    4. Huang J, Lucero-Prisno DE 3rd, Zhang L, et al. Updated epidemiology of gastrointestinal cancers in East Asia. Nat Rev Gastroenterol Hepatol 2023;20:271-87. Crossref
    5. Wong MC, Huang JL, George J, et al. The changing epidemiology of liver diseases in the Asia-Pacific region. Nat Rev Gastroenterol Hepatol 2019;16:57-73. Crossref
    6. Macias RI, Monte MJ, Serrano MA, et al. Impact of aging on primary liver cancer: epidemiology, pathogenesis and therapeutics. Aging (Albany NY) 2021;13:23416-34. Crossref
    7. McGlynn KA, Petrick JL, El-Serag HB. Epidemiology of hepatocellular carcinoma. Hepatology 2021;73 Suppl 1:4-13. Crossref
    8. Choi CK, Ho CH, Wong MY, et al. Efficacy, toxicities, and prognostic factors of stereotactic body radiotherapy for unresectable liver metastases. Hong Kong Med J 2023;29:105-11. Crossref
    9. Perz JF, Armstrong GL, Farrington LA, Hutin YJ, Bell BP. The contributions of hepatitis B virus and hepatitis C virus infections to cirrhosis and primary liver cancer worldwide. J Hepatol 2006;45:529-38. Crossref
    10. Wong MC, Huang J. The growing burden of liver cirrhosis: implications for preventive measures. Hepatol Int 2018;12:201-3. Crossref
    11. Bialecki ES, Di Bisceglie AM. Clinical presentation and natural course of hepatocellular carcinoma. Eur J Gastroenterol Hepatol 2005;17:485-9. Crossref
    12. Hsu YC, Huang DQ, Nguyen MH. Global burden of hepatitis B virus: current status, missed opportunities and a call for action. Nat Rev Gastroenterol Hepatol 2023;20:524-37. Crossref
    13. Liu KS, Seto WK, Lau EH, et al. A territory-wide prevalence study on blood-borne and enteric viral hepatitis in Hong Kong. J Infect Dis 2019;219:1924-33. Crossref
    14. Yau AT, Chen MY, Lam CH, Ho YY, Xiao Y, Chung SW. Dietary exposure to mycotoxins of the Hong Kong adult population from a Total Diet Study. Food Addit Contam Part A Chem Anal Control Expo Risk Assess 2016;33:1026-35. Crossref
    15. Lok WY, Kong CW, To WW. Prevalence of hepatitis B carrier status and its negative association with hypertensive disorders in pregnancy. Obstet Gynecol Int 2021;2021:9912743. Crossref
    16. Viral Hepatitis Control Office; Centre for Health Protection; Department of Health, Hong Kong SAR Government. Serologic testing after hepatitis B vaccination for babies born to mothers infected with hepatitis B virus. December 2021. Available from: https://www.hepatitis.gov.hk/english/health_professionals/files/PVST_website.pdf. Accessed 12 Dec 2024.
    17. Huang DQ, Singal AG, Kono Y, Tan DJ, El-Serag HB, Loomba R. Changing global epidemiology of liver cancer from 2010 to 2019: NASH is the fastest growing cause of liver cancer. Cell Metab 2022;34:969-77.e2. Crossref
    18. Tan EY, Danpanichkul P, Yong JN, et al. Liver cancer in 2021: Global Burden of Disease Study. J Hepatol 2024 Oct 29. Epub ahead of print. Crossref
    19. Polaris Observatory Collaborators. Global prevalence, treatment, and prevention of hepatitis B virus infection in 2016: a modelling study. Lancet Gastroenterol Hepatol 2018;3:383-403. Crossref
    20. Liu Z, Jiang Y, Yuan H, et al. The trends in incidence of primary liver cancer caused by specific etiologies: results from the Global Burden of Disease Study 2016 and implications for liver cancer prevention. J Hepatol 2019;70:674-83. Crossref
    21. Conners EE, Panagiotakopoulos L, Hofmeister MG, et al. Screening and testing for hepatitis B virus infection: CDC recommendations—United States, 2023. MMWR Recomm Rep 2023;72:1-25. Crossref
    22. Toy M, Hutton D, Harris AM, Nelson N, Salomon JA, So S. Cost-effectiveness of 1-time universal screening for chronic hepatitis B infection in adults in the United States. Clin Infect Dis 2022;74:210-7. Crossref
    23. Hong Kong SAR Government. The Chief Executive’s 2024 Policy Address. 2024. Available from: https://www.policyaddress.gov.hk/2024/public/pdf/policy/policy-full_en.pdf. Accessed 18 Nov 2024.
    24. World Health Organization. Hepatitis. Elimination of hepatitis by 2030. Available from: https://www.who.int/health-topics/hepatitis/elimination-of-hepatitis-by-2030#tab=tab_1. Accessed 12 Dec 2024.
    25. Viral Hepatitis Control Office, Department of Health, Hong Kong SAR Government. Focused risk-based testing for chronic hepatitis B virus infection. July 2022. Available from: https://www.hepatitis.gov.hk/english/ health_professionals/files/iCE_focused_risk_based_HBV_ testing_web.pdf. Accessed 12 Dec 2024.
    26. Schoeb V. Healthcare service in Hong Kong and its challenges. The role of health professionals within a social model of health. China Perspect 2016;4:51-8. Crossref
    27. Leung CM, Wong WH, Chan KH, et al. Public awareness of hepatitis B infection: a population-based telephone survey in Hong Kong. Hong Kong Med J 2010;16:463-9.
    28. Chan HL, Wong GL, Wong VW, Wong MC, Chan CY, Singh S. Questionnaire survey on knowledge, attitudes, and behaviour towards viral hepatitis among the Hong Kong public. Hong Kong Med J 2022;28:45-53. Crossref
    29. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci 2009;4:50. Crossref
    30. Powell BJ, Waltz TJ, Chinman MJ, et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci 2015;10:21. Crossref
    31. Holey EA, Feeley JL, Dixon J, Whittaker VJ. An exploration of the use of simple statistics to measure consensus and stability in Delphi studies. BMC Med Res Methodol 2007;7:52. Crossref

    COVID-19 responses in vulnerable populations: from clinical management to healthcare policies

    © Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
     
    EDITORIAL
    COVID-19 responses in vulnerable populations: from clinical management to healthcare policies
    Harry HX Wang, PhD1,2,3; Vivian Yawei Guo, PhD2; Yao-jie Xie, PhD4,5,6; Yu-ting Li, MPH7; Junjie Huang, PhD1,8; Martin CS Wong, MD, MPH8,9,10,11,12
    1 Editor, Hong Kong Medical Journal
    2 School of Public Health, Sun Yat-Sen University, Guangzhou, China
    3 Baoan Central Hospital of Shenzhen, Shenzhen, China
    4 School of Nursing, The Hong Kong Polytechnic University, Hong Kong SAR, China
    5 Joint Research Centre for Primary Health Care, The Hong Kong Polytechnic University, Hong Kong SAR, China
    6 Research Centre for Chinese Medicine Innovation, The Hong Kong Polytechnic University, Hong Kong SAR, China
    7 State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
    8 Centre for Health Education and Health Promotion, The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
    9 Editor-in-Chief, Hong Kong Medical Journal
    10 School of Public Health, Fudan University, Shanghai, China
    11 The Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
    12 School of Public Health, Peking University, Beijing, China
     
    Corresponding author: Prof Martin CS Wong (wong_martin@cuhk.edu.hk)
     
     Full paper in PDF
     
    Healthcare for vulnerable populations, including but not limited to children, women (particularly during pregnancy), older adults, individuals with underlying long-term conditions, and those facing structural barriers associated with lower socio-economic status, remains one of the most formidable challenges in health protection and promotion worldwide. The advent of coronavirus disease 2019 (COVID-19) has exacerbated the vulnerability of these groups, placing them at greater risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and worse health outcomes.1 Global data indicate that COVID-19 has disproportionately affected these vulnerable groups, driven by a complex interplay of biological factors, social determinants, and overstretched healthcare services.2
     
    A substantial body of evidence demonstrates the harmful and long-lasting consequences of COVID-19 on the development of children and adolescents, encompassing physical health, mental well-being, academic performance, and socio-emotional skills, both directly and indirectly.3 A recent review of the literature revealed that adolescents, children from ethnic minority backgrounds or lower-income families, and those with obesity were more susceptible to SARS-CoV-2 infection.4 While COVID-19 generally presents as a milder or moderate illness in children compared to adults, due to fundamental differences in immune responses, continued surveillance—such as wastewater monitoring and universal or pooled testing—remains critical to managing the spread of infection within communities.4 Serious conditions, although fortunately rare, require preparedness and response efforts from frontline paediatricians and intensivists to provide optimal respiratory support. A framework for airway management procedures has been proposed, based on a comprehensive system incorporating respiratory pattern monitoring, spontaneous respiration oxygenation, apnoeic oxygenation, manual ventilation, and scavenging to reduce the risk of healthcare-associated transmission.5 Case reports have described adolescent patients presenting with rare conditions, such as laboratory-confirmed SARS-CoV-2 infection with chilblain-like lesions6 and paediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2 after recovery from COVID-19.7 Both cases suggest that paediatricians should remain vigilant for potential symptoms and signs to enable timely diagnosis and mitigate transmission risks.
     
    Although vaccination has proven effective in reducing the severity of COVID-19 and providing protection against post—COVID-19 conditions, increasing concerns persist regarding the knowledge gap on long-term efficacy and potential adverse events associated with COVID-19 vaccines.4 8 Gut microbiota may play an important role in the immune response to vaccination, offering a promising avenue for management of vaccine-related adverse effects. A pilot study in Hong Kong demonstrated the safety and tolerability of a microbiota-derived health supplement among children aged 5 to 17 years.8 This supplement, administered prior to COVID-19 vaccination and continued for 7 days post-vaccination, showed potential for alleviating vaccine hesitancy among parents and children.8
     
    The impacts of COVID-19 on the dramatically increased use of digital tools in school education have also attracted considerable public attention, partly due to mitigation strategies such as school closures and restrictions, which have affected at least half of the global student population.9 Despite rapid advances in virtual learning technology and home-schooling platforms, the prolonged reliance on remote or distance learning in response to the COVID-19 pandemic poses profound risks to the cognitive and social development of adolescents. These risks arise from the absence of physical interactions with peers and teachers during the transition to adulthood.9 Such effects may be more pronounced in children and youth with behavioural or intellectual disabilities who rely on special education support services. In resource-constrained settings or among low-income families, effective education time is often substantially reduced due to inadequate access to electronic devices and limited internet connectivity, thereby exacerbating academic inequality. Addressing this challenge may require sustained government investment in community-based, targeted socio-technical interventions to close the social class achievement gaps and reduce the digital divide.10
     
    Excessive screen time resulting from increased reliance on digital media has led to a range of public health concerns, including asthenopia and vision impairment. A clinical assessment of visual acuity among school-aged adolescents in western rural China revealed a significantly higher prevalence of asthenopia and worsened vision impairment during the COVID-19 pandemic compared with the pre-pandemic period.11 The striking progression of vision impairment highlights the urgent need for policymakers to develop system-level strategies and tailored guidelines aimed at promoting healthy screen time practices. Such measures are essential to address the increasing incidence of eye problems among students in the post—COVID-19 era, where digital media is deeply embedded in nearly every aspect of adolescents’ daily lives.
     
    Coronavirus disease 2019 also posed multiple challenges throughout pregnancy because pregnant women infected with the virus faced a higher risk of severe illness relative to their non-pregnant counterparts.12 Additionally, they may experience exacerbation of COVID-19 symptoms due to reduced lung capacity associated with fetal growth and immune suppression during pregnancy.13 Although compelling evidence indicates that rigorous public health measures effectively mitigate the spread of SARS-CoV-2,14 pregnant women often exhibited high levels of anxiety about contracting COVID-19, largely due to their vulnerable immune status.15 This widespread anxiety may arise from perceived risks of pregnancy complications, fears of vertical transmission to the newborn, and uncertainties regarding delivery and breastfeeding practices in the event of infection.15 These observations highlight the importance of ensuring enhanced laboratory support for universal screening and providing adequate personal protective equipment. Emotional support is equally important. Satisfaction with maternity care can be achieved through partner companionship during labour.15 A multidisciplinary approach involving expert teams has proven essential in providing optimal care.12 However, changes to childbirth companionship and peripartum services during the COVID-19 pandemic frequently fell short of pregnant women’s expectations, potentially leading to negative psychological consequences such as heightened antenatal anxiety and emotional disturbance.16 Guidelines and decision-making in obstetric practice must balance infection control measures with the peripartum needs of women; the nulliparous group requires additional attention.
     
    Older patients with COVID-19 are considered among the most vulnerable groups during the pandemic because advanced age and co-morbidities are well-documented risk factors for mortality.17 Clinical findings have supported frailty screening as a reliable predictor of clinical deterioration and adverse outcomes in older patients upon hospital admission.17 Furthermore, older adults were more likely to remain at home during the pandemic, with limited access to recreational activities or social support, while facing an increased risk of elder abuse.18 Tackling these issues may require government-led legislation and integrated social welfare services to reduce vulnerability to abuse and neglect among older adults, particularly those residing in long-term care facilities.19
     
    A recent global review examined national plans and policies on maternal, newborn, child, and adolescent health services, as well as health services for older people across 110 countries.20 The findings revealed a significant knowledge gap, particularly regarding the absence of specific activities, monitoring indicators, or resource allocations aimed at mitigating potential service disruptions in the COVID-19 response and recovery plans. The insights gained from clinical management during this pandemic will undoubtedly inform the development of policy interventions and guide future interdisciplinary research to enhance preparedness for emerging and unforeseen public health challenges, ultimately improving health outcomes for vulnerable populations.
     
    Author contributions
    All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.
     
    Conflicts of interest
    All authors have declared no conflict of interest.
     
    Funding/support
    This editorial received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
     
    References
    1. World Health Organization. Considerations for COVID-19 surveillance for vulnerable populations. Manila: World Health Organization; 2021.
    2. World Health Organization. COVID-19 and the social determinants of health and health equity: evidence brief. Geneva: World Health Organization; 2021.
    3. Irwin M, Lazarevic B, Soled D, Adesman A. The COVID-19 pandemic and its potential enduring impact on children. Curr Opin Pediatr 2022;34:107-15. Crossref
    4. Wurm J, Ritz N, Zimmermann P. COVID-19 in children: evolving epidemiology, immunology, symptoms, diagnostics, treatment, post covid conditions, prevention strategies, and future directions. J Allergy Clin Immunol 2024 Nov 15. Epub ahead of print. Crossref
    5. Leung KK, Ku SW, Fung RC, et al. Airway management in children with COVID-19. Hong Kong Med J 2022;28:315-20. Crossref
    6. Wong JS, Wong TS, Chua GT, et al. COVID toe in an adolescent boy: a case report. Hong Kong Med J 2022;28:175-7. Crossref
    7. Chua GT, Wong JS, Chung J, et al. Paediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2: a case report. Hong Kong Med J 2022;28:76-8. Crossref
    8. Chow CM, Cheong PK, Hu J, Ching JY. Can a microbiota-derived health supplement mitigate adverse events after COVID-19 vaccination in children? Hong Kong Med J 2023;29:542-4. Crossref
    9. Leung KK, Hon KL, Ip P, Ng DK. COVID-19 and children: potential impacts and alleviation strategies. Hong Kong Med J 2023;29:443-7. Crossref
    10. Golden AR, Srisarajivakul EN, Hasselle AJ, Pfund RA, Knox J. What was a gap is now a chasm: remote schooling, the digital divide, and educational inequities resulting from the COVID-19 pandemic. Curr Opin Psychol 2023;52:101632.Crossref
    11. Ding Y, Guan H, Du K, Zhang Y, Wang Z, Shi Y. Asthenopia prevalence and vision impairment severity among students attending online classes in low-income areas of western China during the COVID-19 pandemic. Hong Kong Med J 2023;29:150-7. Crossref
    12. Nana M, Hodson K, Lucas N, Camporota L, Knight M, Nelson-Piercy C. Diagnosis and management of COVID-19 in pregnancy. BMJ 2022;377:e069739. Crossref
    13. Ahmed AK, Sijercic VC, Sayad R, et al. Risks and preventions for pregnant women and their preterm infants in a world with COVID-19: a narrative review. Vaccines (Basel) 2023;11:640. Crossref
    14. Leung HH, Kwok CY, Sahota DS, et al. Effects of strict public health measures on seroprevalence of anti- SARS-CoV-2 antibodies during pregnancy. Hong Kong Med J 2022;28:294-9. Crossref
    15. Lok WY, Chow CY, Kong CW, To WW. Knowledge, attitudes, and behaviours of pregnant women towards COVID-19: a cross-sectional survey. Hong Kong Med J 2022;28:124-32. Crossref
    16. Hui PW, Seto MT, Cheung KW. Behavioural adaptations and responses to obstetric care among pregnant women during an early stage of the COVID-19 pandemic in Hong Kong: a cross-sectional survey. Hong Kong Med J 2022;28:367-75. Crossref
    17. Tam EM, Kwan YK, Ng YY, Yam PW. Clinical course and mortality in older patients with COVID-19: a clusterbased study in Hong Kong. Hong Kong Med J 2022;28:215-22. Crossref
    18. Shea YF, Ip WC, Luk JK. Comparison of the pattern of elderly abuse in Hong Kong before and after the COVID-19 pandemic. Hong Kong Med J 2022;28:502-3. Crossref
    19. Gardner W, States D, Bagley N. The coronavirus and the risks to the elderly in long-term care. J Aging Soc Policy 2020;32:310-5. Crossref
    20. Czerniewska A, Sharkey A, Portela A, Drapkin S, Mustafa S. National COVID-19 preparedness and response plans: a global review from the perspective of services for maternal, newborn, child and adolescent health and older people. BMJ Glob Health 2024;9:e013711. Crossref

    Enhancing human papillomavirus vaccine acceptance in Hong Kong: a call for action and public education

    © Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
     
    EDITORIAL
    Enhancing human papillomavirus vaccine acceptance in Hong Kong: a call for action and public education
    Zigui Chen, BS, PhD1; Jason YK Chan, FRCSEd (ORL), FHKAM (Otorhinolaryngology)2; Paul KS Chan, FHKCPath, FHKAM (Pathology)1
    1 Department of Microbiology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
    2 Department of Otorhinolaryngology, Head and Neck Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
     
    Corresponding author: Dr Zigui Chen (zigui.chen@cuhk.edu.hk)
     
     Full paper in PDF
     
    Growing global awareness of human papillomavirus (HPV) and its associated health risks, particularly cervical cancer, has led to widespread implementation of HPV vaccination programmes. In Hong Kong, HPV remains a substantial but underestimated public health burden, as Chu et al1 highlighted in their recent study published in the Hong Kong Medical Journal. The study investigated parental acceptance of HPV vaccination for boys and girls in Primary 4 to 6, offering critical insights into the factors influencing vaccination uptake.
     
    Human papillomavirus vaccine awareness and uptake
    The study by Chu et al1 evaluated parental awareness, knowledge, and attitudes towards HPV vaccination in Hong Kong, a city that—like many others—has integrated HPV vaccination into its Childhood Immunisation Programme (HKCIP). As these vaccination programmes expand globally, an understanding of factors that influence parental decision-making is needed to improve uptake and reduce the burden of HPV-associated diseases. Chu et al1 found high awareness of HPV among most parents (81.4% among boys’ parents and 78.5% among girls’ parents). Despite this awareness, knowledge about HPV and the vaccine remains limited. Moreover, the actual vaccine uptake rates are alarmingly low: 6.8% for boys and 4.9% for girls.1 The study identified several key factors influencing vaccine acceptance, including parental HPV vaccination status, household income, and concerns about HPV infection.1 Focused efforts regarding safety education and implement catch-up vaccination are needed to overcome vaccine hesitancy in Hong Kong.
     
    These results are consistent with global tendencies towards vaccine hesitancy and low uptake, despite the documented effectiveness of HPV vaccines in preventing HPV-related diseases. For example, a study by Wang et al2 in China similarly showed that parental knowledge of HPV was limited, and acceptance was hindered by misconceptions about the vaccine’s safety and necessity, particularly for boys. In the United States, although HPV vaccination coverage has increased since introduction of the vaccine, disparities remain. A 2021 study revealed that only 58.6% of adolescents were fully vaccinated; the acceptance rate was lower among boys than among girls.3 In Europe, similar trends have been observed. Countries such as Italy have reported relatively low HPV vaccination rates due to scepticism about vaccine safety and insufficient public health campaigns.4
     
    These regional disparities in vaccine uptake suggest that although awareness campaigns may increase recognition of HPV, they often do not result in higher vaccination rates unless they address underlying concerns about vaccine safety, efficacy, and the perceived importance of vaccinating boys. The study by Chu et al1 showed results consistent with this challenge in Hong Kong, where boys’ parents were significantly less likely to accept the vaccine than girls’ parents, despite the government’s efforts to provide the vaccine free of charge to girls under the HKCIP.
     
    Barriers to human papillomavirus vaccine acceptance
    A key finding in the study by Chu et al1 is the misconception about the cost of the vaccine. Although the HPV vaccine is provided free of charge to girls under the HKCIP, many parents still considered it too expensive. This finding indicates a disconnect between the availability of free vaccines and public understanding of the Programme, likely exacerbated by the coronavirus disease 2019 pandemic, which disrupted routine healthcare services and public health campaigns worldwide.5
     
    The reluctance of boys’ parents to accept the HPV vaccine also reflects global trends. Many parents continue to primarily associate HPV with cervical cancer, which is regarded as a disease that only affects girls and women. This association has persisted despite increasing evidence that links HPV to other cancers, such as penile, anal, and oropharyngeal cancers, which affect boys and men.6 7 This perception gap is not unique to Hong Kong; studies from the Australia, Georgia, and the United States have also identified gender bias as a major barrier to HPV vaccine acceptance for boys.8 9 10
     
    Moreover, the study by Chu et al1 demonstrated that boys’ parents were more likely than girls’ parents to discuss sexually transmitted diseases with their children (33% vs 15.2%). Despite these discussions, vaccine acceptance remained lower for boys. This paradox suggests that although parents may be aware of the risks of HPV transmission, they may not fully understand the broader health implications of the virus for both genders or the protective benefits of vaccination.
     
    The importance of public education and policy interventions
    The study by Chu et al1 underscores the urgent need for more effective public education campaigns in Hong Kong. Public health authorities should focus on dispelling misconceptions about the cost and safety of the HPV vaccine, along with their efforts to emphasise its importance for both boys and girls. The fact that many parents remain unaware of the free vaccination programme for girls indicates a lack of effective communication between the government and the public. This communication issue is not unique to Hong Kong; similar challenges have been reported in Europe, where vaccine uptake has been hindered by misinformation and inadequate public health messaging.11
     
    Additionally, targeted interventions should be implemented to address the gender disparity in vaccine acceptance. Public health campaigns must highlight the risks of HPV-related cancers for boys and the benefits of achieving high vaccination coverage in both genders. Studies have shown that gender-neutral vaccination programmes, such as those implemented in Australia12 and some parts of Europe,12 13 have led to significant reductions in HPV infections and associated diseases. These programmes also provide indirect protection for unvaccinated individuals through herd immunity, reinforcing the importance of including boys in national vaccination strategies.14 15
     
    Recommendations for future research and policy
    To improve HPV vaccination rates in Hong Kong and worldwide, policymakers and healthcare providers should consider the following recommendations:
    1. Expand public health campaigns: Government-led campaigns should focus on increasing awareness regarding the availability of free vaccines for girls and the benefits of vaccinating boys. These campaigns must address common misconceptions about HPV and concerns about the vaccine’s cost, safety, and efficacy.
    2. Enhance school-based vaccination programmes: Schools serve as a critical platform for vaccine delivery and education. The integration of HPV education into the school curriculum, along with routine vaccination programmes, could help increase acceptance among both parents and students.
    3. Implement gender-neutral vaccination policies: Given the evidence supporting gender-neutral vaccination programmes, policymakers should consider expanding free HPV vaccination to boys under the HKCIP. This would protect boys from HPV-related diseases while contributing to the overall reduction of HPV transmission within the community.
    4. Address vaccine hesitancy through healthcare providers: Physicians and other healthcare professionals play a pivotal role in promoting vaccination. Efforts to train healthcare providers to effectively communicate the benefits of the HPV vaccine and address parental concerns are essential for greater vaccine uptake.
     
    Conclusion
    The study by Chu et al1 provides valuable insights into the factors influencing HPV vaccine acceptance among parents in Hong Kong. The low uptake rates, despite high awareness, highlight the need for more robust public health campaigns and gender-neutral vaccination policies. By addressing misconceptions about the vaccine and expanding access to boys, Hong Kong can improve its vaccination coverage and protect future generations from HPV-related diseases. Similar efforts in other regions have shown that, with the right interventions, substantial progress can be made in increasing HPV vaccine acceptance and uptake.
     
    Author contributions
    All authors have contributed equally to the concept, development and critical revision of the manuscript. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.
     
    References
    1. Chu JK, Sing CW, Li Y, Wong PH, So EY, Wong IC. Factors affecting human papillomavirus vaccine acceptance among parents of Primary 4 to 6 boys and girls in Hong Kong. Hong Kong Med J 2024;30:386-99. Crossref
    2. Wang Z, Wang J, Fang Y, et al. Parental acceptability of HPV vaccination for boys and girls aged 9-13 years in China—a population-based study. Vaccine 2018;36:2657-65. Crossref
    3. Pingali C, Yankey D, Elam-Evans LD, et al. National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 years—United States, 2020. MMWR Morb Mortal Wkly Rep 2021;70:1183-90. Crossref
    4. Montalti M, Salussolia A, Capodici A, et al. Human papillomavirus (HPV) vaccine coverage and confidence in Italy: a nationwide cross-sectional study, the OBVIOUS project. Vaccines (Basel) 2024;12:187. Crossref
    5. Shet A, Carr K, Danovaro-Holliday MC, et al. Impact of the SARS-CoV-2 pandemic on routine immunisation services: evidence of disruption and recovery from 170 countries and territories. Lancet Glob Health 2022;10:e186-94. Crossref
    6. Machalek DA, Poynten M, Jin F, et al. Anal human papillomavirus infection and associated neoplastic lesions in men who have sex with men: a systematic review and meta-analysis. Lancet Oncol 2012;13:487-500. Crossref
    7. Gillison ML, Chaturvedi AK, Anderson WF, Fakhry C. Epidemiology of human papillomavirus–positive head and neck squamous cell carcinoma. J Clin Oncol 2015;33:3235-42. Crossref
    8. Gilkey MB, Calo WA, Moss JL, Shah PD, Marciniak MW, Brewer NT. Provider communication and HPV vaccination: the impact of recommendation quality. Vaccine 2016;34:1187-92. Crossref
    9. Petagna CN, Perez S, Hsu E, et al. Facilitators and barriers of HPV vaccination: a qualitative study in rural Georgia. BMC Cancer 2024;24:592. Crossref
    10. Netfa F, King C, Davies C, et al. Perceived facilitators and barriers to the uptake of the human papillomavirus (HPV) vaccine among adolescents of Arabic-speaking mothers in NSW, Australia: a qualitative study. Vaccine X 2023;14:100335. Crossref
    11. Karafillakis E, Simas C, Jarrett C, et al. HPV vaccination in a context of public mistrust and uncertainty: a systematic literature review of determinants of HPV vaccine hesitancy in Europe. Hum Vaccin Immunother 2019;15:1615-27. Crossref
    12. Drolet M, Bénard É, Pérez N, Brisson M; HPV Vaccination Impact Study Group. Population-level impact and herd effects following the introduction of human papillomavirus vaccination programmes: updated systematic review and meta-analysis. Lancet 2019;394:497-509.Crossref
    13. Diakite I, Nguyen S, Sabale U, et al. Public health impact and cost-effectiveness of switching from bivalent to nonavalent vaccine for human papillomavirus in Norway: incorporating the full health impact of all HPV-related diseases. J Med Econ 2023;26:1085-98. Crossref
    14. Brisson M, Bénard É, Drolet M, et al. Population-level impact, herd immunity, and elimination after human papillomavirus vaccination: a systematic review and meta-analysis of predictions from transmission-dynamic models. Lancet Public Health 2016;1:e8-17. Crossref
    15. Brisson M, Kim JJ, Canfell K, et al. Impact of HPV vaccination and cervical screening on cervical cancer elimination: a comparative modelling analysis in 78 low-income and lower-middle-income countries. Lancet 2020;395:575-90. Crossref

    Can we eliminate mother-to-child transmission of hepatitis B virus in Hong Kong by 2030?

    © Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
     
    EDITORIAL
    Can we eliminate mother-to-child transmission of hepatitis B virus in Hong Kong by 2030?
    WC Leung, MD, FHKAM (Obstetrics & Gynaecology)1; Martin CS Wong, MD, FHKAM (Family Medicine)2,3
    1 Department of Obstetrics and Gynaecology, Kwong Wah Hospital, Hong Kong SAR, China
    2 The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
    3 Editor-in-Chief, Hong Kong Medical Journal
     
    Corresponding author: Dr WC Leung (leungwc@ha.org.hk)
     
     Full paper in PDF
     
    Hepatitis B virus (HBV) infection is an important public health issue. Hong Kong’s universal HBV immunisation programme for newborns began in 1988.1 This programme consists of administering hepatitis B immunoglobulin (HBIg) to infants born to hepatitis B surface antigen (HBsAg)–positive mothers, along with the first dose of the HBV vaccine at birth. The second and third doses of the vaccine are typically given in Maternal and Child Health Centres at 1 and 6 months, respectively. Notably, the proportion of HBsAg-positive pregnant women has steadily decreased in recent years, from 5.2% in 20162 to 2.4% in 2023 (unpublished data). Despite a 99.8% HBsAg screening rate among antenatal women, together with 99.5% coverage for both HBIg and HBV vaccinations in newborns of HBsAg-positive mothers,2 a local study3 of 641 HBsAg-positive pregnant women showed that the overall mother-to-child transmission (MTCT) rate remained 1.1%, indicating immunoprophylaxis failure. To align with the World Health Organization’s (WHO) goal of eliminating viral hepatitis as a public health threat by 2030,4 and specifically to achieve the WHO target of <0.1% HBsAg prevalence among 5-year-old children by that year, further reduction of MTCT of HBV has been targeted by the multidisciplinary Steering Committee on Prevention and Control of Viral Hepatitis, established in 2018 and chaired by the Director of Health and the Chief Executive of Hospital Authority.5 As an obstetrics representative on the Steering Committee, the first author had the opportunity to present a literature review for use in formulating the action plan. Three strategies were considered: (1) maintaining the current approach of administering HBIg and HBV vaccinations to newborns of HBsAg-positive mothers, (2) conducting another randomised controlled trial on the use of tenofovir in further prevention of MTCT of HBV, and (3) implementing a universal programme to use tenofovir for this purpose. Although two major randomised controlled trials,6 7 both published in The New England Journal of Medicine, appeared to reach conflicting conclusions, the MTCT of HBV rates were zero in both the Mainland China study6 (n=92, per-protocol) and the Thailand study7 (n=147). The safety of tenofovir in pregnancy has also been established. Rebound increases in alanine aminotransferase after tenofovir discontinuation were mild in most cases (acute hepatic exacerbation, defined as alanine aminotransferase elevation of >300 IU/L, occurred in 6% of the tenofovir group vs 3% of the control group7). The administration of antivirals to HBsAg-positive pregnant women with high HBV DNA levels has been recommended by the American Association for the Study of Liver Diseases, European Association for the Study of the Liver, Asian Pacific Association for the Study of the Liver, and Advisory Committee on Immunization Practices.5 Despite these recommendations, the WHO had not made any recommendations by 2018. The Steering Committee ultimately decided to proceed with option 3.5
     
    All HBsAg-positive pregnant women with an HBV viral load >200 000 IU/mL will receive an early referral to the corresponding hepatology clinic under Hospital Authority to discuss starting tenofovir (tenofovir disoproxil fumarate; United States Food and Drug Administration pregnancy category B8) by 28 weeks of gestation to further reduce the risk of MTCT of HBV. This programme began as a pilot at Queen Mary Hospital and Prince of Wales Hospital in the first quarter of 2020; it was expanded to Pamela Youde Nethersole Eastern Hospital, Kwong Wah Hospital, Queen Elizabeth Hospital, Princess Margaret Hospital, United Christian Hospital, and Tuen Mun Hospital in the third quarter of 2020.5 In this issue of the Hong Kong Medical Journal, Cheung et al9 published the 2024 Hong Kong College of Obstetricians and Gynaecologists guideline on antenatal screening and management of hepatitis B to prevent MTCT, summarising current clinical practices in Hong Kong. This evidence-based guideline aligns with the core strategy of reducing MTCT risk in the Hong Kong Viral Hepatitis Action Plan 2020-2024.10 Additionally, the guideline addresses important issues such as immunoprophylaxis failure, antenatal management, and the indications for and duration of continued antiviral treatment after delivery. We strongly encourage our readers to incorporate the recommendations of the Hong Kong College of Obstetricians and Gynaecologists into their clinical practice.
     
    Between September 2020 and December 2022, a total of 2151 HBsAg-positive pregnant women attended Hospital Authority antenatal clinics.11 Among them, 328 (15.2%) had a high viral load (HBV DNA >200 000 IU/mL) and were referred to hepatologists, and 314 (95.7%) of these pregnant women attended hepatology clinics. After consultation with hepatologists, most women (n=292, 93.0%) accepted tenofovir prophylaxis.11 Among those who refused tenofovir after consultation, common reasons included concerns about potential side-effects on the fetus and fears of hepatitis flare-ups after postpartum discontinuation of tenofovir.11
     
    A key aspect of outcome assessment is post-vaccination serology testing, which will be performed in infants after they complete the full course of vaccination. Infants born to HBsAg-positive mothers will be recruited from Maternal and Child Health Centres and referred to the Hong Kong Children’s Hospital for blood tests. We anticipate favourable results, confirming the elimination of MTCT of HBV in Hong Kong by 2030!
     
    Author contributions
    Both authors contributed equally to the development of the manuscript. Both authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.
     
    Conflicts of interest
    Both authors have declared no conflicts of interest.
     
    Funding/support
    This editorial received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
     
    References
    1. Wong VC, Ip HM, Reesink HW, et al. Prevention of the HBsAg carrier state in newborn infants of mothers who are chronic carriers of HBsAg and HBeAg by administration of hepatitis-B vaccine and hepatitis-B immunoglobulin. Double-blind randomised placebo-controlled study. Lancet 1984;1:921-6. Crossref
    2. Department of Health, Hong Kong SAR Government. Surveillance of Viral Hepatitis in Hong Kong: 2022 Report. 2023. Available from: https://www.hepatitis.gov.hk/english/health_professionals/files/hepsurv22.pdf. Accessed 8 Oct 2024.
    3. Cheung KW, Seto MT, Kan AS, et al. Immunoprophylaxis failure of infants born to hepatitis B carrier mothers following routine vaccination. Clin Gastroenterol Hepatol 2018;16:144-5. Crossref
    4. World Health Organization. Global Hepatitis Report 2017. Geneva: Global Hepatitis Programme; 2017. Available from: http://apps.who.int/iris/bitstream/10665/255016/1/9789241565455-eng.pdf?ua=1. Accessed 27 Sep 2024.
    5. Leung WC. Use of tenofovir in further prevention of mother-to-child-transmission of hepatitis B virus. Hong Kong Med Diary 2020;25:11-5.
    6. Pan CQ, Duan Z, Dai E, et al. Tenofovir to prevent hepatitis B transmission in mothers with high viral load. N Engl J Med 2016;374:2324-34. Crossref
    7. Jourdain G, Ngo-Giang-Huong N, Harrison L, et al. Tenofovir versus placebo to prevent perinatal transmission of hepatitis B. N Engl J Med 2018;378:911-23. Crossref
    8. United States Food and Drug Administration. Prescribing information: tenofovir disoproxil fumarate tablets, for oral use. Revised 2017. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/pepfar/078800PI.pdf. Accessed 9 Oct 2024.
    9. Cheung KW, So PL, Mak LL, et al. 2024 Hong Kong College of Obstetricians and Gynaecologists guideline on antenatal screening and management of hepatitis B for prevention of mother-to-child transmission. Hong Kong Med J 2024;30:400-8. Crossref
    10. Department of Health, Hong Kong SAR Government. Hong Kong Viral Hepatitis Action Plan 2020-2024. 2020. Available from: https://www.hepatitis.gov.hk/doc/action_plan/Action%20Plan_Full%20Version_PDF_en.pdf. Accessed 8 Oct 2024.
    11. Tsui WM, Leung WC, Kung KN, Lai CH. Antiviral prophylaxis for the prevention of mother-to-child transmission of hepatitis B virus. Hospital Authority Convention 2024 poster presentation F3_3.34. Available from: https://d1j0dbg7fhovrj.cloudfront.net/assets/haconvention2024/filemanager/images/1712735576F_P3.34_TSUIWaiManVivien.jpg. Accessed 27 Sep 2024.

    The use of paracetamol in clinical consultations: are current prescribing practices safe?

    © Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
     
    EDITORIAL
    The use of paracetamol in clinical consultations: are current prescribing practices safe?
    Bosco HM Ma, MD, FHKAM (Medicine)1; Martin CS Wong, MD, FHKAM (Family Medicine)2,3
    1 Division of Geriatric Medicine, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
    2 The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
     
    Corresponding author: Dr Bosco HM Ma (hmma@cuhk.edu.hk)
     
     Full paper in PDF
     
    Chronic pain is a very common ailment. An early local survey of 1051 adults revealed that 113 (10.8%) had chronic pain lasting >3 months within the previous year.1 Of these individuals, 30.1% had attempted self-treatment with analgesics.1 Female gender (odds ratio [OR]=1.5) and advanced age (≥60 years) [OR=2.2] were independent risk factors for chronic pain.1 Another local study assessed the prevalence of pain in older people attending a geriatric outpatient specialist clinic at a regional hospital.2 Among 749 participants, 461 (61.5%) had experienced pain in the previous 2 weeks.2 Over half (51.3%) of the individuals with pain had taken analgesics.2
     
    Paracetamol is an effective and easily accessible first-choice analgesic. It is available alone as a non-prescription medication or in combination with other medications.3 This drug is considered safe when the daily dose does not exceed 4 g in adults. It is usually preferred over non-steroidal anti-inflammatory drugs, which are associated with renal, gastrointestinal, and cardiovascular side-effects, especially in older people with multiple co-morbidities.4 Paracetamol is one of the most commonly prescribed analgesics worldwide.5
     
    Paracetamol reduces the production of pro-inflammatory prostaglandins and thromboxanes by inhibiting the enzyme cyclooxygenase,6 which is considered a key mechanism for inducing analgesia. It is extensively metabolised by hepatic glucuronidation and sulphation (85%-90%). The remaining drug is either oxidised by cytochrome P450 isoenzymes to form a toxic metabolite, N-acetyl-p-benzoquinone-imine (5%-10%), or excreted unchanged in urine (5%). N-acetyl-p-benzoquinone-imine is further neutralised by glutathione and excreted in urine. In cases of paracetamol overdose, the accumulation of N-acetyl-p-benzoquinone-imine may lead to acute liver failure. Additionally, paracetamol toxicity is more common in patients with chronic liver diseases or malnutrition. Pharmacokinetic studies have indicated that paracetamol absorption is not altered in older people compared with younger individuals. Nonetheless, both the volume of distribution and clearance of paracetamol metabolites decline with age, especially in frail older people.7 Thus, older people also have a greater risk of paracetamol-induced hepatotoxicity.
     
    In this issue of the Hong Kong Medical Journal, Tsang et al8 present a territory-wide study of paracetamol-induced hepatotoxicity based on data from 3873 cases of drug-induced poisoning. After the exclusion of ineligible patients, 76 cases were included in the analysis. The findings showed that age >80 years, low body weight (<50 kg), prolonged exposure (>2 days), daily dose >3 g, and malnutrition (documented insufficient energy intake for >1 week) were risk factors for death or acute liver failure.8 Among these risk factors, prolonged paracetamol use (OR=16.9), older age (OR=7.2), and higher paracetamol dosage (OR=7.2) displayed the strongest effects.8 The findings are consistent with the STOPP/START criteria (Screening Tool of Older Persons’ Prescriptions and Screening Tool to Alert to Right Treatment), which recommend that the daily dose of paracetamol should not exceed 3 g in older people (aged ≥65 years) with malnutrition (body mass index ≤18 kg/m2 or chronic liver diseases9 due to the risk of hepatotoxicity. Furthermore, Tsang et al8 reported other remarkable findings. First, the majority (60.5%) of paracetamol users had pain or fever. Second, over one-third (34.2%) of paracetamol overdose cases were related to cognitive impairment. However, the study had limitations of retrospective design and a modest number of included patients.8
     
    Hong Kong is a rapidly ageing society. Cognitive impairment affects one in 10 people aged ≥70 years and one in three people aged ≥85 years.10 11 Many older people attend multiple medical appointments in public healthcare clinics. Concomitant care in both private and public clinics is also common. Furthermore, they have easy access to paracetamol or paracetamol-containing combination products from community pharmacies. Thus, these individuals have a risk of paracetamol overdose through the use of multiple sources.12 Family physicians and community pharmacists play important roles in ensuring medication reconciliation for frail older people with multiple co-morbidities and medical appointments.
     
    In summary, Tsang et al’s study offers a timely reminder of the need for cautious use of paracetamol when treating frail older people.8 Future prospective studies involving a broader population may help enhance the generalisability of these findings.
     
    Author contributions
    Both authors contributed equally to the development of the manuscript. Both authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.
     
    Conflicts of interest
    Both authors have declared no conflicts of interest.
     
    Funding/support
    This editorial received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
     
    References
    1. Ng KF, Tsui SL, Chan WS. Prevalence of common chronic pain in Hong Kong adults. Clin J Pain 2002;18:275-81. Crossref
    2. Miu DK, Chan TY, Chan MH. Pain and disability in a group of Chinese elderly out-patients in Hong Kong. Hong Kong Med J 2004;10:160-5.
    3. Chan TY. Safety packaging of acetaminophen combination preparations and severity of adult poisoning. J Toxicol Clin Toxicol 1996;34:747-9. Crossref
    4. Alchin J, Dhar A, Siddiqui K, Christo PJ. Why paracetamol (acetaminophen) is a suitable first choice for treating mild to moderate acute pain in adults with liver, kidney or cardiovascular disease, gastrointestinal disorders, asthma, or who are older. Curr Med Res Opin 2022;38:811-25. Crossref
    5. Caparrotta TM, Carduff E, Dear JW. Paracetamol use in adults. BMJ 2023:383:e070753. Crossref
    6. Sharma CV, Mehta V. Paracetamol: mechanisms and updates. Contin Educ Anaesth Crit Care Pain 2014;14:153-8. Crossref
    7. Mian P, Allegaert K, Spriet I, Tibboel D, Petrovic M. Paracetamol in older people: towards evidence-based dosing? Drugs Aging 2018;35:603-24. Crossref
    8. Tsang WH, Chan CK, Tse ML. Paracetamol-induced hepatotoxicity after normal therapeutic doses in the Hong Kong Chinese population. Hong Kong Med J 2024;30:355-61. Crossref
    9. O’Mahony D, Cherubini A, Guiteras AR, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 3. Eur Geriatr Med 2023;14:625-32. Crossref
    10. Hong Kong Population Projections 2015-2064. Hong Kong: Census and Statistics Department; 2015.
    11. Yu R, Chau PH, McGhee SM, et al. Dementia Trends: Impact of the Ageing Population and Societal Implications for Hong Kong. Hong Kong: The Hong Kong Jockey Club; 2010.
    12. Wolf MS, King J, Jacobson K, et al. Risk of unintentional overdose with non-prescription acetaminophen products. J Gen Intern Med 2012;27:1587-93. Crossref

    Integration of traditional Chinese medicine and Western medicine: some food of thought on clinical liability

    Hong Kong Med J 2024 Aug;30(4):268–70 | Epub 28 Jun 2024
    © Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
     
    EDITORIAL
    Integration of traditional Chinese medicine and Western medicine: some food of thought on clinical liability
    Albert Lee, MD, LLM1,2,3; KW Tong, JSD, PhD4; Billy CF Chiu, MPH, FHKAM (Family Medicine)1,5,6; Wendy Wong, PhD, RCMP5,7
    1 The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong SAR, China
    2 Centre for Medical Ethics and Law, The University of Hong Kong, Hong Kong SAR, China
    3 Board of Governors and Education Committee, World Association for Medical Law
    4 City University of Hong Kong, Hong Kong SAR, China
    5 Hong Kong Association for Integration of Chinese-Western Medicine, Hong Kong SAR, China
    6 Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong SAR, China
    7 Hong Kong Institute of Integrative Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
     
    Corresponding author: Dr Albert Lee (alee@cuhk.edu.hk)
     
     Full paper in PDF
     
     
    In Hong Kong, 50% to 60% of the population consulted traditional Chinese medicine (TCM) practitioners at least once in their lives notwithstanding the wide availability of services from Western medicine (WM).1 A study has shown the concomitant use of TCM and WM by 25.9% of patients in Hong Kong.2 There is a need for better integration clinically and legally, especially when both WM and TCM practitioners are uncertain of their liabilities if any medico-legal incidents arise during co-care. Application of various common-law elements of negligence (duty of care, standard of care, causation and foreseeability) would help to develop deeper insights into how liabilities would fall on different parties.
     
    When a patient comes to consult a practitioner, WM or TCM, a doctor-patient relationship is arguably already established. If a patient is under the co-care with prescriptions of both TCM and WM, who owes the duty of care to the patient? A three-pronged test can be used to determine the duty of care3:
  • the proximity (sufficient close) in the relationship between the claimant (patient) and the defendant (practitioner);
  • damage being reasonably foreseeable; and
  • whether the court considers it fair, just and reasonable to impose a duty of the given scope upon the defendant practitioner.
  •  
    Who has the closest relationship with the patient claimant for a particular management? For instance, a patient consulted a WM doctor for back pain with no significant abnormalities detected, and the patient was advised bed rest, with sick leave certification and analgesia if needed. The patient then consulted a TCM practitioner and was prescribed some herbal medicine to take regularly. The patient also took analgesia, and s/he developed an allergic reaction. Who should owe a greater duty of care? Likewise, a patient consulted TCM for health maintenance with a prescription of TCM supplements. The patient then had a bad cough and was diagnosed with bronchitis by a WM doctor, who prescribed a course of antibiotics. The patient developed severe diarrhoea. Which practitioner owed a greater duty of care?
     
    It is the submission of the authors that in the back pain case, the TCM practitioner may have had a closer relationship with the patient claimant upon initiation of regular treatments. The TCM practitioner should ask firstly whether the patient has been prescribed any medication. In the bronchitis case, the WM doctor may have had a closer relationship and should enquire about any concurrent medication including supplements. The patient claimant then bears the burden of proof with respect to whether the medication is likely to cause damage (causation). The defendant practitioner could defend against the claimant’s allegations with scientific evidence. If the best available evidence has not revealed any significant adverse drug interaction, the court may not see it “fair, just and reasonable” to impose a duty on the defendant practitioner (reasonable standard of care).
     
    In WM, the Bolam test is applied, where a doctor is “not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art”.4 Traditional Chinese medicine practitioners hold themselves as practitioners specialised in treatment of certain health conditions, and they might use methods not in perfect line with WM practices, and patients look for TCM because they prefer not to receive WM, should the Bolam test also apply, or should TCM follow its own specific standard of care?5 Let us consider three cases to provide some insights.
     
    In the United Kingdom, Abdur Shakoor was treated by Situ, an herbalist (TCM practitioner) with 5 years’ experience in China possessing both a traditional “medicine” and “modern” medical qualifications, but no British professional medical qualifications. Situ prescribed a course of Chinese herbal remedies for Shakoor’s lipoma.6 Shakoor got very ill and died of liver failure. Post-mortem examination found that his liver contained Bai Xian Pi (白蘚皮), or Dictamnus dasycarpus, which could be hepatotoxic as published in western journals. The judge concluded that as long as the herbalist has complied with the United Kingdom’s laws, not prescribing substances prohibited or regulated by statutes, and taking steps to keep abreast of pertinent information in TCM textbooks and periodicals, this would fulfil the standard of care of a reasonable herbalist.6
     
    In Singapore, Lim Poh Eng,7 a TCM practitioner, was charged criminally negligence in having caused grievous harm to a patient by prescribing colonic washouts without proper training in the procedure and use of equipment, and without any understanding of the risks and complications involved. Lim was convicted after trial and failed on appeal to argue that the standard of negligence in criminal cases should be higher than the civil standard. The High Court ruled that a TCM practitioner embanking on management without prior knowledge and training can be found negligent.
     
    Practitioners providing TCM or complementary and alternative medicine for management should provide evidence to create a hypothetical standard of care, otherwise the same standard will apply as WM. A United States case, Gonzalez,8 provides a legal reference. Dr Gonzalez (defendant doctor) initiated a cancer treatment including pancreatic enzymes, specific diets, vitamin and mineral supplements, animal organs extracts, and coffee enemas. Such departure from good and accepted medical practice was a proximate cause of the claimant’s injuries. If the treatment risks and the alternatives had been appropriately given, a reasonably prudent person in the claimant’s position would not have agreed.
     
    The Bolam4 test can still be applied to TCM/complementary and alternative medicine, in accordance with the standard of care provided by responsible TCM practitioners skilled in that particular field. This is particularly important for the ‘but for’ test to prove causation: “but for the defendant’s negligence, would the claimant suffer injuries?” In a claim, the claimant bears the burden of proof, and the defendant doctor can adduce expert opinions to rebut. In the United Kingdom case Wilsher v Essex,9 a junior doctor mistakenly inserted a catheter into a vein instead of an artery in a preterm baby for oxygen monitoring and excess oxygen was given, which may be a possible cause of blindness but not a definite cause. So, the claim failed in causation. The damage must not be too remote or unforeseeable as in Goodwill,10 where a doctor did not owe a duty of care for contraceptive advice to the person having sexual relationship in future after vasectomy.
     
    Healthcare practitioners can refer to the basic doctrine of bio-medical ethics to avoid medical mishaps.11 Identification of the ‘material risk’ in adopting ‘patient-centred’ care, particularly after the leading judgement of Montgomery12 in the United Kingdom Supreme Court, would enable both WM and TCM practitioners to understand why patients seek alternative treatments in line with the principles of autonomy and also justice and fidelity,13 acting for the best interests for patients. However, patients should understand the limitations that practitioners of TCM and WM might not fully comprehend the practices on other side. They can only advise on the benefits of treatment of their own specialities as well as the potential harmful effects (beneficence and non-malfeasance). It is the authors’ submission that it is not fair, just and reasonable to ask WM doctors to be liable for any harmful effects of treatment under TCM and vice versa.
     
    There is also concern of liability of referring patients from each side. The basic principle is whether the alternative therapeutic options are generally accepted within the medical community and a referral to a medical specialist usually does not attract malpractice liability, so referring doctors ought to know, through reasonable inquiry, the credentials of the practitioner to whom they refer.14 Another concern is vicarious liability if the TCM practitioners are employed by or affiliated with an institution. A key factor is the degree of control that Chief Medical Executives, usually WM doctors, have over TCM practitioners. United Kingdom court cases provide good references. In Barclays Bank, the Supreme Court held that the bank was not vicariously liable by having referred its employees to doctors for pre-employment check if an employee was subsequently sexually harassed by a doctor referred.15 In Christian Brothers, the Supreme Court discussed the test of control that “[m]any employees apply a skill or expertise that is not susceptible to direction by anyone else in the company that employs them. Thus, the significance of control today is that the employer can direct what the employee does, not how he does it.” (para 36).16 Chief Medical Executives can only control that their TCM practitioners comply with law and regulations, but not how those practitioners consult with patients. This is particularly important when a complaint is filed against a Chief Medical Executive regarding the performance of a TCM practitioner.
     
    When patient is under co-care of a TCM practitioner and a WM doctor, there should be clear delineation of the duties and standard of care in those particular circumstances. Regulatory bodies should examine causation under co-care to determine issues of liability. If a WM/TCM practitioner embanks on management under other’s domain, the standard of care required is that of an ordinary skilled person exercising and professing to have the special skill as in Lim7 and Wilsher9 (the House of Lords held that a junior doctor owes the same duty of care and standard of care as a qualified doctor). Structured inter-professional education and research can drive integration with better understanding of the clinical science of each other.17 18 With the integrated Chinese-Western Medicine Programme executed by the Hospital Authority for cancer care, stroke, and low back pain since 2014, an integrated healthcare framework should be shared among the key stakeholders to ensure patient safety for definition of clear professional boundaries and roles.
     
    Author contributions
    All authors have contributed to the concept, review and analysis of literature and critical revision of the manuscript for important intellectual content. A Lee is responsible for the first draft. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.
     
    Conflicts of interest
    All authors have disclosed no conflicts of interest.
     
    Declaration
    Content in this presentation is intended solely to provide general discussion concerning medico-legal perspective of Integrated Chinese and Western Medicine. It is not intended as legal or medical advice. Legal or medical advice should be obtained from qualified legal counsel or other professionals to address specific facts and circumstances and to ensure compliance with applicable laws and standards. This paper is written in personal capacity of the authors and the opinions expressed therein do not represent the organisations which they work for or affiliated with.
     
    Funding/support
    This editorial received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
     
    References
    1. Wong W, Lam CL, Bian XZ, Zhang ZJ, Ng ST, Tung S. Morbidity pattern of traditional Chinese medicine primary care in the Hong Kong population. Sci Rep 2017;7:7513. Crossref
    2. Leung GK, Wong SW, Ng GK, Hung KN. Concomitant use of Western and Chinese medicine treatments in neurosurgical patients in Hong Kong. Chin J Integr Med 2011 Jul 30. Crossref
    3. Caparo Industries plc v Dickman [1990] UKHL 2 (House of Lords).
    4. Bolam v Friern Health Management Committee [1957] 1 WLR 582 (Queen’s Bench).
    5. Raposo VL. Complementary and alternative medicine, medical liability and the proper standard of care. Complement Ther Clin Pract 2019;35:183-8. Crossref
    6. Estate of Shakoor (deceased) v Situ (t/a Eternal Health Co) [2001] 1 WLR 410; All ER 181 (Queen’s Bench).
    7. Lim Poh Eng v Public Prosecutor [1999] 1 SLR(R) 428 (High Court).
    8. Charell v Gonzalez [1997] 173 Misc.2d 227; 660 N.Y.S. 2d 665 (N.Y. Sup.Ct.1997) (Supreme Court of New York).
    9. Wilsher v Essex [1988]. AC 1074 (House of Lords).
    10. Goodwill v British Pregnancy Advice Service [1996] 7 Med LR 129 (Court of Appeal).
    11. Beauchamp TL, Childress JF. Principles of biomedical ethics. Oxford (Great Britain): Oxford University Press; 1989.
    12. Lee A. ‘Bolam’ to ‘Montgomery’ is result of evolutionary change of medical practice towards ‘patient-centered care’. Postgrad Med J 2017;93:46-50. Crossref
    13. Tarvydas VM, Cottone RR. The Code of Ethics for Professional Rehabilitation Counselors: what we have and what we need. Rehabil Couns Bull 2000;43:188-96. Crossref
    14. Cohen MH. Legal and ethical issues in complimentary medicine: a United States perspective. Med J Aust 2004;181:168-9. Crossref
    15. Barclays Bank plc v Various Claimants [2020] UKSC 13 (Supreme Court).
    16. The Catholic Child Welfare Society and others v Various Claimants (FC) and The Institute of the Brothers of the Christian Schools and others [2012] UKSC 56 (Supreme Court), UK (“Christian Brothers”).
    17. Chiu SW, Sze TO. Revival or innovation? Chinese medicine at the crossroads of professionalization in Hong Kong. SSM–Qualitative Research in Health 2021;1:100004. Crossref
    18. Perharic-Walton L, Murray V. Toxicity of Chinese herbal remedies. Lancet 1992;340:674. Crossref

    Maternal vaccination: a promising preventive strategy to protect infants from respiratory syncytial virus

    Hong Kong Med J 2024 Aug;30(4):264–7 | Epub 8 Jul 2024
    © Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
     
    EDITORIAL
    Maternal vaccination: a promising preventive strategy to protect infants from respiratory syncytial virus
    Mike YW Kwan, MSc, MRCPCH1,2; Patrick CY Chong, MRCPCH, FHKAM (Paediatrics)3; Gilbert T Chua, MB, BS, MRCPCH2,4; Marco HK Ho, MD, FRCPCH5; Liona C Poon, MD, FRCOG6
    1 Department of Paediatrics and Adolescent Medicine, Princess Margaret Hospital, Hong Kong SAR, China
    2 Department of Paediatrics and Adolescent Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
    3 Virtus Medical Group, Hong Kong SAR, China
    4 Allergy Centre, Union Hospital, Hong Kong SAR, China
    5 Lee Tak Hong Allergy Centre, Hong Kong Sanatorium & Hospital, Hong Kong SAR, China
    6 Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong SAR, China
     
    Corresponding author: Dr Mike YW Kwan (kwanyw1@ha.org.hk)
     
     Full paper in PDF
     
     
    Respiratory syncytial virus (RSV) is the leading cause of acute lower respiratory tract infection (ALRTI) in early childhood.1 2 In most patients, RSV infection is self-limiting and manifests as an upper respiratory illness.1 However, in high-risk infants and young children, RSV infection can manifest as bronchiolitis, pneumonia, and acute respiratory failure; it may require hospitalisation or mechanical ventilation and potentially result in death.1 Risk factors for severe illness in early childhood include prematurity, young age, and underlying conditions (ie, congenital heart disease, chronic lung disease, and neurodevelopmental conditions).1 3
     
    Respiratory syncytial virus circulates year-round globally but peaks during the winter months in temperate regions and the rainy season in tropical climates.4 In Hong Kong, RSV activity peaks from March to August, when relative humidity is elevated and wind speed is low.5 6 An understanding of RSV seasonality facilitates effective public health planning and resource allocation.
     
    Whereas the implementation of infection control measures during the coronavirus disease 2019 (COVID-19) pandemic effectively flattened the infection curve, the subsequent relaxation of such measures had severe impacts on RSV epidemiology and its seasonal patterns.7 Studies in multiple countries revealed an off-season RSV epidemic among children aged <5 years after the peak of the COVID-19 pandemic,8 9 10 indicating a major shift in seasonality and the need for continuous RSV surveillance.
     
    Although RSV is a well-recognised threat in early childhood,2 local data concerning RSV epidemiology and disease burden remain scarce due to the lack of systematic collection methods.5 6 The under-recognition of RSV as a substantial contributor to morbidity and mortality among children might also explain the scarcity of local prevalence data. In Hong Kong, RSV currently is not considered a notifiable communicable disease. Most patients with clinical features of acute respiratory infection are offered laboratory testing, particularly in clinics with access to point-of-care testing facilities. Because respiratory viruses cause nonspecific symptoms, laboratory testing to identify the infectious agent is essential for guided management strategies.1 11 Both rapid antigen diagnostic tests and nucleic acid assays are common laboratory tests for RSV detection, although nucleic acid assays have higher diagnostic accuracy than rapid antigen diagnostic tests.12 The development of multiplex nucleic acid assays and rapid antigen diagnostic tests has allowed for the simultaneous detection of various respiratory pathogens13; however, the lack of access to subsidised diagnostic tests often limits their clinical utility.
     
    In the absence of sufficient local prevalence data, it is important to prioritise the implementation of territory-wide RSV surveillance and promote the use of laboratory testing for patients with suspected acute respiratory infection. Surveillance data can help understand local RSV epidemiology and disease burden (particularly among infants aged ≤6 months); it can also inform local vaccination policy.
     
    Globally, there were approximately 33.0 million cases of RSV-related ALRTI among children aged <5 years in 2019, including 3.6 million hospitalisations.2 Notably, there were 101 400 RSV-attributable deaths; of these, 97% occurred in low- and middle-income countries, and 45% occurred in children aged <6 months.2 In 1999, the estimated annual incidence of RSV-related hospitalisation in Hong Kong was 2.5 cases per 1000 children aged <5 years, with a mortality rate of 0.15% among hospitalised children.5
     
    The economic burden of RSV infection is substantial. The estimated global medical cost of RSV infection in young children was EUR€4.82 billion in 2017; hospitalisation costs constituted 55% of the global RSV economic burden, and high-income countries carried 35% of the burden.14 In Hong Kong, the estimated annual healthcare expenditure for RSV-related ALRTI was HK$6.67 million.5
     
    Multiple studies have shown that severe RSV infection in early childhood is associated with long-term respiratory sequelae (ie, decreased pulmonary function,15 wheezing,16 17 and the development of atopic asthma and clinical allergy18 19), emphasising the high actual disease burden.
     
    Given the absence of specific treatment for RSV infection, the current approach to managing RSV infection focuses on supportive care.1 11 Moreover, although monoclonal antibody remains a promising approach for RSV prevention in high-risk paediatric patients,20 a safe and effective RSV vaccine remains necessary. Considering the naïve immune system and challenges associated with neonatal vaccination, active immunisation of pregnant women during the third trimester is a viable approach to protect neonates from vaccine-preventable diseases.21
     
    Previous efforts to develop various types of RSV vaccines have yielded no positive outcomes.22 Efforts to understand structural differences in the fusion (F) glycoprotein between its pre-F and pro-F conformations have led to the development of an effective RSV vaccine.22 The RSV pre-F protein (RSVpreF) is the target for vaccine development because it is an immunologically important antigen with high conservation across all known RSV subgroups.22
     
    In August 2023, the United States Food and Drug Administration approved the RSVpreF bivalent vaccine as the first and only vaccine for use in pregnant women to protect infants (birth until 6 months of age) from developing RSV-related ALRTI and severe ALRTI. The decision was based on results from the phase III MATISSE study (Maternal Immunization Study for Safety and Efficacy), which showed that the RSVpreF vaccine had efficacies of 81.8% and 69.4% in preventing medically attended severe RSV-related ALRTI among newborns within 3 and 6 months after birth, respectively.23 No safety signals were detected in maternal participants or their infants up to 24 months of age.23 Moreover, concurrent administration of RSVpreF with either tetanus, diphtheria, and pertussis or inactivated influenza vaccine was immunogenic and well-tolerated by non-pregnant women and older adults, respectively.24 25
     
    In October 2023, the United States Centers for Disease Control and Prevention issued an official recommendation regarding the administration of a single dose of RSVpreF bivalent vaccine to pregnant women at 32 to 36 weeks of gestation for the prevention of RSV-related ALRTI in infants.26
     
    Similar to the maternal tetanus, diphtheria, and pertussis vaccination programme, strong government support for including the RSV vaccine in the Vaccination Subsidy Scheme is needed to encourage its uptake. Importantly, RSV vaccination and counselling should be offered by obstetricians during routine prenatal care visits to reduce additional appointments, waiting, and travelling time.27 28 29 Strong collaborations between obstetricians and paediatricians allow for effective dissemination of public messaging; obstetricians can counsel expectant mothers about vaccine safety and benefits, while paediatricians can reinforce the messaging to the general public.
     
    Clinicians should be equipped with evidence-based information to effectively advocate for maternal RSV vaccination. Public health agencies and professional bodies should collaborate to develop educational materials for the medical community, such as clinical practice guidelines, consensus recommendations, and continuing medical education materials. Clinical guidelines for simplified immunisation schedules, achieved by combining the administration of two or more vaccines, could address concerns related to vaccine hesitancy.
     
    Government-led public education campaigns should address knowledge gaps concerning the RSV disease burden in the paediatric population to promote vaccine confidence and encourage vaccination uptake. All campaign materials should be developed in multiple languages, made available in various formats, and disseminated through various platforms to maximise the reach of vaccination campaigns.
     
    Additional data are needed to achieve full support for maternal RSV vaccination. Data regarding the duration of protection conferred by maternal vaccination could provide insights into herd immunity and the timing of booster vaccination for children aged ≤2 years. Investigations of whether maternal RSV-specific antibodies are present in the breast milk of RSV-vaccinated mothers could raise the possibility of postnatal RSV vaccination for cases in which the vaccine is not administered during pregnancy.
     
    Author contributions
    All authors contributed to the development of the manuscript. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.
     
    Conflicts of interest
    LC Poon has received speaker fees and consultancy payments from Roche Diagnostics and Ferring Pharmaceuticals. Additionally, she has received in-kind contributions from Roche Diagnostics, Revvity Inc (formerly PerkinElmer Life and Analytical Sciences), Thermo Fisher Scientific, Ningbo Aucheer Biological Technology Co Ltd, and GE HealthCare. Other authors declare no conflicts of interest.
     
    Funding/support
    Funding for this study was provided by Pfizer Hong Kong. Editorial and medical writing support was provided by Dr Analyn Lizaso from Weber Shandwick Health HK, funded by Pfizer Hong Kong. The funders had no role in study design, data collection/analysis/interpretation or manuscript preparation.
     
    References
    1. Jain H, Schweitzer JW, Justice NA. Respiratory syncytial virus infection in children. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Treasure Island (FL). Available from: https://www.ncbi.nlm.nih.gov/books/NBK459215/". Accessed 13 Oct 2023.
    2. Li Y, Wang X, Blau DM, et al. Global, regional, and national disease burden estimates of acute lower respiratory infections due to respiratory syncytial virus in children younger than 5 years in 2019: a systematic analysis. Lancet 2022;399:2047-64. Crossref
    3. Kaler J, Hussain A, Patel K, Hernandez T, Ray S. Respiratory syncytial virus: a comprehensive review of transmission, pathophysiology, and manifestation. Cureus 2023;15:e36342. Crossref
    4. Li Y, Reeves RM, Wang X, et al. Global patterns in monthly activity of influenza virus, respiratory syncytial virus, parainfluenza virus, and metapneumovirus: a systematic analysis. Lancet Glob Health 2019;7:e1031-45. Crossref
    5. Chan PK, Sung RY, Fung KS, et al. Epidemiology of respiratory syncytial virus infection among paediatric patients in Hong Kong: seasonality and disease impact. Epidemiol Infect 1999;123:257-62. Crossref
    6. 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
    7. Abu-Raya B, Viñeta Paramo M, Reicherz F, Lavoie PM. Why has the epidemiology of RSV changed during the COVID-19 pandemic? EClinicalMedicine 2023;61:102089. Crossref
    8. Eden JS, Sikazwe C, Xie R, et al. Off-season RSV epidemics in Australia after easing of COVID-19 restrictions. Nat Commun 2022;13:2884. Crossref
    9. Bardsley M, Morbey RA, Hughes HE, et al. Epidemiology of respiratory syncytial virus in children younger than 5 years in England during the COVID-19 pandemic, measured by laboratory, clinical, and syndromic surveillance: a retrospective observational study. Lancet Infect Dis 2023;23:56-66. Crossref
    10. Zheng Z, Warren JL, Artin I, Pitzer VE, Weinberger DM. Relative timing of respiratory syncytial virus epidemics in summer 2021 across the United States was similar to a typical winter season. Influenza Other Respir Viruses 2022;16:617-20. Crossref
    11. Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics 2014;134:e1474-502. Crossref
    12. Chartrand C, Tremblay N, Renaud C, Papenburg J. Diagnostic accuracy of rapid antigen detection tests for respiratory syncytial virus infection: systematic review and meta-analysis. J Clin Microbiol 2015;53:3738-49. Crossref
    13. Ferrani S, Prazuck T, Béchet S, Lesne F, Cohen R, Levy C. Diagnostic accuracy of a rapid antigen triple test (SARS-CoV- 2, respiratory syncytial virus, and influenza) using anterior nasal swabs versus multiplex RT-PCR in children in an emergency department. Infect Dis Now 2023;53:104769. Crossref
    14. Zhang S, Akmar LZ, Bailey F, et al. Cost of respiratory syncytial virus–associated acute lower respiratory infection management in young children at the regional and global level: a systematic review and meta-analysis. J Infect Dis 2020;222(Suppl 7):S680-7. Crossref
    15. Verwey C, Ramocha L, Laubscher M, et al. Pulmonary sequelae in 2-year-old children after hospitalisation for respiratory syncytial virus lower respiratory tract infection during infancy: an observational study. BMJ Open Respir Res 2023;10:e001618. Crossref
    16. Carbonell-Estrany X, Pérez-Yarza EG, García LS, et al. Long-term burden and respiratory effects of respiratory syncytial virus hospitalization in preterm infants—the SPRING study. PLoS One 2015;10:e0125422. Crossref
    17. Ruotsalainen M, Piippo-Savolainen E, Hyvärinen MK, Korppi M. Respiratory morbidity in adulthood after respiratory syncytial virus hospitalization in infancy. Pediatr Infect Dis J 2010;29:872-4. Crossref
    18. Sigurs N, Gustafsson PM, Bjarnason R, et al. Severe respiratory syncytial virus bronchiolitis in infancy and asthma and allergy at age 13. Am J Respir Crit Care Med 2005;171:137-41. Crossref
    19. Sigurs N, Aljassim F, Kjellman B, et al. Asthma and allergy patterns over 18 years after severe RSV bronchiolitis in the first year of life. Thorax 2010;65:1045-52. Crossref
    20. Sun M, Lai H, Na F, et al. Monoclonal antibody for the prevention of respiratory syncytial virus in infants and children: a systematic review and network meta-analysis. JAMA Netw Open 2023;6:e230023. Crossref
    21. Crofts KF, Alexander-Miller MA. Challenges for the newborn immune response to respiratory virus infection and vaccination. Vaccines (Basel) 2020;8:558. Crossref
    22. Mazur NI, Higgins D, Nunes MC, et al. The respiratory syncytial virus vaccine landscape: lessons from the graveyard and promising candidates. Lancet Infect Dis 2018;18:e295-311. Crossref
    23. Kampmann B, Madhi SA, Munjal I, et al. Bivalent prefusion F vaccine in pregnancy to prevent RSV illness in infants. N Engl J Med 2023;388:1451-64. Crossref
    24. Peterson JT, Zareba AM, Fitz-Patrick D, et al. Safety and immunogenicity of a respiratory syncytial virus prefusion F vaccine when coadministered with a tetanus, diphtheria, and acellular pertussis vaccine. J Infect Dis 2022;225:2077-86. Crossref
    25. Falsey AR, Walsh EE, Scott DA, et al. Phase 1/2 randomized study of the immunogenicity, safety, and tolerability of a respiratory syncytial virus prefusion F vaccine in adults with concomitant inactivated influenza vaccine. J Infect Dis 2022;225:2056-66. Crossref
    26. Fleming-Dutra KE, Jones JM, Roper LE, et al. Use of the Pfizer respiratory syncytial virus vaccine during pregnancy for the prevention of respiratory syncytial virus–associated lower respiratory tract disease in infants: recommendations of the Advisory Committee on Immunization Practices—United States, 2023. MMWR Morb Mortal Wkly Rep 2023;72:1115-22. Crossref
    27. Tarrant MA, Fong DY, Lee IL, Sing C, Yuen CY. Prevalence of maternal immunisation with seasonal influenza vaccine in Hong Kong. Hong Kong Med J 2016;22 Suppl 7:4-5.
    28. Attwell K, Betsch C, Dubé E, et al. Increasing vaccine acceptance using evidence-based approaches and policies: insights from research on behavioural and social determinants presented at the 7th Annual Vaccine Acceptance Meeting. Int J Infect Dis 2021;105:188-93. Crossref
    29. Cheung WL, Law JY. The knowledge, perceptions, and attitudes toward vaccination in pregnancy, pertussis, and pertussis vaccination during pregnancy among pregnant women in Hong Kong. J Obstet Gynaecol Res 2021;47:1556-66. Crossref

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