Expert witnesses play important roles in medicolegal and disciplinary proceedings through the provision of opinions that are within their respective areas of expertise. Contentions may occasionally arise concerning the expertise of an individual witness and whether the scope of his expertise has been exceeded in certain situations.

The terms “specialist” and “expert” are often used interchangeably but they may carry different meanings in the case of professionals. In 1998, the Medical Council of Hong Kong established a Specialist Register to provide for specialist registration of medical practitioners who have been awarded Fellowships of the Hong Kong Academy of Medicine or who have achieved a comparable professional standard and have applied to the Medical Council of Hong Kong for specialist registration.1 By contrast, there is no official list of medical experts in Hong Kong and the term “expert” is not defined in Cap. 1 Interpretation and General Clauses Ordinance or Cap. 4A The Rules of the High Court. The Hong Kong Academy of Medicine maintains a list of Academy Fellows who are willing to serve as expert witnesses in their respective specialties. However, disputing parties and their legal advisers may freely engage any registered doctor or dentist of their choice to be their expert witness, whether the individual is on the Academy’s list or not.

In the landmark case of The Ikarian Reefer,2 the court set out the duties and responsibilities of expert witnesses in civil cases, two of which are related to expertise. First, an expert witness should provide independent assistance to the Court by way of objective unbiased opinion in relation to matters within his expertise. Second, an expert witness should make it clear when a particular question or issue falls outside his expertise. Similarly, the Code of Conduct for Expert Witnesses3 provides that an expert witness has an overriding duty to help the Court impartially and independently on matters relevant to the expert’s area of expertise. A report by an expert witness must (in the body of the report or in an annexure) specify, if applicable, that a particular question or issue falls outside his field of expertise. In Zahid Anwar v Graceful Sound Limited,4 Bharwaney J stated that, “Experts are instructed to assist the court by offering their expert opinion on areas which are within their specialist experience and which are not matters of common knowledge”.

Medicine has evolved to include many specialties under which there are multiple subspecialties. Professional expertise is accumulated from years of studying, training, and personal experience in a specific area of medicine. It follows that not all specialists are competent expert witnesses. A specialist in Gastroenterology and Hepatology may not act as an expert witness for a case concerning endoscopic retrograde cholangiopancreatography, sphincterotomy, and extraction of common bile duct stones if he does not have substantial knowledge and practical experience in these procedures.

In a recent Hong Kong case, the expert witness for the defendants was a specialist in paediatrics, and that for the plaintiffs was a specialist in paediatric surgery. The court acknowledged that the relevant standard to be applied under the Bolam test on the issue of liability for medical negligence was whether the defendant (who was a paediatrician) had acted in accordance with the practice accepted as proper by a responsible body of “medical men skilled in that particular art”, which particular art was that of paediatric specialists and not that of paediatric surgery specialists.5 The boundary becomes less clear when a specialist in general surgery is asked to comment on an orthopaedic case. It may be proper for him to comment on general principles of postoperative care but not detailed surgical techniques in orthopaedics. The situation is even more challenging when the case involves several body systems and multidisciplinary care. Medical and dental practitioners invited to be expert witnesses should be mindful of any limitations of their areas of expertise in relation to the medicolegal issue at hand and to act within those boundaries as a matter of duty to the court and professional respect towards their peers who possess the relevant specialised skills and knowledge. In cases involving matters of multiple areas of expertise, the practitioner may suggest the parties to invite suitable experts of other specialties or subspecialties to be witnesses, if necessary.

Medical and dental practitioners appointed to give evidence in courts, tribunals, or inquests are advised to: consider seeking legal advice; provide answers truthfully based on their personal knowledge and beliefs; avoid making up answers; avoid answering questions that are beyond their scope of practice; and exercise the right to refuse to answer questions that could result in self-incrimination.6

Misleading or “manifestly wrong” expert evidence can have untoward and far-reaching consequences. The professional or academic status of an expert witness by itself offers no excuses. In the United Kingdom case of R v Sally Clark,7 a prosecution expert witness was Professor Sir Roy Meadow, an Emeritus Professor of Paediatrics and Child Health. Evidence relating to statistics were given by the professor, who did not disclose his lack of expertise in statistics. Mrs Clark was convicted of the murder of her two sons and received two life sentences in 1999. Her appeal was dismissed. It later transpired that Professor Meadow made one mistake, which was to misunderstand and misinterpret the statistics. Mrs Clark made a second appeal and was set free in 2003. Her father then made a complaint to the General Medical Council (GMC) alleging serious professional misconduct on the part of Professor Meadow. In 2005, the GMC found him guilty, and his name was erased from the register. He appealed to the High Court and the order of the GMC was quashed. The GMC appealed to the Court of Appeal in 2006.8 There were two distinct parts of the appeal. The first was whether an expert witness should be entitled to immunity from disciplinary, regulatory or fitness to practise proceedings in relation to statements made or evidence given by him in or for the purpose of legal proceedings. The second entailed a consideration of the GMC’s challenge to the High Court judge’s decision that Professor Meadow was not guilty of serious professional misconduct. The Court of Appeal allowed the first part of the appeal and held that the Fitness to Practice Panel of the GMC had jurisdiction to entertain the allegations against Professor Meadow. However, the second part of GMC's appeal on the issue of 'serious professional misconduct' was rejected.

Specialists do not automatically make good expert witnesses. It is advisable for anyone interested to take up this job to undergo formal training first. Start with simple cases and work closely with instructing lawyers to gain experience and accumulate the necessary skills. Otherwise, it can result in unpleasant experience if he has to appear in courts or tribunals and may even become a defendant himself or cause irreversible harm to the parties.

Both authors contributed to the editorial, approved the final version for publication, and take responsibility for its accuracy and integrity.

The authors have declared no conflict of interest.

1. The Medical Council of Hong Kong. Available from: https://www.mchk.org.hk/english/registration/specialist_registration.html. Accessed 25 Nov 2021.

2. The Ikarian Reefer [1993] Lloyd’s Rep 68, pp 81-82.

3. Cap. 4A, The Rules of the High Court, Appendix D.

4. Zahid Anwar v Graceful Sound Limited & Ors HCPI 410/2008 & HCPI 370/2009

5. Sun Ming Lok v Choy Wing Ho & St Teresa’s Hospital HCPI 200/2017

6. Tsang C, Lee V. Coroner’s inquest—What do you need to know? Hong Kong Medical Association News, October 2021: 23.

7. R v Sally Clark [2003] EWCA Crim 1020

8. GMC v Professor Sir Roy Meadow [2006] EWCA Civ 1390

Global attention has been drawn to combat coronavirus disease 2019 (COVID-19), draining tremendous government resources, political commitment, public health measures, manpower of healthcare professionals, media, and public interest. The COVID-19 has also seriously affected the global effort against antimicrobial resistance (AMR). According to a survey conducted in late 2020 by the World Health Organization (WHO) AMR Surveillance and Quality Assessment Collaborating Centres Network, 63% (35 out of 56 countries) reported an increase in total prescriptions of antibiotics, with 47% (23/49), 57% (27/47), and 40% (18/45) of countries reporting increased use of WHO Access, Watch, and Reserve antibiotics, respectively.1 More importantly, 37% (13/35) and 40% (12/30) of countries reported an increase in multidrug-resistant organism (MDRO) healthcare-associated infections and MDRO infections in long-term care facilities, respectively. Outbreaks and increases in AMR acquisition, such as carbapenemase-producing Enterobacteriaceae, have also been reported by hospitals during the COVID-19 pandemic.2 3 4

The situation of MDRO in Hong Kong is worrisome. The Hospital Authority has reported a higher rate of methicillin-resistant Staphylococcus aureus bacteraemia detected after 48 hours of admission in 2020 and the first half of 2021, compared with that of previous years, although this may be due to a reduction in hospital admission of milder cases.5 An outbreak of Candida auris, an often highly resistant emerging infection, during the third wave of the COVID-19 pandemic is also concerning. From 29 June 2020 to 9 October 2020, the Hospital Authority reported 41 patients with Candida auris colonisation to the Infection Control Branch of the Centre for Health Protection for infection control advice after discharge to residential care homes.6 The number of cases of carbapenem-resistant Enterobacteriaceae discharged to residential care homes for the elderly rose from 242 cases in 2019 to 259 cases in 2020, and then sharply to 329 cases between January and August 2021.

The COVID-19 pandemic has affected antimicrobial stewardship activities and driven AMR in various ways. Drifting of resources, including laboratory capacity, reduced reagents and consumables, physician and nursing manpower, and public health staff, have undermined antimicrobial stewardship programmes in many countries. Weakened infection control due to fatigue and heavy workload of healthcare workers, and shortages of personal protective equipment in the early days of the pandemic further aggravated the problem. Hospital admission may increase the risk of healthcare-associated infections and the transmission of MDROs, which in turn may lead to increased antimicrobial use. Disruption to routine immunisation activities, due to COVID-19-related measures, has led to reductions in overall vaccination coverage globally, potentially leading to an overuse of antimicrobials.7 8 9 Low-level exposure to biocidal agents can strengthen drug-resistant strains and enhance the risk of cross resistance to antibiotics, particularly those that treat Gram-negative bacteria.10

Another important impact of COVID-19 on increasing AMR is secondary bacterial infection among patients with COVID-19. Empirical treatment of patients with COVID-19 using antibiotics is common. A meta-analysis involving 154 studies and over 30 000 patients revealed that 74.6% of patients with COVID-19 received antibiotics, significantly higher than the estimated prevalence of bacterial co-infection.11 This is echoed by another review of studies published on hospitalised patients with COVID-19, which revealed 72% (1450/2010) of patients received antibiotics but only 8% (62/806) had bacterial or fungal co-infections.12 The most common type of secondary infection of COVID-19 was pneumonia (especially ventilator-associated pneumonia), followed by bloodstream and urinary tract infections, and the most commonly used agents included fluoroquinolones, cephalosporins, carbapenems, azithromycin, vancomycin, and linezolid.13 14 Those with complications of COVID-19 may require mechanical ventilation or other invasive devices, which increases the risk of acquiring hospital-associated pathogens that are often highly resistant, such as methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, and Acinetobacter baumannii.15

Despite the challenges posed to AMR, the COVID-19 pandemic also creates some opportunities, such as enhanced infection control measures among healthcare workers and the high alertness of personal hygiene among the general public. These measures, which include cough etiquette, hand hygiene, wearing of masks, and social distancing, have helped to reduce various infections, in particular those caused by respiratory pathogens.16 17 18 In addition, increased fear of attending healthcare facilities and postponement of elective hospital procedures have resulted in fewer medical consultations and antibiotic prescriptions. Surveillance data on wholesale antimicrobial consumption in Hong Kong show a substantial reduction (28.3%) in daily defined doses of antimicrobials from 19.02 million in 2019 to 13.63 million in 2020. In particular, there were major reductions (of between 35.3% and 51.5%) in wholesale supply to general practitioners of amoxicillin with or without beta-lactamase inhibitor, azithromycin, and cefuroxime, which are commonly prescribed to manage upper and lower respiratory tract infections. In Hong Kong, social distancing measures imposed by public health authorities, school and kindergarten closures, work-from-home policies, other restrictions involving catering businesses and scheduled premises such as fitness centres, beauty salons, karaoke establishments and sport centres, have all helped limit transmission through the respiratory route and person-to-person contact of not only COVID-19 but also other infections. Enhanced environmental hygiene using diluted household bleach containing 5.25% sodium hypochlorite can kill severe acute respiratory syndrome coronavirus 2 and other pathogens including MDROs.

Although more research is needed to dissect the intermingled relationship between COVID-19 and AMR, it is of utmost importance to maintain efforts against AMR. The theme for World Antibiotic Awareness Week, held on 18 to 24 November 2021, was “Spread Awareness, Stop Resistance”. The dedicated page on the Centre for Health Protection website (https://www.chp.gov.hk/en/features/47850. html) includes access to the latest IMPACT (Interhospital Multi-disciplinary Programme on Antimicrobial ChemoTherapy) guideline, an evidence-based clinical guideline to ensure that patients receive the right antibiotic, at the right dose, at the right time, and for the right duration that leads to the best clinical outcome for the treatment or prevention of infection while producing low risk for subsequent resistance. The website also allows access to patient education and publicity materials on AMR. Similar to COVID-19, AMR is a complex global priority and everyone has a role to play.

All authors contributed to the editorial, approved the final version for publication, and take responsibility for its accuracy and integrity.

The authors have declared no conflict of interest.

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

1. Tomczyk S, Taylor A, Brown A, et al. Impact of the COVID-19 pandemic on the surveillance, prevention and control of antimicrobial resistance: a global survey. J Antimicrob Chemother 2021;76:3045-58. Crossref

2. Tiri B, Sensi E, Marsiliani V, et al. Antimicrobial Stewardship Program, COVID-19, and infection control: spread of carbapenem-resistant Klebsiella pneumoniae colonization in ICU COVID-19 patients. What did not work? J Clin Med 2020;9:2744. Crossref

3. Farfour E, Lecuru M, Dortet L, et al. Carbapenemase-producing Enterobacterales outbreak: another dark side of COVID-19. Am J Infect Control 2020;48:1533-6. Crossref

4. Gomez-Simmonds A, Annavajhala MK, McConville TH, et al. Carbapenemase-producing Enterobacterales causing secondary infections during the COVID-19 crisis at a New York City hospital. J Antimicrob Chemother 2021;76:380-4. Crossref

5. Hospital Authority, Hong Kong SAR Government. MRSA bacteremia in HA Hospitals—2021-Q1 & 2021-Q2. Available from: https://www.ha.org.hk/haho/ho/cico/MRSA_Bacteremia_in_HA_hospitals_2021Q1_2021Q2.pdf. Accessed 12 Sep 2021.

6. Centre for Health Protection, Department of Health, Hong Kong SAR Government. Letter to doctor: alert on the rise in Candida auris colonisation in Hong Kong. Available from: https://www.chp.gov.hk/files/pdf/lti_c_auris_20201015_eng.pdf. Accessed 12 Sep 2021.

7. Bramer CA, Kimmins LM, Swanson R, et al. Decline in child vaccination coverage during the COVID-19 pandemic—Michigan Care Improvement Registry, May 2016-May 2020. MMWR Morb Mortal Wkly Rep 2020;69:630-1. Crossref

8. McDonald HI, Tessier E, White JM, et al. Early impact of the coronavirus disease (COVID-19) pandemic and physical distancing measures on routine childhood vaccinations in England, January to April 2020. Euro Surveill 2020;25:2000848. Crossref

9. Saxena S, Skirrow H, Bedford H. Routine vaccination during covid-19 pandemic response. BMJ 2020;369:m2392. Erratum in: BMJ 2020;369:m2435. Crossref

10. Getahun H, Smith I, Trivedi K, Paulin S, Balkhy HH. Tackling antimicrobial resistance in the COVID-19 pandemic. Bull World Health Organ 2020;98:442-442A. Crossref

11. Langford BJ, So M, Raybardhan S, et al. Antibiotic prescribing in patients with COVID-19: rapid review and meta-analysis. Clin Microbiol Infect 2021;27:520-31. Crossref

12. Rawson TM, Moore LS, Zhu N, et al. Bacterial and fungal coinfection in individuals with coronavirus: a rapid review to support COVID-19 antimicrobial prescribing. Clin Infect Dis 2020;71:2459-68.

13. Clancy CJ, Buehrle DJ, Nguyen MH. PRO: The COVID-19 pandemic will result in increased antimicrobial resistance rates. JAC Antimicrob Resist 2020;2:dlaa049. Crossref

14. Clancy CJ, Nguyen MH. Coronavirus disease 2019, superinfections, and antimicrobial development: what can we expect? Clin Infect Dis 2020;71:2736-43. Crossref

15. Knight GM, Glover RE, McQuaid CF, et al. Antimicrobial resistance and COVID-19: intersections and implications. Elife 2021;10:e64139. Crossref

16. Wan WY, Thoon KC, Loo LH, et al. Trends in respiratory virus infections during the COVID-19 pandemic in Singapore, 2020. JAMA Netw Open 2021;4:e2115973. Crossref

17. Park KY, Seo S, Han J, Park JY. Respiratory virus surveillance in Canada during the COVID-19 pandemic: an epidemiological analysis of the effectiveness of pandemic-related public health measures in reducing seasonal respiratory viruses test positivity. PLoS One 2021;16:e0253451. Crossref

18. Tanislav C, Kostev K. Fewer non-COVID-19 respiratory tract infections and gastrointestinal infections during the COVID-19 pandemic. J Med Virol 2021 Sep 7. Epub ahead of print. Crossref

In Hong Kong, the coronavirus disease 2019 (COVID-19) vaccination programme started on 26 February 2021. CoronaVac (an inactivated virus vaccine developed by Sinovac) and Comirnaty (BNT162b2 mRNA vaccine co-developed by BioNTech and Pfizer, and manufactured and distributed in China by Fosun Pharma) are the available formulations for public use. Comirnaty is safe and provides good antibody response, including for patients aged 12 to 15 years with clinical efficacy in protecting against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection of 100%.1 On 14 June 2021, the Food and Health Bureau, Hong Kong SAR Government lowered the age limit for receiving the Comirnaty vaccine to ≥12 years.2

Since April 2021, there have been reports that myocarditis and pericarditis occur more frequently in adolescents and young adults after mRNA COVID-19 vaccinations internationally.3 4 5 In Hong Kong, Comirnaty is the only mRNA technology platform COVID-19 vaccine available, but others are available elsewhere (eg, from Moderna).

Myocarditis and pericarditis have many virological and immunological causes, and are known to occur after vaccination; for example, the incidence of myocarditis after smallpox vaccination is around 12 to 16.1 per million vaccinated individuals.6 Myocarditis can also occur after SARS-CoV-2 infection alone or as a consequence of multisystem inflammatory syndrome in children after COVID-19 or paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2.3 7 8

Reported cases of myocarditis after mRNA COVID-19 vaccination are mostly male adolescents and young adults aged between 12 and 24 years who received the second dose of the mRNA vaccine.9 10 11 12 13 14 These heart complications are exceedingly rare, but are increasingly reported as hundreds of million doses of mRNA COVID-19 vaccines have been administered worldwide.4 5 9 10 The typical symptoms of myocarditis and pericarditis are chest pain, shortness of breath, and palpitations occurring within 1 week (usually 2-4 days) after vaccination. The condition is mild in most of the affected individuals, with only minimal treatment required and full recovery within a few days.

Although myocarditis and pericarditis have many virological and immunological causes, a causal link was suspected due to the immunological reaction to the mRNA COVID-19 vaccine. Individuals are recommended to rest and refrain from heavy strenuous activities for 1 week after mRNA COVID-19 vaccination, which will be helpful during the rare occurrence of myocarditis or pericarditis. Individuals experiencing chest pain, shortness of breath, or palpitations after receiving the mRNA vaccine are advised to seek immediate medical attention.

Myocarditis and pericarditis are diagnosed according to the Brighton Collaboration case definitions,11 which include clinical symptoms (cardiac or non-specific symptoms), elevated myocardial biomarkers (troponin T, troponin I, or CK myocardial band), electrocardiographic, echocardiogram or cardiac magnetic resonance abnormalities and with other alternative aetiologies for symptoms excluded.12 Supportive therapy is the mainstay of treatment with cardiac treatment and intervention if needed. Individuals with myocarditis/pericarditis are advised to rest until symptoms resolved.12

Based on the latest scientific data, the benefits of COVID-19 vaccination to the individual, family members, and society outweigh the reported known and potential risks of vaccination (including the possibility of myocarditis and pericarditis) in the current pandemic.13 Owing to the recent emergence of SARS-CoV-2 variants with increased transmissibility, higher rates of vaccination will be required to achieve sufficient herd immunity to prevent further community spread and allow society to return to normal.

On 30 June 2021, a joint consensus statement was issued by the Hong Kong Paediatric Society, The Hong Kong Society for Paediatric Immunology Allergy and Infectious Diseases, the Hong Kong College of Paediatric Nursing, and the Hong Kong Paediatric Nurses Association.14 The consensus statement appeals to children and adolescents (aged ≥12 years), parents, adult household members, and child-carers to receive the COVID-19 vaccine for self-protection, and for the physical health and long-term psychosocial development of all children in Hong Kong.

The Centers for Disease Control and Prevention and the Food and Health Bureau of Hong Kong SAR Government endorse the use of Comirnaty vaccine in adolescents mainly because the benefits of vaccination exceed the risks of SARS-CoV-2 infection.15 Although there is no alternative vaccine for this age-group currently available, data are being gathered on CoronaVac, which utilises the inactivated virus platform. If this proves safe and effective for children and adolescents, and is approved for use, CoronaVac may be an alternative for this age-group in Hong Kong.

All authors contributed to the concept or design of the study, acquisition of the data, analysis or interpretation of the data, drafting of the manuscript, and critical revision of the manuscript for important intellectual content. 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.

All authors have disclosed no conflicts of interest.

1. Frenck RW, Jr, Klein NP, Kitchin N, et al. Safety, immunogenicity, and efficacy of the BNT162b2 Covid-19 vaccine in adolescents. N Engl J Med 2021;385:239-50. Crossref

2. Persons aged 12 to 15 can make reservations to receive BioNTech vaccine from tomorrow. Press release. Hong Kong SAR Government. 10 Jun 2021. Available from: https://www.info.gov.hk/gia/general/202106/10/P2021061000556.htm. Accessed 22 Jul 2021.

3. Siripanthong B, Nazarian S, Muser D, et al. Recognizing COVID-19–related myocarditis: The possible pathophysiology and proposed guideline for diagnosis and management. Heart Rhythm 2020;17:1463-71. Crossref

4. Marshall M, Ferguson ID, Lewis P, et al. Symptomatic acute myocarditis in seven adolescents following Pfizer-BioNTech COVID-19 vaccination. Pediatrics 2021 Jun 4. Epub ahead of print.

5. Starekova J, Bluemke DA, Bradham WS, et al. Evaluation for myocarditis in competitive student athletes recovering from coronavirus disease 2019 with cardiac magnetic resonance imaging. JAMA Cardiol 2021;6:945-50. Crossref

6. Keinath K, Church T, Kurth B, Hulten E. Myocarditis secondary to smallpox vaccination. BMJ Case Rep 2018;2018:bcr2017223523. Crossref

7. Feldstein LR, Tenforde MW, Friedman KG, et al. Characteristics and outcomes of US children and adolescents with multisystem inflammatory syndrome in children (MIS-C) compared with severe acute COVID-19. JAMA 2021;325:1074-87. Crossref

8. Whittaker E, Bamford A, Kenny J, et al. Clinical characteristics of 58 children with a pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2. JAMA 2020;324:259-69. Crossref

9. Gargano JW, Wallace M, Hadler SC, et al. Use of mRNA COVID-19 vaccine after reports of myocarditis among vaccine recipients: update from the Advisory Committee on Immunization Practices—United States, June 2021. MMWR Morb Mortal Wkly Rep 2021;70:977-82. Crossref

10. Abu Mouch S, Roguin A, Hellou E, et al. Myocarditis following COVID-19 mRNA vaccination. Vaccine 2021;39:3790-3. Crossref

11. Myocarditis/pericarditis case definition. 16 July 2021. Available from: https://brightoncollaboration.us/myocarditis-case-definition-update/. Accessed 22 Jul 2021.

12. Maron BJ, Udelson JE, Bonow RO, et al. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 3: Hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy and other cardiomyopathies, and myocarditis: a scientific statement from the American Heart Association and American College of Cardiology. Circulation 2015;132:e273-80. Crossref

13. Wallace M, Oliver S. COVID-19 mRNA vaccines in adolescents and young adults: benefit-risk discussion. ACIP Meeting. 23 June 2021. Available from: https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2021-06/05-COVID-Wallace-508.pdf. Accessed 23 Jul 2021.

14. Joint Statement of The Hong Kong Paediatric Society, The Hong Kong Society for Paediatric Immunology Allergy and Infectious Diseases, Hong Kong College of Paediatric Nursing and Hong Kong Paediatric Nurses Association on occurrence of myocarditis and pericarditis after mRNA COVID-19 vaccination (30 June 2021). Available from: http://www.medicine.org.hk/hkps/statements.php. Accessed 21 Jul 2021.

15. Authorisation of COVID-19 vaccines under the Prevention and Control of Disease (Use of Vaccines) Regulation (Cap.599K). Available from: https://www.fhb.gov.hk/en/our_work/health/rr3.html. Accessed 7 Jul 2021.

Much research has been conducted into the coronavirus disease 2019 (COVID-19) pandemic internationally and regionally.1 2 3 4 Before the pandemic became widespread, researchers in Hong Kong have alerted health authorities to initiate emergency measures.5 6 The accumulated scientific evidence on COVID-19, including clinical characteristics, transmission, risk factors, diagnostic testing and screening, immune responses, treatment and pharmaceutical prophylaxis, and vaccines has greatly helped inform the infection prevention, early recognition, rapid identification, and disease control of COVID-19. Research attention paid to the routine clinical management of chronic conditions are of equal importance in the wider context of the pandemic, given the dynamic links between COVID-19 and underlying health conditions.7

In this issue of the Hong Kong Medical Journal, Yee et al8 reviewed institutional data from all urology centres in the government-run healthcare sector in Hong Kong during the COVID-19 pandemic, to assess the changes in urology practice and resident training. Compared with a control period, the authors report drastic reductions of 28.5% to 49.6% in the numbers of operating sessions, clinic attendances, cystoscopy sessions, prostate biopsies, and shockwave lithotripsy sessions across all the centres reviewed. The number of surgeries performed by residents was also reduced dramatically during the pandemic. Key aspects of urology practice have undergone substantial changes, which resulted as a response to challenges including shortages in frontline healthcare resources such as personal protective equipment, or rigid management of patient flow in hospitals. Similar challenges were identified in primary care during the early phase of the COVID-19 outbreak, as shown in a cross-sectional study conducted among family doctors affiliated with the Hong Kong College of Family Physicians.9 In other specialist services such as obstetrics and gynaecology practices, restrictive measures intended to limit the spread of COVID-19 resulted in an increased psychological burden on pregnant women who experienced cancellation of prenatal exercises, antenatal talks, hospital tours, and postnatal classes.10 Local researchers also advocated the importance of identifying and prioritising ‘time-sensitive’ patients for assisted reproductive technology.11 From a clinical perspective, the gap in clinical preparedness for COVID-19 necessitates further frontline research to develop risk triage protocols with optimal diagnostic performance and a widely accepted ‘gold-standard’ cut-off level to inform guideline recommendations and support clinical management decisions.12

Research conducted to explore the epidemiological and clinical manifestations of COVID-19 has substantially contributed to reducing community spread of severe acute respiratory syndrome coronavirus 2 in Hong Kong. A local investigation using data retrieved from the Clinical Management System of the Hospital Authority demonstrated the successful role of the first public COVID-19 temporary test centre in identifying infected individuals in a large-scale high-turnover setting.13 The volume and complexity of information documented in electronic health records, including clinical symptoms, imaging investigations, contact history, nucleic acid testing and vaccination records, has been growing exponentially to underpin digital solutions that support efforts to limit the spread of COVID-19. Big data analytics, artificial intelligence, and machine learning techniques have gained increasing prominence in generating reliable evidence that can help measure personalised clinical risk of severe illness and may potentially contribute to regional and global forecasts.14 Such progress will inevitably be accelerated by increasing uptake of electronic health records and mobile apps in mass data collection to support scientific research and public health measures. Nevertheless, due consideration in protecting personally identifiable information and ensuring data privacy in the context of COVID-19 is becoming a controversial but crucial concern over individual-level data exchange and sharing that deserves concomitant research.

Coping with COVID-19 requires simultaneous inputs from and participation of different medical disciplines. A local study conducted by radiologists assessed the use of computed tomography (CT) scanning of the thorax as a non-invasive imaging modality in exploring viral pneumonia patterns that were commonly encountered in affected patients.15 This provides an opportunity to gain temporal insights into the extent of lung involvement on CT images and determine the accuracy of CT severity scoring in clinical triage and the prediction of post-COVID outcomes. It is highly sensitive, accessible, portable, and easy to operate,16 playing an important role in identification of COVID-19.17 A group of specialists in ophthalmology, anaesthesiology, otorhinolaryngology, pathology and surgery, together with other relevant stakeholders, have formulated a risk stratification protocol with structured workflow for emergency surgeries.18 It bears a wider applicability to frontline healthcare staff with regard to timely assessment and decision making in the arrangement of emergency operations across different disciplines. There have also been suggestions to use chemoprophylaxis in adjunct with health behaviours and social distancing measures,19 which could achieve a synergistic effect.20 Meanwhile, social distancing remains an important strategy along with concurrent measures of infection control, even for individuals who have completed the vaccination course.21 A deeper understanding of such dynamic interaction warrants extensive research that bridges biostatistics and mathematical modelling. In managing COVID-19, there will continue to be a reliance on multidisciplinary clinical work to optimise patient care, following guidelines and recommendations that are both internationally recognised and locally adaptable, given the availability of resources and the changing severity of the pandemic. High-quality evidence generated from appropriately designed, well-planned, and ethically approved studies are continuously needed.

Behavioural research conducted to understand people’s behaviours and their linkage to knowledge, beliefs, and concerns is a key step to shape the messages on prevention measures delivered to target population and thus enhance risk communications and community engagement against the spread of COVID-19.22 An example was illustrated in an observational study published recently in the Hong Kong Medical Journal, which assessed the public views on face mask performance, reuse of surgical mask, and health information source among pedestrians in well-populated locations in Hong Kong.23 The authors brought behavioural insights into the issues of a high mask reuse rate during the initial spread of COVID-19 and the popularity of social media over government websites for information seeking. Research drawing on valuable perspectives from social science disciplines that twin with the biomedical understanding of the COVID-19 carries a great potential to inform the planning of effective behavioural interventions, as the containment of complex epidemics is as much behavioural as medical. A further step towards empirical evidence on behaviour changes and cultural factors can therefore support the pandemic response through promoting risk and science communication with the public to achieve optimal compliance to infection prevention and control measures.

The above examples, and others published in the Hong Kong Medical Journal (https://www. hkmj.org/COVID-19), are a small part of the huge volume of research activities led by local researchers in Hong Kong in response to the global pandemic of COVID-19. Despite the rapid progress made, many unknown but unique characteristics of severe acute respiratory syndrome coronavirus 2 are yet to be uncovered. Uncertainties remain on issues such as the natural history of COVID-19, the impact of viral changes over time, the long-term effectiveness and safety of vaccines, and the cost-effectiveness of different public health and social epidemic control measures. Ongoing medical and translational research is required that thinks globally and acts locally, to investigate the epidemiological, clinical, therapeutic, and service aspects of COVID-19 management, incorporating the latest advances in virology, immunology, molecular microbiology, and other disciplines of laboratory-based basic science.

All authors contributed to the concept or design; acquisition of data; analysis or interpretation of data; drafting of the article; and critical revision for important intellectual content. 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.

The authors have declared no conflict of interest.

1. Park JJ, Mogg R, Smith GE, et al. How COVID-19 has fundamentally changed clinical research in global health. Lancet Glob Health 2021;9:e711-20. Crossref

2. Wong MC, Ng RW, Chong KC, et al. Stringent containment measures without complete city lockdown to achieve low incidence and mortality across two waves of COVID-19 in Hong Kong. BMJ Glob Health 2020;5:e003573. Crossref

3. Huang J, Teoh JY, Wong SH, Wong MC. The potential impact of previous exposure to SARS or MERS on control of the COVID-19 pandemic. Eur J Epidemiol 2020;35:1099-103. Crossref

4. Wong SY, Tan DH, Zhang Y, et al. A tale of 3 Asian cities: how is primary care responding to COVID-19 in Hong Kong, Singapore, and Beijing. Ann Fam Med 2021;19:48-54. Crossref

5. Hon KL, Leung KK. Severe acute respiratory symptoms and suspected SARS again 2020. Hong Kong Med J 2020;26:78-9. Crossref

6. To KK, Yuen KY. Responding to COVID-19 in Hong Kong. Hong Kong Med J 2020;26:164-6. Crossref

7. Clark A, Jit M, Warren-Gash C, et al. Global, regional, and national estimates of the population at increased risk of severe COVID-19 due to underlying health conditions in 2020: a modelling study. Lancet Glob Health 2020;8:e1003-17. Crossref

8. Yee CH, Wong HF, Tam MH, et al. Effect of SARS and COVID-19 outbreaks on urology practice and training. Hong Kong Med J 2021 Feb 26. Epub ahead of print. Crossref

9. Yu EY, Leung WL, Wong SY, Liu KS, Wan EY; HKCFP Executive and Research Committee. How are family doctors serving the Hong Kong community during the COVID-19 outbreak? A survey of HKCFP members. Hong Kong Med J 2020;26:176-83. Crossref

10. Hui PW, Ma G, Seto MT, Cheung KW. Effect of COVID-19 on delivery plans and postnatal depression scores of pregnant women. Hong Kong Med J 2021;27:113-7. Crossref

11. Lee WY, Mok A, Chung JP. Potential effects of COVID-19 on reproductive systems and fertility; assisted reproductive technology guidelines and considerations: a review. Hong Kong Med J 2021;27:118-26. Crossref

12. Knight SR, Ho A, Pius R, et al. Risk stratification of patients admitted to hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: development and validation of the 4C Mortality Score. BMJ 2020;370:m3339. Crossref

13. Leung WL, Yu EL, Wong SC, et al. Findings from the first public COVID-19 temporary test centre in Hong Kong. Hong Kong Med J 2021;27:99-105. Crossref

14. Abd-Alrazaq A, Alajlani M, Alhuwail D, et al. Artificial intelligence in the fight against COVID-19: scoping review. J Med Internet Res 2020;22:e20756. Crossref

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The Journal of Korean Medical Science (JKMS; https://jkms.org/") is an international, peer-reviewed Open Access journal of medicine published weekly in English. The journal is published by the Korean Academy of Medical Sciences and the Korean Medical Association. The JKMS aims to publish evidence-based scientifically written articles from various disciplines of the medical sciences. The journal welcomes articles of general interest to medical researchers, especially those that contain original information. Articles on the clinical evaluation of drugs and other therapies, epidemiologic studies of the general population, studies on pathogenic organisms and toxic materials, and the toxicities and adverse effects of therapeutics are welcome. The JKMS was founded in 1986 and was indexed in MEDLINE in 1989. In 1999, the journal launched a website and was included in Science Citation Index Expanded (SCIE). Through steady efforts thereafter, JKMS was finally included in Science Citation Index in 2005. In 2007, JKMS established its own online submission system, and in 2017, began to use a submission system provided by Editorial Manager (Aries Systems Corporation, North Andover [MA], United States). Since 2010, JKMS has been published all articles as Open Access under the terms of the Creative Commons Attribution-NonCommercial 4.0 International license. The JKMS is indexed/tracked/covered by MEDLINE, PubMed, PubMed Central, Web of Science (SCIE), BIOSIS Previews, Scopus, Embase, Chemical Abstracts Service, KoreaMed, Synapse, KoMCI, KCI, and Google Scholar. In 2016, JKMS became a member journal of the International Committee of Medical Journal Editors (http://icmje.org/). The 2020 Journal Impact Factor of JKMS is 2.153 and total citation counts 9573 (Clarivate Analytics, 2021) while the CiteScore 2020 is 4.0 (Scopus, 2021).

Since boldly launching weekly publication in 2018, JKMS is currently published every Monday, 50 issues a year.1 The page layout of the articles was edited to a single-column format to provide the online audience with better readability and visuality. Article categories include Original Article, Review Article, Special Article, Case Report, Brief Communication, Editorial, Opinion, Correspondence, and Images in this Issue. Thanks to weekly publication, JKMS significantly reduced the interval between the submission of manuscripts and publication. This advantage is particularly evident in the rapid publication of articles in the field of coronavirus disease 2019 (COVID-19). For example, the first case report of COVID-19 in Korea was submitted on 31 January 2020, accepted on 2 February, and published online on 3 February.2 As of 9 August 2021, 177 articles relating to COVID-19 have been published in JKMS (https://jkms.org/index.php?main=COVID-19) and five of them have received >100 citations.3 4 5 6 In 2020, JKMS received 1614 submissions, and the acceptance rate was 26.1%. In 2020, a huge rush of COVID-19 papers was received and a special section was prepared.

The peer review of manuscripts is the most important step in journal publishing. We always thank dedicated reviewers for providing feedback to authors so that the manuscripts can be published in their best form.7 The JKMS evaluates reviewers by combining the number of complete reviews and the scores of their review comments, and awards the highest rated reviewers the Best Reviewer Award at the general assembly of the Korean Academy of Medical Sciences every year (https://jkms.org/index.php?main=reviewer).

The Yoon Kwang-Yull Medical Prize was jointly established by the Korean Academy of Medical Sciences and the Gasong Foundation in 2008. The prize was established to promote the noble spirit of late founder Yoon Kwang-Yull’s devotion to social service and academic research support. The prize is given to the author who has published excellent papers in JKMS in the past decade and contributed the most to spreading the outstanding medical research from Korea to the world. In 2021, Dr Sang-joon Park (Myongji Hospital, Goyang, Korea) received the 12th prize (https://jkms.org/index.php?main=prize).

The JKMS is an influential flagship journal of Korea. It adheres to global standards of editing and publishing for the purpose of leading research in medicine, proposing and discussing controversial issues, and archiving evidence-based science. It introduces new editing strategy and achieves publishing updates and publication ethics in Korea. Furthermore, it provides a publication platform for international researchers with trustworthy rapid publishing following global standards.

The staff of JKMS include an Editor-in-Chief (Dr Sung-Tae Hong), three deputy editors (Dr Kyung Pyo Hong, Dr Jin-Hong Yoo, Dr Jong-Min Kim), a managing editor (Dr Jong-Min Kim), four section editors (Dr Armen Yuri Gasparyan, Dr Kyung Pyo Hong, Dr Jin-Hong Yoo, Dr Jong-Min Kim), one language editor (Ms Allison B Alley), one statistics editor (Dr Moo-Song Lee), one image editor (Dr Jeehyoung Kim), one social media editor (Dr Olena Zimba), 13 executive board members, and 77 members of 37 subspecialties as the editorial board (ttps://jkms.org/index.php?main=exboard). Two assistant editors (Ms Ye-jin Lee, Ms So-yeon Jung) work in the editorial office. Manuscript editing, online publishing, and website management services are provided by XMLink Publishing Co. (https://xmlink.kr/; Seoul, Korea).

The JKMS will continue to fulfil its mission as an authentic scholarly journal providing global readers with academically validated theories. In this context, we are sincerely pleased to have the opportunity to introduce the Hong Kong Medical Journal (HKMJ) under agreement between the Korean Academy of Medical Sciences and the Hong Kong Academy of Medicine.8 The JKMS and HKMJ will collaborate for mutual benefit and synergistic contribution in medical science.

1. Hong ST. Fostering strategic changes in publishing: Journal of Korean Medical Science in 2018. J Korean Med Sci 2018;33:e8. Crossref

2. Kim JY, Choe PG, Oh Y, et al. The first case of 2019 novel coronavirus pneumonia imported into Korea from Wuhan, China: implication for infection prevention and control measures. J Korean Med Sci 2020;35:e61. Crossref

3. Korean Society of Infectious Diseases, Korean Society of Pediatric Infectious Diseases, Korean Society of Epidemiology, Korean Society for Antimicrobial Therapy, Korean Society for Healthcare-associated Infection Control and Prevention, Korea Centers for Disease Control and Prevention. Report on the epidemiological features of coronavirus disease 2019 (COVID-19) outbreak in the Republic of Korea from January 19 to March 2, 2020. J Korean Med Sci 2020;35:e112. Crossref

4. Kim ES, Chin BS, Kang CK, et al. Clinical course and outcomes of patients with severe acute respiratory syndrome coronavirus 2 infection: a preliminary report of the first 28 patients from the Korean cohort study on COVID-19. J Korean Med Sci 2020;35:e142. Crossref

5. Ahn JY, Sohn Y, Lee SH, et al. Use of convalescent plasma therapy in two COVID-19 patients with acute respiratory distress syndrome in Korea. J Korean Med Sci 2020;35:e149. Crossref

6. Lee Y, Min P, Lee S, Kim SW. Prevalence and duration of acute loss of smell or taste in COVID-19 patients. J Korean Med Sci 2020;35:e174. Crossref

7. Hong ST. Appreciation to reviewers for the Journal of Korean Medical Science in 2020. J Korean Med Sci 2021;36:e60. Crossref

8. Li KK, Ma ES, Lui RN, Huang J, Xue H, Wong MC. Hong Kong Medical Journal—the Premier General Medical Journal in Hong Kong. J Korean Med Sci 2021;36:e226. Crossref