The total number of new cases of coronavirus disease 2019 (COVID-19) is decreasing in Hong Kong, but two recent paediatric cases have attracted immense public attention—a 4-month-old baby who contracted the viral infection from his family and a 4-year-old boy who was likely infected in the community several months before, possibly concurrently with roseola infantum, and tested positive despite the long interval between infection and testing.

Since the outbreak of COVID-19 in Hong Kong in January 2020, there has been a great deal of research by local paediatricians on the clinical manifestations1 2 3 and scientific findings4 5 of the paediatric cases, including comparative studies with paediatric cases in South Korea,6 Wuhan,6 7 8 and other regions of mainland China,6 7 8 and with those of children infected with severe acute respiratory syndrome in 2003.9 Collaborations with local and overseas researchers have also contributed to a deeper understanding of COVID-19.10 11 12 13

The overt effects of COVID-19 on children are known: severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection generally causes mild illness in children and adolescents, with 99.2% of paediatric patients with COVID-19 experiencing mild symptoms8 and 26% to 38% asymptomatic.3 8 However, serious complications have occurred in children in Hong Kong, such as PIMS-TS (paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2), post-COVID-19 autoimmune haemolytic anaemia, and COVID toes.8 These patients required lengthy hospital management including intensive care and prolonged follow-up after recovery.

In order to protect vulnerable individuals in Hong Kong, such as children and older and/or chronically ill adults, social distancing measures to mitigate the spread of infection have been enforced. Intermittently, schools have been closed and were fully open for <3 months in the entire year of 2020, and school closures have continued into 2021. Schools are fundamental to child and adolescent development and wellbeing, providing academic instruction, social and emotional skills, safety, reliable nutrition, physical/speech and mental health therapy, and opportunities for physical activity, among other benefits. Schools also play a critical role in addressing racial and social inequity.14 In the past 15 months of school suspensions, online teaching has played a central role in ensuring academic provisions but other aspects of development and wellbeing have been compromised.

In addition to providing a learning environment, schools serve to satisfy students’ non-academic needs and school closures have serious consequences on the physical and mental wellbeing of students.15 Internationally, studies have found that obesity16 and myopia17 among school-age children have increased because of longer screen times, lack of physical activities, and the small living and learning spaces at home. These indirect consequences can affect all children, but some are disproportionately more likely to be affected, such as those with special educational needs or those who are financially deprived. Tso et al18 conducted a large-scale cross-sectional population online survey of 29 202 Hong Kong families with children aged 2 to 12 years. The authors found that, amid the COVID-19 outbreak and the resulting related school closures and disease containment measures in Hong Kong, the risk of child psychosocial problems was higher in children with special educational needs, and/or acute or chronic disease, mothers with mental illness, single-parent families, and low-income families. Delayed bedtime, inadequate sleep, inadequate exercise, and extended use of electronic devices were associated with significantly higher levels of stress among parents and more psychosocial problems among pre-school children. These indirect impacts of COVID-19 could potentially create a social crisis because school closures are likely to widen the learning gap between children from lower-income and those from higher-income families.19

In Hong Kong, Chua et al3 found that household transmission was the main source of infection for children and youths, and the risk of being infected at school was small. On 10 May 2021, the Hong Kong College of Paediatricians, The Hong Kong Paediatric Society, and the Hong Kong Society for Paediatric Immunology, Allergy and Infectious Diseases jointly issued an appeal to adult household members and carers (aged ≥16 years) to receive the COVID-19 vaccine for the benefit of the younger generation.20

However, this is only the first step in the appeal from paediatricians. The ultimate goal is to boost the overall immunisation rate in the community and to restore societal normalcy. On 24 May 2021, whole-school half-day face-to-face classes resumed for all school grades in Hong Kong. However, students were still not permitted to interact with peers at lunch, enjoy many of the non-core subjects that have to be missed due to shortened class time, nor socialise outside of “class bubbles”.

The United States, Canada, Singapore, and Israel have approved COVID-19 vaccination for those aged 12 to 15 years. This is a welcome development in the efforts to protect the population from COVID-19, and we look forward to newer scientific evidence for vaccine safety and efficacy in even younger children.

The take-home message remains: community-wide immunisation is safe and effective—and much more desirable than closures of educational and leisure facilities—for protecting the physical health and long-term psychosocial and emotional development of children, and for reducing social inequity.

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

All authors have disclosed no conflicts of interest.

1. Mak PQ, Chung KS, Wong JS, Shek CC, Kwan MY. Anosmia and ageusia: not an uncommon presentation of COVID-19 infection in children and adolescents. Pediatr Infect Dis J 2020;39:e199-200. Crossref

2. Duque JS, Mak PQ, Wong JS, et al. Discharging coronavirus disease 2019 (COVID-19) patients with faecal viral shedding and prolonged hospitalisation. J Hosp Adm 2020;9:26-30. Crossref

3. Chua GT, Wong JS, Lam I, et al. Clinical characteristics and transmission of COVID-19 in children and youths during 3 waves of outbreaks in Hong Kong. JAMA Netw Open 2021;4:e218824. Crossref

4. To KK, Chua GT, Kwok KL, et al. False-positive SARSCoV- 2 serology in 3 children with Kawasaki disease. Diagn Microbiol Infect Dis 2020;98:115141. Crossref

5. Chua GT, Wong JS, To KK, et al. Saliva viral load better correlates with clinical and immunological profiles in children with coronavirus disease 2019. Emerg Microbes Infect 2021;10:235-41. Crossref

6. Chua GT, Xiong X, Choi EH, et al. COVID-19 in children across three Asian cosmopolitan regions. Emerg Microbes Infect 2020;9:2588-96. Crossref

7. Xiong XL, Wong KK, Chi SQ, et al. Comparative study of the clinical characteristics and epidemiological trend of 244 COVID-19 infected children with or without GI symptoms. Gut 2021;70:436-8. Crossref

8. Xiong XL, Chua GT, Chi SQ, et al. Haematological and immunological data of Chinese children infected with coronavirus disease 2019. Data Brief 2020;31:105953. Crossref

9. Xiong X, Chua GT, Chi S, et al. A comparison between Chinese children infected with coronavirus disease-2019 and with severe acute respiratory syndrome 2003. J Pediatr 2020;224:30-6. Crossref

10. Cowling BJ, Ali ST, Ng TW, et al. Impact assessment of non-pharmaceutical interventions against coronavirus disease 2019 and influenza in Hong Kong: an observational study. Lancet Public Health 2020;5:e279-88. Crossref

11. Zhang Q, Bastard P, Liu Z, et al. Inborn errors of type I IFN immunity in patients with life-threatening COVID-19. Science 2020;370:eabd4570.

12. Bastard P, Rosen LB, Zhang Q, et al. Autoantibodies against type I IFNs in patients with life-threatening COVID-19. Science 2020;370:eabd4585.

13. Sancho-Shimizu V, Brodin P, Cobat A, et al. SARS-CoV-2-related MIS-C: A key to the viral and genetic causes of Kawasaki disease? J Exp Med 2021;218:e20210446.

14. American Academy of Pediatrics. COVID-19 guidance for safe schools. Available from: https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-planning-considerations-return-to-in-person-education-in-schools/. Accessed 28 May 2021.

15. Hoffman JA, Miller EA. Addressing the consequences of school closure due to COVID-19 on children’s physical and mental well-being. World Med Health Policy 2020;12:300-10. Crossref

16. Jenssen BP, Kelly MK, Powell M, Bouchelle Z, Mayne SL, Fiks AG. COVID-19 and changes in child obesity. Pediatrics 2021;147:e2021050123. Crossref

17. Wang J, Li Y, Musch DC, et al. Progression of myopia in school-aged children after COVID-19 home confinement. JAMA Ophthalmol 2021;139:293-300. Crossref

18. Tso WW, Wong RS, Tung KT, et al. Vulnerability and resilience in children during the COVID-19 pandemic. Eur Child Adolesc Psychiatry 2020 Nov 17. Available from: https://doi.org/10.1007/s00787-020-01680-8. Accessed 28 May 2021. Crossref

19. van Lancker W, Parolin Z. COVID-19, school closures, and child poverty: a social crisis in the making. Lancet Public Health 2020;5:e243-4. Crossref

20. Hong Kong College of Paediatricians. Appealing to adults to receive COVID-19 vaccination for the psychosocial and physical health of our children (updated 10th May 2021). Hong Kong College of Paediatricians. Available from: https://www.paediatrician.org.hk/index.php?option=com_content&view=article&id=427&catid=2&Itemid=26. Accessed 28 May 2021.

Living with chronic kidney disease (CKD) is associated with hardships for patients and their care partners. Empowering patients and their care partners, including family members or friends involved in their care, may help minimise the burden and consequences of CKD-related symptoms to enable life participation. There is a need to broaden the focus on living well with kidney disease and re-engagement in life, including an emphasis on patients being in control. The World Kidney Day (WKD) Joint Steering Committee has declared 2021 the year of ‘Living Well with Kidney Disease’ in an effort to increase education and awareness on the important goal of patient empowerment and life participation. This calls for the development and implementation of validated patient-reported outcome measures to assess and address areas of life participation in routine care. It could be supported by regulatory agencies as a metric for quality care or to support labelling claims for medicines and devices. Funding agencies could establish targeted calls for research that address the priorities of patients. Patients with kidney disease and their care partners should feel supported to live well through concerted efforts by kidney care communities including during pandemics. In the overall wellness programme for kidney disease patients, the need for prevention should be reiterated. Early detection with a prolonged course of wellness despite kidney disease, after effective secondary and tertiary prevention programmes, should be promoted. World Kidney Day 2021 continues to call for increased awareness of the importance of preventive measures throughout populations, professionals, and policy makers, applicable to both developed and developing countries.

Chronic kidney disease, its associated symptoms, and its treatment, including medications, dietary and fluid restrictions, and kidney replacement therapy can disrupt and constrain daily living, and impair the overall quality of life of patients and their family members. Consequently, this can also impact treatment satisfaction and clinical outcomes.1 Despite this, the past several decades have seen limited improvement in the quality of life of people with CKD.1 To advance research, practice, and policy, there is increasing recognition of the need to identify and address patient priorities, values, and goals.1

Several regional and global kidney health projects have addressed these important questions including the Standardised Outcomes in Nephrology with more than 9000 patients, family members, and healthcare professionals from over 70 countries.2 3 Across all treatment stages, including CKD, dialysis and transplantation, Standardised Outcomes in Nephrology participating children and adults with CKD consistently gave higher priority to symptoms and life impacts than healthcare professionals.2 3 In comparison, healthcare professionals gave higher priority to mortality and hospitalisation than patients and family members. The patient-prioritised outcomes are shown in the Figure. Irrespective of the type of kidney disease or treatment stage, patients wanted to be able to live well, maintain their role and social functioning, protect some semblance of normality, and have a sense of control over their health and well-being.

Life participation, defined as the ability to do meaningful activities of life including, but not limited to, work, study, family responsibilities, travel, sport, social, and recreational activities, was established a critically important outcome across all treatment stages of CKD.1 2 The quotations from patients with kidney disease provided in the Box demonstrates how life participation reflects the ability to live well with CKD.4 According to the World Health Organization (WHO), participation refers to “involvement in a life situation.”5 This concept is more specific than the broader construct of quality of life. Life participation places the life priorities and values of those affected by CKD and their family at the centre of decision making. The World Kidney Day Steering Committee calls for the inclusion of life participation, a key focus in the care of patients with CKD, to achieve the ultimate goal of living well with kidney disease. This calls for the development and implementation of validated patient-reported outcome measures, that could be used to assess and address areas of life participation in routine care. Monitoring of life participation could be supported by regulatory agencies as a metric for quality care or to support labelling claims for medicines and devices. Funding agencies could establish targeted calls for research that address the priorities of patients, including life participation.

Patients with CKD and their family members including care partners should be empowered to achieve the health outcomes and life goals that are meaningful and important to them. The WHO defines patient empowerment as “a process through which people gain greater control over decisions or actions affecting their health,”6 which requires patients to understand their role, to have knowledge to be able to engage with clinicians in shared decision making, skills, and support for self-management. For patients receiving dialysis, understanding the rationale for a lifestyle change, having access to practical assistance and family support promoted patient empowerment, while feeling limited in life participation undermined their sense of empowerment.7

The World Kidney Day Steering Committee advocates for strengthened partnership with patients in the development, implementation, and evaluation of interventions for practice and policy settings, that enable patients to live well with kidney diseases. This needs to be supported by consistent, accessible, and meaningful communication. Meaningful involvement of patients and family members across the entire research process, from priority setting and planning the study through to dissemination and implementation, is now widely advocated.8 There have also been efforts, such as the Kidney Health Initiative, to involve patients in the development of drugs and devices to foster innovation.9

We urge for greater emphasis on a strengths-based approach as outlined in the Table, which encompasses strategies to support patient resilience, harness social connections, build patient awareness and knowledge, facilitate access to support, and establish confidence and control in self-management. The strengths-based approach is in contrast to the medical model where chronic disease is traditionally focussed on pathology, problems, and failures.10 Instead, the strengths-based approach acknowledges that each individual has strengths and abilities to overcome the problems and challenges faced, and requires collaboration and cultivation of the patient’s hopes, aspirations, interests, and values. Efforts are needed to ensure that structural biases, discrimination, and disparities in the healthcare system also need to be identified, so all patients are given the opportunity to have a voice.

A care partner is often an informal caregiver who is also a family member of the patient with CKD.11 They may take on a wide range of responsibilities including coordinating care (including transportation to appointments), administration of treatment including medications, home dialysis assistance, and supporting dietary management. Caregivers of patients with CKD have reported depression, fatigue, isolation, and also burnout. The role of the care partner has increasingly become more important in CKD care given the heightened complexity in communicative and therapeutic options including the expansion of telemedicine under the coronavirus disease 2019 (COVID-19) pandemic and given the goal to achieve higher life expectancy with CKD.12 The experience of caring for a partially incapacitated family member with progressive CKD can represent a substantial burden on the care partner and may impact family dynamics. Not infrequently, the career goals and other occupational and leisure aspects of the life of the care partner are affected because of CKD care partnership, leading to care partner overload and burnout. Hence, the above-mentioned principles of life participation need to equally apply to care partners as well as all family members and friends involved in CKD care.

In low and lower-middle-income countries including in sub-Saharan Africa, Southeast Asia, and Latin America, patient’s ability to self-manage or cope with the chronic disease vary but may often be influenced by internal factors including spirituality, belief system, and religiosity, and external factors including appropriate knowledge of the disease, poverty, family support system, and one’s grit and social relations network. The support system comprising healthcare providers and caregivers plays a crucial role as most patients rely on them in making decisions, and for the necessary adjustments in their health behaviour.13 In low-income regions, where there are often a relatively low number of physicians and even lower number of kidney care providers per population especially in rural areas, a stepwise approach can involve local and national stakeholders including both non-governmental organisations and government agencies by (1) extending kidney patient education in rural areas; (2) adapting telehealth technologies if feasible to educate patients and train local community kidney care providers, and (3) implementing effective retention strategies for rural kidney health providers including adapting career plans and competitive incentives.

Many patients in low-resource settings present in very late stage needing to commence emergency dialysis.14 The very few fortunate ones to receive kidney transplantation may acquire an indescribable chance to normal life again, notwithstanding the high costs of immunosuppressive medications in some countries. For some patients and care partners in low-income regions, spirituality and religiosity may engender hope, when ill they are energised by the anticipation of restored health and spiritual wellbeing. For many patients, informing them of a diagnosis of kidney disease is a harrowing experience both for the patient (and caregivers) and the healthcare professional. Most patients present to kidney physicians (usually known as “renal physicians” in many of these countries) with trepidations and apprehension. It is rewarding therefore to see the patient’s anxiety dissipate after reassuring him or her of a diagnosis of simple kidney cysts, urinary tract infection, simple kidney stones, solitary kidneys, etc, that would not require extreme measures like kidney replacement therapy. Patients diagnosed with glomerulonephritis who have an appropriate characterisation of their disease from kidney biopsies and histology; who receive appropriate therapies and achieve remission are relieved and are very grateful. Patients are glad to discontinue dialysis following resolution of acute kidney injury or acute-on-chronic kidney disease.

Many patients with CKD who have residual kidney function appreciate being maintained in a relatively healthy state with conservative measures, without dialysis. They experience renewed energy when their anaemia is promptly corrected using erythropoiesis-stimulating agents. They are happy when their peripheral oedema resolves with treatment. For those on maintenance haemodialysis who had woeful stories from emergency femoral cannulations, they appreciate the construction of good temporary or permanent vascular accesses. Many patients in low-resource settings present in very late stage needing to commence emergency dialysis. Patients remain grateful for waking from a uraemic coma or recovering from recurrent seizures when they commence dialysis.

World Kidney Day 2021 theme on ‘Living Well with Kidney Disease’ is deliberately chosen to have the goals to redirect more focus on plans and actions towards achieving patient-centred wellness. “Kidney Health for Everyone, Everywhere” with emphasis on patient-centred wellness should be a policy imperative that can be successfully achieved if policy makers, nephrologists, healthcare professionals, patients, and care partners place this within the context of comprehensive care. The requirement of patient engagement is needed. The WHO in 2016 put out an important document on patient empowerment15:

In the International Society of Nephrology Community Film Event at World Congress of Nephrology 2020, it is good to see a quote in the film from patients:

The International Society of Nephrology Global Kidney Policy Forum 2019 included a patient speaker Nicki Scholes-Robertson from New Zealand:

World Kidney Day 2021 would like to promote to the policy makers on increasing focus and resources on both drug and non-drug programmes in improving patient wellness. Examples include funding for erythropoiesis-stimulating agents and antipruritic agents for managing anaemia and itchiness, respectively, just name but a few.16 17 Home dialysis therapies have been consistently found to improve patient autonomy and flexibility, quality of life in a cost-effective manner, enhancing life participation. Promoting home dialysis therapies should tie in with appropriate ‘assisted dialysis’ programmes to reduce patient and care partner fatigue and burnout. Also, examples like self-management programmes, cognitive behavioural therapy, and group therapies for managing depression, anxiety, and insomnia should be promoted before resorting to medications.18 The principle of equity recognises that different people with different levels of disadvantage require different approaches and resources to achieve equitable health outcomes. The kidney community should push for adapted care guidelines for vulnerable and disadvantaged populations. The involvement of primary care and general physicians especially in low and lower-middle-income countries would be useful in improving the affordability and access to services through the public sector in helping the symptom management of patients with CKD and improve their wellness. In the overall wellness programme for kidney disease patients, the need for prevention should be reiterated. Early detection with a prolonged course of wellness despite kidney disease, after an effective secondary prevention programme, should be promoted.19 Prevention of CKD progression can be attempted by lifestyle and diet modifications such as a plant-dominant low-protein diet and by means of effective pharmacotherapy including administration of sodium-glucose transport protein 2 inhibitors.20 World Kidney Day 2021 continues to call for increased awareness of the importance of preventive measures throughout populations, professionals, and policy makers, applicable to both developed and developing countries.19

Effective strategies to empower patients and their care partners strive to pursue the overarching goal of minimising the burden of CKD-related symptoms in order to enhance patient satisfaction, health-related quality of life, and life participation. World Kidney Day 2021 theme on ‘Living Well with Kidney Disease’ is deliberately chosen to have the goals to redirect more focus on plans and actions towards achieving patient-centred wellness. Notwithstanding the COVID-19 pandemic that had overshadowed many activities in 2020 and beyond, the World Kidney Day Steering Committee has declared 2021 the year of ‘Living well with Kidney Disease’ in an effort to increase education and awareness on the important goal of effective symptom management and patient empowerment. Whereas the World Kidney Day continues to emphasise the importance of effective measures to prevent kidney disease and its progression,18 patients with pre-existing kidney disease and their care partners should feel supported to live well through concerted efforts by kidney care communities and other stakeholders throughout the world even during a world-shattering pandemic as COVID-19 that may drain many resources.21 Living well with kidney disease is an uncompromisable goal of all kidney foundations, patient groups, and professional societies alike, to which the International Society of Nephrology and the International Federation of Kidney Foundation World Kidney Alliance are committed at all times.

K Kalantar-Zadeh reports honoraria from Abbott, AbbVie, ACI Clinical, Akebia, Alexion, Amgen, Ardelyx, Astra-Zeneca, Aveo, BBraun, Cara Therapeutics, Chugai, Cytokinetics, Daiichi, DaVita, Fresenius, Genentech, Haymarket Media, Hospira, Kabi, Keryx, Kissei, Novartis, Pfizer, Regulus, Relypsa, Resverlogix, Dr Schaer, Sandoz, Sanofi, Shire, Vifor, UpToDate, and ZS-Pharma. PKT Li reports personal fees from Fibrogen and Astra-Zeneca. G Saadi reports personal fees from Multicare, Novartis, Sandoz, and Astra-Zeneca. V Liakopoulos reports non-financial support from Genesis Pharma. All other authors have disclosed no conflicts of interest.

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

This article was published in Kidney International, volume 99, pages 278-284, Copyright World Kidney Day Steering Committee (2021), and reprinted concurrently in several journals. The articles cover identical concepts and wording, but vary in minor stylistic and spelling changes, detail, and length of manuscript in keeping with each journal’s style. Any of these versions may be used in citing this article.

1. Tong A, Manns B, Wang AY, et al. Implementing core outcomes in kidney disease: report of the Standardized Outcomes in Nephrology (SONG) implementation workshop. Kidney Int 2018;94:1053-68. Crossref

2. Carter SA, Gutman T, Logeman C, et al. Identifying outcomes important to patients with glomerular disease and their caregivers. Clin J Am Soc Nephrol 2020;15:673-84. Crossref

3. Hanson CS, Craig JC, Logeman C, et al. Establishing core outcome domains in pediatric kidney disease: report of the Standardized Outcomes in Nephrology-Children and Adolescents (SONG-KIDS) consensus workshops. Kidney Int 2020;98:553-65. Crossref

4. González AM, Gutman T, Lopez-Vargas P, et al. Patient and caregiver priorities for outcomes in CKD: a multinational nominal group technique study. Am J Kid Dis 2020;76:679-89. Crossref

5. World Health Organization, The International Classification of Functioning, Disability and Health. Towards a common language for functioning, disability and health. 2002. Available from: https://www.who.int/classifications/icf/icfbeginnersguide.pdf. Accessed 11 Apr 2021.

6. World Health Organization. Health Promotion Glossary. 1998. Available from: https://www.who.int/publications/i/item/WHO-HPR-HEP-98.1. Accessed 11 Apr 2021.

7. Baumgart A, Manera KE, Johnson DW, et al. Meaning of empowerment in peritoneal dialysis: focus groups with patients and caregivers. Nephrol Dial Transplant 2020;35:1949-58. Crossref

8. PCORI. The Value of Engagement. Available from: https:// www.pcori.org/about-us/our-programs/engagement/public-and-patient-engagement/value-engagement. 2018. Accessed 1 Sep 2020.

9. Bonventre JV, Hurst FP, West M, Wu I, Roy-Chaudhury P, Sheldon M. A technology roadmap for innovative approaches to kidney replacement therapies: a catalyst for change. Clin J Am Soc Nephrol 2019;14:1539-47. Crossref

10. Ibrahim N, Michail M, Callaghan P. The strengths based approach as a service delivery model for severe mental illness: a meta-analysis of clinical trials. BMC Psychiatry 2014;14:243. Crossref

11. Parham R, Jacyna N, Hothi D, Marks SD, Holttum S, Camic P. Development of a measure of caregiver burden in paediatric chronic kidney disease: The Paediatric Renal Caregiver Burden Scale. J Health Psychol 2014;21:93-205. Crossref

12. Subramanian L, Kirk R, Cuttitta T, et al. Remote management for peritoneal dialysis: a qualitative study of patient, care partner, and clinician perceptions and priorities in the United States and the United Kingdom. Kidney Med 2019;1:354-65. Crossref

13. Angwenyi V, Aantjes C, Kajumi M, De Man J, Criel B, Bunders-Aelen J. Patients experiences of self-management and strategies for dealing with chronic conditions in rural Malawi. PLoS One 2018;13:e0199977. Crossref

14. Ulasi II, Ijoma CK. The enormity of chronic kidney disease in Nigeria: the situation in a teaching hospital in South-East Nigeria. J Trop Med 2010;2010:501957. Crossref

15. World Health Organization. Patient engagement. Available from: https://apps.who.int/iris/handle/10665/252269. Accessed 11 Apr 2021.

16. Spinowitz B, Pecoits-Filho R, Winkelmayer WC, et al. Economic and quality of life burden of anemia on patients with CKD on dialysis: a systematic review. J Med Econ 2019;22:593-604. Crossref

17. Sukul N, Speyer E, Tu C, et al. Pruritus and patient reported outcomes in non-dialysis CKD. Clin J Am Soc Nephrol 2019;14:673-81. Crossref

18. Gregg LP, Hedayati SS. Pharmacologic and psychological interventions for depression treatment in patients with kidney disease. Curr Opin Nephrol Hypertens 2020;29:457-64. Crossref

19. Li PK, Garcia-Garcia G, Lui SF, et al. Kidney health for everyone everywhere—from prevention to detection and equitable access to care. Kidney Int 2020;97:226-32. Crossref

20. Kalantar-Zadeh K, Li PK. Strategies to prevent kidney disease and its progression. Nat Rev Nephrol 2020;16:129-30. Crossref

21. Kalantar-Zadeh K, Wightman A, Liao S. Ensuring choice for people with kidney failure—dialysis, supportive care, and hope. N Engl J Med 2020;383:99-101. Crossref

At the time of writing, Hong Kong has just experienced the end of a fourth wave of the coronavirus disease 2019 (COVID-19) pandemic after imposing stringent infection control measures.1 With the recent launch of the COVID-19 vaccination programme, we are finally seeing the light at the end of the tunnel. Nevertheless, it will take major efforts from the Hong Kong SAR Government and various parties to reach the herd immunity level in order to lift all infection control measures.

In 2003, there was a severe acute respiratory syndrome (SARS) outbreak in Hong Kong and mainland China. Between March and June 2003, 1750 patients were diagnosed to have SARS in Hong Kong, with 286 deaths.2 Despite identification of the SARS coronavirus as the cause of SARS3 and description of the disease pathogenesis model by a team from The University of Hong Kong,4 it was a painful experience with hefty loss of life. The major outbreak in the Amoy Garden estate due to contamination of the sewage in the U-traps which subsequently led to the airborne transmission of the SARS infection among the estate residents highlighted the overcrowded living conditions in Hong Kong.5 By June 2003, 386 healthcare workers were diagnosed to have SARS and eight of them—four doctors, one nurse, and three healthcare assistants–had succumbed.3 The initial shortage of masks and protective clothing for healthcare personnel and the lack of negative pressure isolation facilities resulted in significant nosocomial transmission of the virus. The majority of the diagnoses were made clinically and radiologically, and patients were cohort in large general medical ward. Treatment options were limited to steroids and ventilator support for those who developed respiratory failure. Many patients who were fortunate to recover from the infection suffered from lung fibrosis and the crippling long-term adverse effects of high-dose steroids.6 The SARS outbreak in 2003 highlighted the lack of communication among the health authorities in Hong Kong, mainland China, and the rest of the world. The establishment of the Centre for Health Protection in Hong Kong has helped overcome this shortcoming. The introduction of negative pressure isolation facilities in all major public hospitals hugely reduces the risk of nosocomial transmission and allows infected patients to safely cohort with minimal environmental contamination.7

Benefitting from experiences with SARS in 2003 and the swine flu pandemic in 2009, the Department of Health in Hong Kong implemented intense surveillance measures including tight border restrictions, social distancing, and mask wearing in the community.8 Vigorous contact tracing by the Centre of Health Protection enabled early quarantine and isolation. Deep throat saliva sampling for diagnostic screening reduced the human resources needed while maintaining high sensitivity.9 Such measures resulted in a relatively low number of confirmed infections despite the Hong Kong’s status as an international transport hub. The negative pressure isolation facilities in Hospital Authority hospitals allowed prompt isolation and treatment of patients with COVID-19 with moderate to severe disease and identified risk factors. The establishment of a community treatment facility at AsiaWorld-Expo allowed the isolation of large number of confirmed patients with mild disease, thus relieving the pressure on isolation bed facilities. The recent establishment of an infection control centre at North Lantau Hospital will further increase the number of negative pressure beds available.

Various measures have been shown to reduce the complication rate and shorten hospital stay for patients with COVID-19. Early treatment from symptom onset with the triple combination of interferon beta-1b, lopinavir-ritonavir, and ribavirin resulted in significantly quicker clinical improvement and shorter duration of viral shedding in patients hospitalised with COVID-19.10 The choice of antivirals was based on results from previous in vitro and in vivo animal studies on repurposing drugs for treatment of SARS 2003, Middle East respiratory syndrome, and SARS-CoV-2.11 12 Remdesivir, low-dose dexamethasone, convalescent plasma, and other immunomodulatory therapies have also been used to treat patients with hyperinflammatory response.13 14 15 16 17 Regular clinical assessment of patients with COVID-19, with regular reverse transcription polymerase chain reaction or biochemical testing, as well as radiological imaging, allows for close monitoring and better prediction of the patient’s progress and for guiding changes to the patient’s treatment. Adopting the immunoglobulin G seroconversion has also facilitated patient’s discharge when clinically deem fit.

Looking to the future, safe and effective COVID-19 vaccines are required. At the time of writing (24 March 2021), more than 80 different vaccines are undergoing human clinical trials, and 13 have gained full approval or have been authorised for emergency use.18 The Hong Kong SAR Government has implemented a territory-wide programme to offer COVID-19 vaccinations free of charge for all Hong Kong residents. To ensure the safety and efficacy of the vaccines, the Food and Health Bureau and the Department of Health have set up an Expert Advisory Panel to the Chief Executive. The joint Scientific Committees on Emerging and Zoonotic Diseases and Vaccine Preventable Diseases also regularly review the scientific evidence and relevant data on COVID-19 vaccines procured by the Government, and provide recommendations on the population groups to receive the COVID-19 vaccines. The Expert Committee on Clinical Events Assessment Following COVID-19 Immunisation has been established to provide independent assessment of potential causal links between adverse events following immunisation with any of the COVID-19 vaccines and to provide expert advice to the Government on safety-related matters. The Hong Kong SAR Government has currently procured three different platforms of COVID-19 vaccine from different vendors, including Comirnaty19 (mRNA vaccine), CoronaVac20 (inactivated whole cell vaccine), and Oxford/AstraZeneca21 (ChAdOx1 adenovirus vector vaccine), which will provide a wide choice of COVID-19 vaccines with good safety and efficacy profiles from which Hong Kong residents can choose. The Government is also planning procurement of a fourth COVID-19 vaccine. With a low COVID-19 seroprevalence among the population in Hong Kong, a high COVID-19 vaccination rate will be important to reach the satisfactory herd immunity level to allow relaxation of infection control measures.22 Important data including the long-term safety, clinical efficacy and effectiveness, and neutralising antibody protection against the new SARS-CoV-2 variants (B.1.1.7, B.1.351 and P.1) will be essential to plan for future vaccination programmes. The frequency of COVID-19 vaccination will also depend on the rate of emergence of these new variants.

The lessons learned from the SARS outbreak in 2003 have helped to successfully limit the spread of COVID-19 within Hong Kong. Nevertheless, the global effort against the COVID-19 pandemic will require cooperation among governments, international organisations, research institutes, scientists, clinicians, and most important of all, individual citizens.

The author contributed to the editorial, approved the final version for publication, and takes responsibility for its accuracy and integrity.

IFN Hung is a member of the Advisory Panel on COVID-19 Vaccines; and the co-convener of the Expert Committee on Clinical Events Assessment Following COVID-19 Immunisation for the Hong Kong SAR Government.

1. Coronavirus disease (COVID-19) in HK. Available from: https://chp-dashboard.geodata.gov.hk/covid-19/en.html. Accessed 24 Mar 2021.

2. Lee SH. The SARS epidemic in Hong Kong: what lessons have we learned? JR Soc Med 2003;96:374-8. Crossref

3. Peiris JS, Lai ST, Poon LL, et al. Coronavirus as a possible cause of severe acute respiratory syndrome. Lancet 2003;361:1319-25. Crossref

4. Peiris JS, Chu CM, Cheng VC, et al. Clinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study. Lancet 2003;361:1767-72. Crossref

5. Chu CM, Cheng VC, Hung IF, et al. Viral load distribution in SARS outbreak. Emerg Infect Dis 2005;11:1882-6. Crossref

6. Chan KS, Zheng JP, Mok YW, et al. SARS: prognosis, outcome and sequelae. Respirology 2003;8:S36-40. Crossref

7. Cheng VC, Wong SC, Chuang V, et al. Absence of nosocomial transmission of coronavirus disease 2019 (COVID-19) due to SARS-CoV-2 in the prepandemic phase in Hong Kong. Am J Infect Control 2020;48:890-6. Crossref

8. Cowling BJ, Ali ST, Ng TW, et al. Impact assessment of non-pharmaceutical interventions against coronavirus disease 2019 and influenza in Hong Kong: an observational study. Lancet Public Health 2020;5:e279-88. Crossref

9. To KK, Tsang OT, Leung WS, et al. Temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by SARS-CoV-2: an observational cohort study. Lancet Infect Dis 2020;20:565-74. Crossref

10. Hung IF, Lung KC, Tso EY, et al. Triple combination of interferon beta-1b, lopinavir-ritonavir, and ribavirin in the treatment of patients admitted to hospital with COVID-19: an open-label, randomised, phase 2 trial. Lancet 2020;395:1695-704. Crossref

11. Yuan S, Chan CC, Chik KK, et al. Broad-spectrum host-based antivirals targeting the interferon and lipogenesis pathways as potential treatment options for the pandemic coronavirus disease 2019 (COVID-19). Viruses 2020;12:628. Crossref

12. Chu CM, Cheng VC, Hung IF, et al. Role of lopinavir/ritonavir in the treatment of SARS: initial virological and clinical findings. Thorax 2004;59;252-6. Crossref

13. Beigel JH, Tomashek KM, Dodd LE, et al. Remdesivir for the treatment of COVID-19—final report. N Engl J Med 2020;383:1813-26. Crossref

14. RECOVERY Collaborative Group; Horby P, Lim WS, et al. Dexamethasone in hospitalized patients with Covid-19. N Engl J Med 2021;384:693-704. Crossref

15. Libster R, Pérez Marc G, Wappner D, et al. Early high-titer Crossref

16. Guaraldi G, Meschiari M, Cozzi-Lepri A, et al. Tocilizumab in patients with severe COVID-19: a retrospective cohort study. Lancet Rheumatol 2020;2:e474-84. Crossref

17. Kalil AC, Patterson TF, Mehta AK, et al. Baricitinib plus remdesivir for hospitalized adults with Covid-19. N Engl J Med 2021;384:795-807. Crossref

18. World Health Organization. The COVID-19 candidate vaccine landscape and tracker. https://www.who.int/publications/m/item/draft-landscape-of-covid-19-candidate-vaccines. Accessed 24 Mar 2021.

19. Dagan N, Barda N, Kepten E, et al. BNT162b2 mRNA Covid-19 vaccine in a nationwide mass vaccination setting. N Engl J Med 2021 Feb 14. Epub ahead of print. Crossref

20. Centre for Health Protection, Department of Health, Hong Kong SAR Government. Consensus interim recommendations on the use of CoronaVac in Hong Kong. https://www.chp.gov.hk/files/pdf/consensus_interim_recommendations_on_the_use_of_coronavac_in_hk_as_of_19_feb_2021.pdf. Accessed 24 Mar 2021.

21. Ramasamy MN, Minassian AM, Ewer KJ, et al. Safety and immunogenicity of ChAdOx1 nCoV-19 vaccine administered in a prime-boost regimen in young and old adults (COV002): a single-blind, randomised, controlled, phase 2/3 trial. Lancet 2021;396:1979-93. Crossref

22. To KK, Cheng VC, Cai JP, et al. Seroprevalence of SARS-CoV-2 in Hong Kong and in residents evacuated from Hubei province, China: a multicohort study. Lancet Microbe 2020;1:e111-8. Crossref

In January 2021, Hong Kong marked the grim anniversary of the first reported case of coronavirus disease 2019 (COVID-19) in the territory.1 At the time of writing, Hong Kong has recorded a total of over 10 000 cases and a death toll of nearly 200, against the backdrop of over 110 000 000 cases and 2 500 000 deaths worldwide.1 2 Non-pharmaceutical interventions are capable of containing the pandemic3 with isolation of cases and quarantine of contacts being the fundamental components. However, pre-symptomatic and asymptomatic transmission of COVID-19 can undermine the effectiveness of isolation and quarantine if these measures are not coupled with rapid contact tracing and testing.4

In a recent review paper, it was found that neither absence nor presence of signs or symptoms of COVID-19 could accurately rule in or rule out the disease but anosmia or ageusia may be regarded as a red flag, and fever or cough is a sensitive indicator for identifying patients who need testing.5 In this issue of the Hong Kong Medical Journal, Leung et al6 report the findings of a cross-sectional study conducted using data collected from the first public temporary test centre in Hong Kong at the AsiaWorld-Expo. The authors found that although symptoms such as cough, sore throat, and runny nose were reported in 86.0% of persons who tested positive for COVID-19, these symptoms were non-specific and were also reported in 96.3% of persons who tested negative. The authors recommend that gatekeeping healthcare providers stay vigilant in arranging early testing and remain aware of both clinical and epidemiological manifestations of COVID-19. Another study conducted in Australia compared the efficiency and sensitivity of different testing approaches in detecting community transmission chains. The authors found that testing of all patients with respiratory symptoms in the community, in combination with thorough contact tracing, was most effective.7

Primary care doctors are the gatekeepers of our healthcare system, and the COVID-19 pandemic has highlighted the important role of primary care from the perspectives of infectious disease control and surveillance in the community. In many countries, primary care doctors are an integral part of surveillance systems for infectious diseases such as influenza.8 Similarly, well-trained primary care doctors are indispensable in the early identification and isolation of COVID-19 cases, by contributing to a successful surveillance system which can also identify changes in transmission patterns and at-risk population subgroups,9 as well as evaluate the efficacy of public health control measures.10

The cost-effectiveness of different COVID-19 testing strategies depends on the transmission scenario in the community, in addition to the cost per test.11 Reimer et al12 recommend evidence-based prioritisation of testing, where testing capacity and resources are limited, in order to flatten epidemic curves, lower values of effective reproduction number, and ease the burden on hospitals and intensive care units. Primary care doctors, being the first access point of the healthcare system for most of the general public, are in a prime position to practice evidence-based testing of patients in the community based on clinical assessments.

Primary care doctors are vital to the unprecedented global vaccination campaign. Healthcare workers are at a higher risk of contracting COVID-19, and in a systematic review, Bandyopadhyay et al13 found that general practitioners were one of the specialties at the highest risk of death from COVID-19. Healthcare workers, including primary care doctors, are recommended as a priority group for COVID-19 vaccination worldwide, including in Hong Kong14 where the COVID-19 Vaccination Programme was launched in late February.

Primary care doctors are also at the forefront of communicating with the community. Wong et al15 found that COVID-19 vaccine acceptance in the Hong Kong community is not high (37.2%; 95% confidence interval=34.5%-39.9%) and perceived severity, benefits of the vaccine, cues to action, access barriers, and harms were among the factors associated with acceptance. Studies from the H1N1 pandemic found that primary care doctors were highly influential in H1N1 vaccine uptake16 and it is reasonable to expect that this will also be the case for COVID-19 vaccines. Primary care doctors will require regular updates and accurate information on the vaccines to communicate clearly with their patients and public health authorities.17

A shortage of primary care professionals is associated with a higher death rate due to COVID-19.18 Primary health care has a crucial role in infectious disease epidemic management and well-integrated primary care and public health systems are vital for a cohesive response.19

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

All authors have disclosed no conflicts of interest.

1. Centre for Health Protection, Hong Kong SAR Government. Latest situation of cases of COVID-19. Available from: https://www.chp.gov.hk/files/pdf/local_situation_covid19_en.pdf. Accessed 1 Mar 2021.

2. World Health Organization. WHO coronavirus (COVID-19) dashboard. Available from: https://covid19.who.int/?gclid=CjwKCAiAm-2BBhANEiwAe7eyFCS8TBp9v0BBj5Rl ysLobOmxwRL_p6NvscnuHkCOwNIaSIxv4DQRcRoCl8UQAvD_BwE. Accessed 1 Mar 2021.

3. Bo Y, Guo C, Lin C, et al. Effectiveness of non-pharmaceutical interventions on COVID-19 transmission in 190 countries from 23 January to 13 April 2020. Int J Infect Dis 2021;102:247-53. Crossref

4. Moghadas SM, Fitzpatrick MC, Sah P, et al. The implications of silent transmission for the control of COVID-19 outbreaks. Proc Natl Acad Sci U S A 2020;117:17513-5. Crossref

5. Struyf T, Deeks JJ, Dinnes J, et al. Signs and symptoms to determine if a patient presenting in primary care or hospital outpatient settings has COVID-19 disease. Cochrane Database Syst Rev 2020;7(7):CD013665. Crossref

6. 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

7. Lokuge, K, Banks E, Davis S, et al. Exit strategies: optimising feasible surveillance for detection, elimination and ongoing prevention of COVID-19 community transmission. BMC Med 2021;19:50. Crossref

8. European Centre for Disease Prevention and Control. Facts about influenza surveillance. Available from: https:// www.ecdc.europa.eu/en/seasonal-influenza/surveillance-and-disease-data/facts-sentinel-surveillance. Accessed 1 Mar 2021.

9. Paquette D, Bell C, Roy M, et al. Laboratory-confirmed COVID-19 in children and youth in Canada, January 15-April 27, 2020. Can Commun Dis Rep 2020;46:121-4. Crossref

10. Lai S, Ruktanonchai NW, Zhou L, et al. Effect of non-pharmaceutical interventions to contain COVID-19 in China. Nature 2020;585:410-3. Crossref

11. Du Z, Pandey A, Bai Y, et al. Comparative cost-effectiveness of SARS-CoV-2 testing strategies in the USA: a modelling study. Lancet Public Health 2021;6:e184-91. Crossref

12. Reimer JR, Ahmed SM, Brintz B, et al. Using a clinical prediction rule to prioritize diagnostic testing leads to reduced transmission and hospital burden: A modeling example of early SARS-CoV-2. Clin Infect Dis 2021 Feb 23. Epub ahead of print. Crossref

13. Bandyopadhyay S, Baticulon RE, Kadhum M, et al. Infection and mortality of healthcare workers worldwide from COVID-19: a systematic review. BMJ Glob Health 2020;5:e003097.

14. Centre for Health Protection, Hong Kong SAR Government. Consensus interim recommendations on the use of COVID-19 vaccines in Hong Kong (as of Jan 7, 2021). Available from: https://www.chp.gov.hk/files/pdf/consensus_interim_recommendations_on_the_use_of_covid19_vaccines_inhk.pdf. Accessed 1 Mar 2021.

15. Wong MC, Wong EL, Huang J, et al. Acceptance of the COVID-19 vaccine based on the health belief model: A population-based survey in Hong Kong. Vaccine 2021;39:1148-56. Crossref

16. Danchin M, Biezen R, Manski-Nankervis JA, Kaufman J, Leask J. Preparing the public for COVID-19 vaccines: How can general practitioners build vaccine confidence and optimise uptake for themselves and their patients? Aust J Gen Pract 2020;49:625-9. Crossref

17. Kunin M, Engelhard D, Thomas S, Ashworth M, Piterman L. General practitioners’ challenges during the 2009/A/H1N1 vaccination campaigns in Australia, Israel and England: a qualitative study. Aust Fam Physician 2013;42:811-5.

18. Baltrus PT, Douglas M, Li C, et al. Percentage of Black population and primary care shortage areas associated with higher COVID-19 case and death rates in Georgia counties. South Med J 2021;114:57-62. Crossref

19. Desborough J, Dykgraaf SH, Phillips C, et al. Lessons for the global primary care response to COVID-19: a rapid review of evidence from past epidemics. Fam Pract 2021 Feb 15. Epub ahead of print.

Globally, alcohol use accounts for approximately 3 million deaths every year and the overall burden of disease and injuries remains high. Health consequences aside, alcohol use incurs significant social and economic losses relating to the justice sector, workforce productivity and unemployment, and pain and suffering of the drinker and other people.

In May 2010, the 63rd World Health Assembly endorsed the Global Strategy to Reduce the Harmful Use of Alcohol (Resolution WHA63.13). The Global Strategy gives a strong mandate to the World Health Organization (WHO) to strengthen action at national, regional and global levels and envisions improved health and social outcomes for individuals, families and communities, with considerably reduced morbidity and mortality due to alcohol use and its ensuing social consequences.

Despite adoption of the political declarations emanating from high-level meetings of the United Nations General Assembly on noncommunicable diseases in 2011; inclusion of alcohol for prevention and treatment of substance abuse in target 3.5 of the Sustainable Development Goals 2030; introduction of the WHO Global Action Plan for the Prevention and Control of NCDs 2013-2020 (subsequently extended to 2030 to align with the Sustainable Development Goals 2030) and updated evidence on a prioritised set of cost-effective or ‘best-buy’ policy measures known as the SAFER initiative, implementation of the Global Strategy worldwide has been uneven, and resources and capacities falling behind the magnitude of the problems. The Global Strategy has not resulted in considerable reductions in alcohol-related morbidity and mortality and the ensuing social consequences. The levels of alcohol consumption and alcohol-attributable harm continue to be unacceptably high.

On this basis, the WHO Executive Board in 2020 requested the WHO Director-General, inter alia, “to develop an action plan (2022-2030) to effectively implement the Global Strategy to reduce the harmful use of alcohol(https://cms.who.int/teams/mental-health-and-substance-use/alcohol-drugs-and-addictive-behaviours/alcohol/global-alcohol-strategy) as a public health priority, in consultation with relevant stakeholders, for consideration by the 75th World Health Assembly in 2022” The WHO Secretariat conducted a web-based consultation (https://www.who.int/news-room/articles-detail/global-action-plan-to-reduce-the-harmful-use-of-alcohol) from 16 November to 13 December 2020 on a working document for development of the action plan open to Member States, United Nations organisations and other international organisations, and non-State actors. All relevant feedback received will be published on the WHO website.

The Hong Kong Alliance for Advocacy Against Alcohol (HKAAAA) was established under the Hong Kong College of Community Medicine in 2015 and comprises individuals from the academic, medical and health, social, and education sectors, to advocate for effective evidence-based policies and actions to reduce alcohol-related harms in Hong Kong. The HKAAAA submitted the following Position Statement in response to the WHO consultation.

Alcohol is a toxic substance with dependence producing properties, contributing to 3 million deaths and 5.1% of disease burden every year globally. It is time the health and social damage of drinking be fully recognised and effectively dealt with at global, national and health systems levels, modelled on the WHO Framework Convention on Tobacco Control.

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

All authors have disclosed no conflict of interest.

This Position Statement was submitted in response to the World Health Organization (WHO) online consultation on a working document on developing a global action plan to reduce the harmful use of alcohol (https://www.who.int/news-room/articles-detail/global-action-plan-to-reduce-the-harmful-use-of-alcohol). Relevant submissions will be published on the WHO website in mid-February 2021.

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