What we can learn from the “second wave” of coronavirus cases in Asia

What we can learn from the “second wave” of coronavirus cases in Asia
The flags of China and Hong Kong fly at half-mast at the Golden Bauhinia Square in Hong Kong to mourn people who died of Covid-19 on April 4. Zhang Wei/China News Service/Getty Images

Hong Kong, Singapore, and Taiwan show the challenges of fighting this pandemic.

Right now, if you fly to Hong Kong, you’ll have to turn over your saliva. That is, if you’re already a resident. If not, you can’t come in at all.

The saliva, of course, is for a coronavirus test, one of the measures the Hong Kong government has adopted — including banning non-residents from entry, and giving tracking bracelets tied to an app to those arrivals who are allowed in — to try to control a small wave of new coronavirus cases that arose in recent weeks.

Hong Kong isn’t the only place in Asia that did a good job controlling its initial coronavirus outbreak only to see a resurgence of coronavirus cases. Singapore and Taiwan were both seen as examples of how to handle the coronavirus outbreak: stanching the growth of infections, while largely keeping their economies open.

Instead of widespread lockdowns, these places relied on tools such as robust testing, contact tracing to identify people who came in contact with infected people and may have been exposed to the virus, mass surveillance, isolation of the ill, and stringent travel restrictions. It wasn’t exactly life as normal, but it wasn’t a total shutdown, either.

This has changed, to varying degrees, as the threat of new cases rises both within these places’ borders, and without.

Hong Kong had to adopt more stringent social distancing measures at the end of March, including strengthening travel rules and closing bars. Singapore avoided mass closures at first, but has now imposed lockdown measures until May 4 and temporarily closed schools. Taiwan hasn’t shut down, but it has put really stringent travel restrictions in place.

And this may be the world’s new normal, at least until an effective medical therapy is widely available that lessens the intensity of the disease, or the world acquires immunity, most likely through a vaccine. Social distancing measures may be a recurring tool — intensifying, easing, and intensifying again as outbreaks surge, diminish, and surge again.

Because as long as the coronavirus is spreading somewhere, it can spread everywhere. That is why no country has beaten the coronavirus yet.

“We will not get rid of the disease until every country has a system to detect the disease and stop it near the origin, as or as close to the origin as possible, before it spreads,” Olga Jonas, a senior fellow at the Harvard Global Health Institute who formerly helped to coordinate the World Bank’s response to avian and pandemic flu threats, told me.

“The weak links have to be addressed in every country,” she added.

Why Hong Kong, Taiwan, and Singapore saw another coronavirus wave — and will likely see more

Hong Kong’s bump in coronavirus infections, beginning in March, was relatively small, and largely attributed to people returning to the territory from places overseas where the coronavirus was then spreading rapidly, such as the United Kingdom, Europe, and the United States.

That created tensions in the territory, as residents blamed returning expats for the spread. Authorities also identified small clusters of local transmissions, including at Lan Kwai Fong, a district in Hong Kong with a lot of bars that’s popular for its nightlife.

In response to the new rise in cases, Hong Kong on March 25 fully closed its borders to non-residents for a two-week period, allowing exceptions for visitors from mainland China, Macau, and Taiwan as long as they hadn’t traveled anywhere else in the 14 days prior.

Schools had already been closed in Hong Kong until at least April 20, but Hong Kong Chief Executive Carrie Lam added new measures at the end of March, including a ban on gatherings of four or more people and the closure of arcades, gyms, and movie theaters. Restaurants had to limit the number of people allowed inside, take the temperatures of everyone entering their establishments, and provide hand sanitizer to patrons.

In April, all bars and pubs were also ordered to close, followed on April 10 by beauty and massage parlors. All of these orders will be in effect until at least April 23. Hong Kong’s government also extended travel restrictions indefinitely and ordered that, starting April 8, all travelers arriving to Hong Kong, symptomatic or not, would need to undergo a coronavirus test and then enter a 14-day quarantine.

As of April 17, Hong Kong has just over 1,000 coronavirus cases (up from 400 when the new restrictions began in late March), with just single-digit increases by the day. At least one Hong Kong lawmaker has said it may be time to loosen some restrictions again.

Taiwan, too, attributed its spike to imported cases, warning Taiwanese people to avoid traveling outside the island and risk bringing the disease back. On March 19, Taiwan barred all foreign nationals (with some exceptions, including for diplomats) from entering the island. The government also barred any travelers from transiting through Taiwan, and required any returnees to quarantine for 14 days.

As of April 14, Taiwan had nearly 400 total cases, 338 of which came from outside the island. Though it recently had no new cases for the first time in more than a month, Taiwan is not letting up travel restrictions until the pandemic is under control elsewhere.

“Of course, we hope it has passed,” Taiwan’s Health Minister Chen Shih-chung said at a press conference this week, according to Reuters. “But we still need to be on our guard. Of course we feel happy at no new cases today.”

Singapore also dealt with a wave of imported cases. Now, though, the city-state’s latest rise in cases is being attributed to migrant workers, who are often crowded together in dormitories. Singapore has taken strict measures to sequester these workers, including by putting four facilities, containing some 50,000 people, under quarantine. The government is also housing healthy workers who work in essential services in separate facilities, so they can continue to work.

Singapore also instituted in early April what it called a “circuit breaker” — basically a partial lockdown by a much nicer name. Singapore hadn’t needed to do that before, but as it saw cases surge past 1,000, it embraced more stringent measures. Now, people can only go outside for essential services, to visit the doctor, or do solo exercise, and are required to keep their distance. Restaurants are allowed to stay open for takeout or delivery only. Schools are closed. These measures will be in place until May 4.

Singapore has over 5,900 total confirmed cases as of April 18; infections jumped more than 1,000 in just three days this week, a sign that the country does not yet have infections under control again. As some critics have pointed out, Singapore’s treatment of migrants, and reluctance to let them put real roots down there, likely helped create this crisis that threatens the rest of the city-state, too.

“Suppression and lift” might become the new normal. That is, if the world can get there.

Gabriel Leung, an infectious disease epidemiologist and dean of medicine at the University of Hong Kong, described Hong Kong’s strategy as “suppression and lift” in a New York Times op-ed on April 6.

“[T]o see us through the next year or more, we must all prepare for several cycles of a ‘suppress and lift’ policy — cycles during which restrictions are applied and relaxed, applied again and relaxed again, in ways that can keep the pandemic under control but at an acceptable economic and social cost,” Leung wrote.

Hong Kong, Singapore, and Taiwan are essentially following this course to varying degrees. They’re using testing, contact tracing, travel restrictions, and social distancing measures as something like a brake, in Leung’s words, to be applied when infections begin to surge, and then loosened up as it comes under control again. It requires constant reaction, adaption, flexibility.

“The bottom-line is that responding appropriately to the epidemic situation is a dynamic process requiring adjustments — loosening and tightening — as is appropriate,” Keiji Fukuda, director and clinical professor of the public health department at the University of Hong Kong, told me in an email.

“While recognizing we are all hoping to get back to normal as soon as possible, realistically, the optimal approach for countries and places will be to apply a dynamic process of monitoring and adjustment until vaccine becomes widely available,” he told me.

But those social distancing measures can be targeted much more effectively if the government has a better idea where the outbreaks are occurring.

“The take-away for me is that it has to involve case-based interventions,” Jennifer Nuzzo, an epidemiologist at the Johns Hopkins Center for Health Security, said, of any effective strategy to control coronavirus. “Case identification, case isolation, contact investigation, and monitoring of contacts. Repeat.”

Nuzzo added that not every country has to do all the measures, “but every country that has been successful has had aggressive case-based interventions.”

Of course, Hong Kong, Singapore, and Taiwan have advantages that a lot of other places don’t have. They are relatively small — Hong Kong and Singapore each have populations slightly smaller than New York City; Taiwan has the largest population of the three, at about 23 million. Geography helps, too; Taiwan and Singapore are small islands, so it’s easier to control who’s coming across their borders than it is for the United States and Europe.

“Advantages are certainly on geography, wealth, medical facilities and a relatively compliant population that follows the rules,” Ramanan Laxminarayan, director and senior research scholar at the Center for Disease Dynamics, Economics and Policy at Princeton University, wrote in an email.

These places, especially Hong Kong and Taiwan, also learned a lot from past virus outbreaks. “Hong Kong has invested heavily in preparedness for emerging infections since SARS in 2004,” Ben Cowling, professor at the school of public health at the University of Hong Kong, told me in an email. “The population are incredibly well informed about public health and have voluntarily changed their behaviors to complement the social distancing policies implemented by the government.”

So does this mean some form of social distancing is inevitable until there is a vaccine, or an effective treatment to lessen the ferocity of the coronavirus? The answer, sadly, is maybe. As experts pointed out, no country has yet been able to totally stop the return of coronavirus.

“This is a reminder that this virus is not going to go away. You have to look at the experience of the last four months in Wuhan to realize that even the most extensive population-movement restrictions ever put in place for a public health issue in modern times has not ended virus transmission within China,” Michael Osterholm, an infectious disease epidemiologist at the University of Minnesota, told me.

Things like antibody tests will help people and governments know who was infected, and whether they have immunity to the disease, which might also help to open up countries. But social distancing — the lifting and easing — might still need to exist.

Because even if countries can successfully test and trace, these tools are much more effective if every country is doing them. As long as the pandemic is active and alive somewhere around the world, the risk of new cases emerging is everpresent.

“Epidemic or pandemic control in the world very much depends on the weak links,” Jonas, the scientist at Harvard, said. “The whole system is as good as its weakest links.”

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