Mok Provides Insight on Preventing COVID-19 Peak in Hong Kong

Tony Mok, MD, associate professor of oncology and urology at Johns Hopkins Medicine

Tony Mok, MD

Hong Kong has seen a significantly lower incidence of the novel coronavirus 2019 (COVID-19) compared with mainland China, explained Tony S. K. Mok, MD, BMSc, FRCPC, FASCO—–adding that early intervention, preventive safety measures, and minimizing border traffic have been critical in preventing a peak in the number of cases and deaths.

“We have a slight surge [in COVID-19 cases], but most of them are young Hong Kong citizens returning from areas such as the United States and the United Kingdom,” said Mok. “They pick up the virus there and bring it back to Hong Kong. Currently, the local incidence rate is quite low.”

Despite uncertainty surrounding the trajectory of the viral outbreak, Mok is hopeful that the virus can be contained with long-standing collaboration.

"I see a lot of humanity in this disaster," said Mok. "People are helping each other and there is a lot of support on the internet. The dark side is that yes, this is a disease that is killing a lot of people, but on the other side, it is bringing out the good in human nature. I certainly hope that will stay when the virus is gone."

In an interview with OncLive, Mok, chairman of the Department of Clinical Oncology and Li Shu Fan Professor of Clinical Oncology at The Chinese University of Hong Kong, discussed the impact of the COVID-19 outbreak on Hong Kong and explained how the implementation of early preventive safety measures may have contributed to the low incidence rate.

OncLive: How has the COVID-19 pandemic impacted Hong Kong? What safety measures has The Chinese University of Hong Kong put in place to reduce the risk of the virus?

Mok: Severe acute respiratory syndrome (SARS) started in Hong Kong in 2003. That was a turmoil that made everybody aware about [the need for] protection [from possible epidemics].

When COVID-19 came around, most of the people in Hong Kong were on high alert.

There is a lot of debate in the United States and other countries regarding the use of masks, but it is very useful. The majority of people in Hong Kong wear surgical masks on the street. Also, hand washing has become a routine practice in Hong Kong. [These elements] helped to dampen the rate of COVID-19.

As a result [of our experience with SARS], we set up a similar kind of task force where every department has their own infection control team. Those teams will develop a specific protocol.

In oncology, there are a few areas that may be helpful to share. We set up a screening procedure so every patient who comes to the clinic will have their temperature taken and their respiratory system checked. If a patient [has a fever or respiratory complications], we are not [allowing them] to come into our cancer ward or cancer clinic. Our nurses will check the patient into a special area of the hospital that is reserved for patients with COVID-19.

We try to build a wall so that the patient who carries the virus is not taken into the cancer clinic. Therefore, screening patients is number 1.

Secondly, traffic flow is important. We are trying to minimize the number of people in the clinic. In a lot of cases, we are doing long-term follow-ups with patients. [In those cases], we’ll call them and tell them not to go out and we’ll schedule them [for a telehealth visit].

Of course, patients who are on acute treatments cannot stop [therapy], so we keep [treating those patients in the clinic]. However, do we have to give some of the regimens [as frequently] as we do? For example, we typically give immunotherapy every 3 weeks [in lung cancer]. However, [given these circumstances], perhaps we give it every 4 or 5 weeks. Overall, we’ve reduced the potential [number] of patients coming to the hospital.

These are standard procedures from administration that will help to reduce the number of cases we have to face in the oncology [ward].

What procedures have been taken in Hong Kong that other cities can learn from?

In a sense, we actually don't have a peak, which is good. The whole objective is to prevent a peak, which essentially means a rise. We don't want to see a rise [in the number of COVID-19 cases].

We talked about the importance of wearing a mask and hand washing, but the most important [measure to take] is social distancing. That is being practiced in most of the country now.

The really important thing about social distancing is when you start practicing it. It needs [to be implemented] in the very beginning of the outbreak before [many people] get infected. In turn, we saw that [social distancing was found to be] more effective. Social distancing includes the closure of all major events, which we have heard about on the news all around the world.

It is also important for a country to close its borders. There has been great controversy [regarding this] in Hong Kong because Hong Kong is a dynamic international city and closing the border is commercially risky. Of course, we cannot close the borders completely, but we have minimized [the people coming in and going out]. Every foreigner that comes into Hong Kong is quarantined for 14 days. That reduces the number of people who come in and will hopefully minimize the risk of individuals carrying the infection into Hong Kong.

How have your patients responded to these preventative new measures?

Patients have been very cooperative because this virus is affecting every single soul in the world. Surprisingly, people have been very supportive of each other. They understand the workflow and the fact that if they get infected, they will add to the workflow of the doctors. I have not heard a single complaint from my patients regarding any of the measures that have been taken.

Could you highlight some of the data that has been published on COVID-19?

Every publication and every journal [has reported] on COVID-19, but I don't think we have solid data yet. Much of the data are preliminary, such as the descriptive data regarding the epidemiology of COVID-19. Those [data] are important because we can learn about the disease, but we are still awaiting breakthrough data about treatment interventions.

Going back to patients with cancer, a lot of articles have recently been published talking about prevention measures. Fortunately, we don't have too many patients with cancer and COVID-19. Hopefully, the incidence rate will be so low that we won't have to write about it.

Have you been using telemedicine to interact with your patients? Do you see the role of telehealth growing once the virus subsides?

I’ve had many Zoom meetings since the outbreak. Telemedicine is slightly different [from the Zoom meetings I have been doing]. At this point, we have a good system where we can transfer medical data. We are not too prepared at this moment for telemedicine. We can talk to the patient on WeChat or Zoom, but just talking to the patient is different from formal telemedicine. We have to prepare ourselves with a better telehealth platform in which we can transfer medical information better. Telemedicine needs to be something more than just seeing each other face to face on a computer.

However, we are building that to some capacity. There is already some preexisting telemedicine capacity in China. There are ways for doctors to provide laboratory results and other [materials] through telemedicine in a more formal consultation format.

Are you experiencing a shortage of personal protective equipment, such as face masks or gloves?

[There are not enough supplies]. The reality is that the whole world wants [these supplies] now. In Hong Kong, we have to be cautious of how we use them.

We tried to obtain supplies early on, so we do have some currently. However, it depends on how long the pandemic will last and whether the increasing capacity is going to meet the demand.

At this moment, we are fine. The government and hospitals report on how much is available. Right now, we are estimating we have a 1- to 2-month supply. This information is important for the medical staff because we are facing patients on a daily basis. Knowing that we are backed up is important.

What modifications are being made to treatment regimens for patients with lung cancer?

Mostly at our institution, this refers to how frequently patients need to come [into the hospital]. We get used to certain schedules with a lot of regimens. However, [some agents], such as nivolumab (Opdivo), have a very long half-life. Typically, it is given every 2 or 3 weeks because that is what was established in the study. There are already some data supporting that we can give nivolumab farther apart. Right now, we are doing this without absolute data, but it is supported by basic genetic data that shows nivolumab has a very long half-life. Therefore, we are reducing the frequency of treatments which in itself has reduced the workload. Also, a lot of maintenance therapies, such as pemetrexed, are being reduced if the patient is stable. Certainly, whether the change in schedule will have an impact on efficacy will be difficult to study.

What lessons can be learned from this pandemic that may be applicable to future practice?

I'm not an infectious disease physician, so I am not able to comment on how well we can be prepared. But on a scientific basis, we want a vaccine for every time [an outbreak] comes around. By the time the vaccine is ready, the disease is gone. There must be a better way.

Therefore, what is the quickest way to obtain a vaccine? What is the best channel by which to get a vaccine approved? Right now, [we are estimating] that developing a vaccine [for COVID-19] will take 1 year to develop, study, and approve. Hopefully this outbreak will not last a [full] year.

We have to have a better mechanism such that when something like this occurs, we have a fast track way to prepare.