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A literature review of the reform of infection control and

practices of public hygiene in Hong Kong and the Mainland
China
Lam, Hon-chung;
Lam, H. []. (2014). A literature review of the reform of
infection control and practices of public hygiene in Hong Kong
and the Mainland China. (Unpublished thesis). University of
Hong Kong, Pokfulam, Hong Kong SAR. Retrieved from
http://dx.doi.org/10.5353/th_b5320415.
2014

http://hdl.handle.net/10722/206930

The author retains all proprietary rights, (such as patent rights)

and the right to use in future works.

A Literature Review of the Reform of Infection Control and Practices

of Public Hygiene in Hong Kong and the Mainland China

Submitted by
Lam Hon Chung
For the degree of Master of Public Health
at The University of Hong Kong
in August 2013

Abstract
Infectious diseases control is one of the most important medical issues since the
outbreak of SARS. The Hong Kong and China governments are awaked from the
miserable event and a series of reforms relevant to infection control and public
hygiene are thus established in order to face further challenges and potential threat in
the future. In terms of strengthening health care system, re-orientation of healthy
public policy, increment of community participation, building personal health skills as
well as reinforcement of global communication and cooperation, there are drastically
improvements regarding capacity for combating hazards due to emergence of novel
infectious agents and diseases in both regions. This literature review aims to portrait
current operating measures for infection control and public health practices in Hong
Kong and the mainland China, and provides evaluation of the effectiveness and
feasibility of these activities.

Declaration

I declare that this project and the research work thereof represents my own work,
except where due acknowledgment is made, and that it has not been previously
included in a thesis, dissertation, or report submitted to this University or to any other
institutions for a degree, a diploma or other qualifications.

Signed ________H.C.Lam____________

Lam Hon Chung

Acknowledgements

I would like express my gratitude to Prof Ben Cowling for his kind guidance and
recommendation throughout the preparation of this project. I would also like to thank
my family and friends for their support and encouragement of this master of public
health program.

Table of Contents

Abstract 1
Declaration ... 2
Acknowledgements .. 3
Table of Contents ...... 4

Introduction ..... 5
Objective ..8
Methodology ... 9
Lesson from the SARS ........11
Infection Control and Public Hygienic Practices in Hong Kong ....12
Health Care System .....12
Infection Control Measures in the Past and the Present ......13
Evaluation of Efficacy of Infection Control Activities .. 17
Public Health Practices .. 19
Infection Control and Public Hygienic Practices in China 21
Health Care System 21
Development of advanced Infection Control Measures . 22
Evaluation of Efficacy of Infection Control Activities .. 25
Strategies for Disease Prevention in the Public . 30
Limitation of this Review .. 33
Conclusion: Future to the Practices for Infectious Diseases in Hong Kong .. 34
Learn from the Review 36
References .. 38

A Literature Review of the Reform of Infection Control and Practices of Public

Hygiene in Hong Kong and the Mainland China

Introduction
Infectious disease is a longstanding topic that affect globally from the past to the
present. By the second half of the 20th century, the prevalence of a number of deadly
infectious diseases is strikingly decreased because of the improvement of hygiene and
diagnostic methods, and the newly developed drugs and vaccines.20 Today, infectious
diseases remain one of the chief cause of death worldwide, and the emergence of new
pathogens is being the main underlying reason. There are miscellaneous types of
existing pathogens, associated with different and specific transmission modes, which
can seriously produce harmful to the human. For example, HIV and hepatitis B virus
are blood-borne viruses while cholera and tuberculosis are transmitted by oral-fetal
route and the air respectively. The number of notifications for the main infectious
diseases reported in 2011 in Hong Kong and China is provided in table 1.3,6

The health care system reform, especially in the way of infectious control and
practices of public hygiene, was evolved after the outbreak of Severe Acute
Respiratory Syndrome (SARS) in both Hong Kong and China in 2003. There was
underestimation of the catastrophic consequences of the newly emergence of
infectious diseases for both governments in advance. Although there was presence of
high technology and system for public health surveillance, a few hundreds of life was
lost by the disease. Since SARS is a communicable disease which appears suddenly
and spreads in China, together with Hong Kong being shaken by the event, it will be
discussed mainly with influenza in this review as influenza also induces significant
threat in our society in this century.
5

There were some common and important factors between these two districts that
would contribute to the worldwide infectious disease burden. These factors include
crowded population, frequent international travel and trade that diseases may affect
distant populations by importing an exotic infectious agent, as well as closely
interaction of people with wide animals in China.23 Also, unlimited pet trade,
urbanization, deforestation, environmental and climatic changes are other reasons that
make up the problem. As a result, eliminating these factors may probably the first and
essential step to prevent and control the emergence and spread of infectious diseases.

Table 1. The number of notifications of the main infectious diseases reported in 2011
in Hong Kong and China.3,6

Diseases

Hong Kong

China

82
61
0
13632
2

20450
237930
309
24

Community-associated Methicillin-resistant
Staphylococcus Aureus Infection
Dengue Fever
Enterovirus 71 Infection
Gonorrhea

624

30
68
-

120
97954

Influenza A
Japanese Encephalitis
Leptospirosis
Malaria

0
1
3
41

9360
1625
396
4088

Measles
Meningococcal Infection
Poliomyelitis
Rabies
Scarlet Fever
Schistosomiasis
Severe Acute Respiratory Syndrome
Syphilis
Tuberculosis

12
8
0
0
1526
0
4794

9943
228
20
1917
63878
4483
395182
953275

Typhoid and Paratyphoid Fevers

Viral Haemorrhagic Fever
Viral Hepatitis
Whooping Cough

55
0
240
23

11798
10779
1372344
2517

Acquired Immunodeficiency Diseases

Amoebic and Bacillary Dysenteries
Anthrax
Chickenpox
Cholera

Objective
It is the first study that summarizes and compares the difference of infection control
and public hygiene between Hong Kong and the mainland China. The aims of the
review are to evaluate the effectiveness of newly established control and preventive
measures after SARS, and to emphasize the importance and consequences of each
level of health practices in the society. As a result, it hopes to enhance the awareness
of individual and communal participation for the activities against emergence of new
pathogens, and prepare well for everyone to face future potential challenges.

Methodology
The relevant literatures were found by conducting searches of four electronic
databases Cochrane Library, MD Consult, Medline and PubMed with
miscellaneous combinations of the keywords used including health care system,
infection control, public health, reform, Hong Kong, China, the
mainland, SARS, H5N1 , H7N9 and influenza. While the Chinese journals
were searched through baidu and the database of Wan Fang, with the keywords
consisted of infection control, measures, effectiveness and evaluation were
used.

Regarding inclusion criteria, the selected searched results were restricted to articles
with English and Chinese languages and the studies must be taken in Hong Kong or
China. The titles and abstracts of the searched articles were briefly screened, which
was followed by retrieving the full text for those which were useful and topic-related.
The reference lists of the retrieved articles were also reviewed and checked for any
suitable literatures.

For exclusion criteria, any article without the full test provided was excluded and
ignored from the search because the detailed information of the studies included could
not be obtained and inspected. Also, the interventions and infection control measures
performed outside clinical environment in the study found in Chinese articles were
excluded in this review.

A total of 17 English articles from different journals, including New England Journal
of Medicine and Hong Kong Medical Journal, and 3 Chinese articles were found and
quoted. These articles were published between January 1st 1995 and May 31st 2013.
9

Other references came from the webpage and documents published by Centre for
Health Protection, Department of Health in Hong Kong and World Health
Organization, as well as the web pages of the Ministry of Health of The Peoples
Republic of China, Chinese Center for Disease Control and Prevention and National
Health and Family Planning Commission of the Peoples Republic of China. Two of
the studies found in Chinese articles were cross-sectional whereas the other was a
retrospective case-control study.

10

Lessons from the SARS

Hong Kong has encountered a black period during the first half year in 2003. The
SARS began in the Guangdong Province of China by November in 2002, and
subsequently spread to Hong Kong and 32 other countries or regions rapidly.2 There
were 8447 cases of SARS worldwide and 21 percent of them were health care
workers.15 In Hong Kong, totally 299 life were lost from this unfortunate episode, and
many of them were died with acute respiratory distress syndrome.

Approximate one-half of patients got the disease in clinics, hospitals or nursing homes
through droplets that remain suspended in the air.15 The most likelihood reason for
health care workers to get infected was direct contact with respiratory secretions and
other body fluids from the patients. The officials of the Department of Health and the
hospital authority were gradually awaked by the severity of the diseases and
immediate to implement series of hospital and health policies for dealing with the
event. With lack of experience and trained specialists, the situation was nearly
collapsed combined with the disappointed outcome until climatic change in July.

Infectious disease can not be discriminated by boundary or region and it is a

ubiquitous threat in every country in the world. The SARS experience teaches us
regarding the importance of international collaboration, privileged access to all
countries, and strong but politically neutral global leadership.24 It helps us to
understand the catastrophic event caused by infectious disease and also the value of
international solidarity when facing a global mutual conundrum is inspired.

11

Infection Control and Public Hygienic Practices in Hong Kong

Health Care System
In Hong Kong, the public health care services are provided by the Department of
Health, which is under the Food and Health Bureau, and also Hospital Authority. The
Department of Health represents the health adviser of Hong Kong government and is
responsible for health legislation and policy. Safeguard the health of the community
by means of providing preventive, promotive, curative as well as rehabilitative
services is its chief duty and work. The other health services provider, the Hong Kong
Hospital Authority, is a statutory body which is established to manage all public
hospitals and institutions in Hong Kong. Although there are some primary medical
services provided by the Authority, its predominant role is delivering secondary and
tertiary specialist care and also rehabilitation services through its hospitals and
facilities arranged in several clusters. The funding for its operation mainly comes
from the government. On the other hand, a private health care is supplied by 11
private hospitals and a number of clinics and institutions. Over 70 percent of all
outpatient consultations are provided by the private general practitioners. 7 However,
the medical fees in this kind of services are given by the patients themselves rather
than supported by the government.

12

Infection Control Measures in the Past and the Present

It is recommended that the current focus on curative and hospital-based care in Hong
Kongs health care system should be shifted to concentrate on preventing diseases and
promoting healthy lifestyles.5 There is a long-standing and sophisticated health care
infrastructure in Hong Kong, which consists of comprehensive immunization
programs, accessibility to safe food and water, excellent system of sewage disposal,
high quality of health care services and good public health surveillance.26 However,
the outbreaks of H3N2 pandemic and avian influenza H5N1 infection has alerted us
that the existing measures for infectious diseases control may be challenged by the
newly emerging infectious agents. Smith et al

20

stated that in addition to study

molecular biology and genomics to understand the origins and pathologies of

infectious agents, analysis of infectious disease ecology and parasite-host interaction
are also indispensable for successful control strategies. In this way, the theoretical
insights from ecology are beneficial for control of diseases which are initiatives for
humans, livestock and wildlife.20 It is demonstrated by mathematical models for
SARS showing that 5-10% of infective contacts that occur before symptoms appear
are of particularly importance so that isolating symptomatic patients and quarantining
their contacts are the main step to determine the effectiveness of the control
measures.20

Lack or insufficient of infection control measures or failure to comply with its

precautions could result in large-scale hospital outbreak and unexpected outcome.19
During the period of SARS outbreak, a number of infection control practices were
employed rapidly because of the increasing number of cases of infection in the
healthcare workers, patients, citizens and visitors. These practices include dedicated
SARS hospitals, management measures such as closure of hospitals and restriction of
13

hospitals visitors, promotion of hand-washing and use of masks and other personal
protective equipment, prompt isolation of SARS patients in negative pressure rooms
along with rapid identification and management of their contacted persons,
environmental decontamination by using disinfectants, education and intensive
training regarding infectious diseases control, as well as providing psychological
services for those affected and experienced anxiety, stress and other negative impacts
from the diseases.19 Moreover, health care workers were barred from work when fever
or respiratory symptoms were found within 10 days of exposure to SARS in them,
and they were forced to take sick leave for a full 10 days before these symptoms had
resolved.15 Nevertheless, unfortunately, many people died eventually from this
episode, and this tragic event led to an increased awareness of infection control and
reinforcement of the present practices thereafter. The Centre for Health Protection
(CHP), which was under the Department of Health, was thus established in 2004. It is
a public health agency which its duties are prevention and control of communicable
and non-communicable diseases in Hong Kong. In order to cope with the health threat
from emerging and re-emerging communicable diseases, the capacity of disease
surveillance was increased by using the Communicable Disease Information System
(CDIS), which was an information system to incorporate with state-of-the-art
technologies including automated electronic data transfer, geographic information
system, advanced statistical packages and functions to support investigation and
sharing of information.4 The Sentinel Surveillance System and laboratory surveillance
were also applied for this purpose. To enhance capacity of infection control and
laboratory diagnosis by maintaining an up-to-date scope of laboratory tests and
quality monitoring, setting up emergency response plans, implementing vaccination
programs, conducting risk communication and health promotion, and developing
appropriate research and training schedules through the established Research Fund
14

were also the aims and roles of the CHP.4 In addition, the new Prevention and Control
of Disease Ordinance was introduced in 2008, which fortified the legislative
framework of infection control and brought the legal provisions to meet the
requirements of the International Health Regulations of the World Health
Organization.4 Furthermore, the Board of Scientific Advisers and Scientific
Committees were formed to devise comprehensive and effective strategies that
reinforce the local health protection system by means of active participation and
professional exchange among local experts, while regional and international
cooperation was undergone by working closely with the corresponding departments in
the Mainland and Macau as well as WHO to enhance the abilities of coordination and
exchange of real-time information, improvement of the notification system, sharing
experience and expertise and mutual handling with the spread of infectious diseases.4
Table 2 showed the infection control measures implemented during pre- and
post-SARS periods in Hong Kong. 4

15

Table 2 showed the infection control measures implemented during pre- and
post-SARS periods in Hong Kong.4

Pre-SARS
Hong Kong

Post-SARS

1. Basic measures such as 1.

hand-washing
and
mask-taking
2.
2. Low priority in health policy
of government
3.

Centre for Health Protection

established in 2004
Communicable
Disease
Information System used
Maintain up-to-date scope

3. Little resources in this field

4. Absence of clear leadership
from
infection
control 4.
doctors
5. Insufficient trained infection 5.

of laboratory tests and

quality monitoring
Improvement of notification
system
Emergency response plans

control nurses
6.
6. Weak
laboratory-based
surveillance
7.
7. Poor
developed
links

Increase
vaccination
programs
Three response levels for
risk assessment of influenza

between
hospital
and
community infection control 8.
teams
8. Inadequate communication
between HK and the
mainland
9.

pandemic is set up
New
Prevention
and
Control
of
Disease
Ordinance introduced in
2008
The Board of Scientific
Advisers and Scientific
Committees formed
10. Works closely with Macau,
Mainland and WHO

16

Evaluation of Efficacy of Infection Control Activities

Since the outbreak of SARS in 2003, there was no significant burden and threat
originated from infectious diseases in Hong Kong. Until the first day at May in 2009,
the first case of pandemic influenza A virus subtype H1N1, or simply called swine flu,
was confirmed locally in a Mexican aged of 25 who came to Hong Kong from
Shanghai.11 Prior to the appearance of this event, Hong Kong government had
declared swine flu as a notifiable disease because of the novel flu epidemic in Mexico
and the Untied States. Avoid to get to the affected places was also advised by the
government officials. A series of surveillance measures at the boundary control points
were set up simultaneously to detect travelers who had fever and respiratory
symptoms, while they would be monitored and quarantined once being suspected with
the infection.

The first case was announced by Hong Kong Chief Executive according to the test
results generated by the Department of Health and the University of Hong Kong. At
the same time, the influenza pandemic alertness level had raised from serious
response level to emergency response level. The infected man was delivered and
isolated with antiviral drugs offered in the designated Princess Margaret Hospital, and
the hotel he previously stayed was closed and quarantined for seven days. The people
who had made contact with him were endeavor to trace back.

The patients who met both epidemiological and clinical criteria were defined as
suspected cases initially, and the Governments Public Health Laboratory was
responsible for free-testing of their specimens by using polymerase chain reaction
method. All kindergartens, primary schools, childcare centers and special schools
were closed for 2 weeks when the first non-imported case was determined, and the
17

time of closure was prolonged thereafter.25 There were more than 20,000
laboratory-confirmed cases between May and September in 2009, and 54.6% of them
were school-age students.11

Based on the potential threat brought by swine flu, The Department of Health in Hong
Kong had launched a large-scale human swine flu vaccination program and thus
introduced a huge amount of vaccines during the period of human swine influenza
pandemic. The vaccines were prepared and targeted specific for highly susceptible
population such as health care workers, children and elderly. It was surprise that the
uptake rate was particularly low even in the group of health care professionals
because of the early report of the development of side effect Guillain-Barre syndrome
in a case who received vaccination. In addition, it was found that there was late
manifestation of the diseases so that the optimal time to take vaccination was missed.
Moreover, influenza was always regarded as a mild disease by the public as it could
recover spontaneously without treatment and so the severity and virulence of its
effects were overlooked easily. Owing to all of these reasons, it was controversial that
there was waste of social resources as the needs for the vaccine stockpile was much
lower than the actual expected. However, the consequence caused by this novel virus
was not thoroughly known at that moment, and the lessons from the past flu
pandemics in the last century and SARS demonstrated that prevention was better than
cure of the disease, which was the dictum of public health principle.

18

Public Health Practices

The largest challenge for public health practice outside the health sector is part of the
measures are determined by those with responsibility for economic and social policy,
such as politicians, industrialists, educators and economists, and the difficulty comes
from the well-coordination between different sectors for initiation of effective control
measures and guiding the community to take role for prevention.1

Active participation of each individual in a community and society is thereby crucial

and determinant for the persistence of a healthy public health practices. At present,
closely monitoring the integrity of sewage disposal systems is carried out not only by
the government, but also contributed by the organization, residents and every person
involved. The effort to maintain a clean street is achieved by frequent cleaning and
reduction of spitting phenomenon because of its increased penalties. In addition, the
Center for Health Protection of Department of Health has developed a number of
promotional materials and regularly organizing hand hygiene campaign, and it is
found that people are more concentrated on strict hand washing during their daily life,
especially prior to eating, after toileting and contact with their ill relatives or friends.
Surgical masks are also taken when getting to high risk places such as hospitals and
clinics, or during suffering from flu even with only mild symptoms. The household
utensils and bedding are also washed regularly and thoroughly.

Broadly promotion of building up the body immunity against infection by the local
health organizations and government through a balanced diet, smoking rejection and
sufficient exercise, rest and sleep by using mass media, newspaper, radio, booklets
and pamphlets are popular recently. It can enhance knowledge and awareness of good
health concept in all people with different age groups and educational backgrounds,
19

which in turn leading them to get enrolled in healthy activities and lifestyles.

Communicable diseases are easily spread through close person-to-person contact and
subsequently cross-infection between children in schools as children are young to take
own proper care and their body immunity are not fully developed. As children spend a
third or a fourth of time each day in school, teachers are required to take responsible
for careful observation of behaviors and activities of children besides teaching only.
Because schools are microcosms of the community, the model of the Health
Promoting Schools and Healthy Schools Award Scheme launched by one of the
local university are successful to offer opportunities and training to children to
develop and practice the skills in supporting a healthy lifestyle, which is beneficial to
the health status of the whole society in the future.1

Furthermore, vaccinations for seasonal influenza are freely provided to the some
target groups such as health care workers, poultry workers and pig-farmers. Students
can also receive financial assistance for hepatitis vaccines through a health scheme
promoted in schools or universities. The incorporation of seven-valent and ten-valent
pneumococcal conjugate vaccine in 2008 and 2010 respectively into the Childhood
Immunization Program has provided striking benefits and protection in children
against

pneumococcus-induced

diseases.18

Since

2010,

thirteen-valent

pneumococcal conjugate vaccine has also been registered and available in Hong Kong.
These vaccination programs allow a considerably decline in the relevant morbidity,
associated with the reduction of 60%, 21% and 11% among children aged below 2
years, below 5 years and individuals of all ages respectively.18

20

Infection Control and Public Hygienic Practices in China

Health Care System
In contrast to the medical financial policy in Hong Kong, a free market system is
currently carried out in China.9 The operation of the system of privatization is similar
to that of Hong Kong private health care services, in which the expenditures of all
levels of health facilities are rely on the fees and insurances from the users, while the
China government delivers relatively little amount of financial support to the public
hospitals.9 This market-based financial system, however, create an unequal access to
health care between the rich and poor. The problem is exacerbated by the
uncoordinated policies and roles between the government and public hospitals which
results in overuse of drugs and tests as well as insufficient quality of medical care.
Nevertheless, the strong and rapid economic growth in China makes the industry of
health care services and facilities to achieve international levels in some large cities
such as Beijing and Shanghai. Meanwhile, because of the more resources
concentrated in these higher developed areas, there is a greater difference of the health
care quality created between the large cities and the secondary and tertiary cities and
also villages.

21

Development of advanced Infection Control Measures

The great contributions obtained from the significantly reduction in rates of infectious
diseases in recent years in China were obvious and encouraged. This was the one of
the reasons that resulted in the decrease of the infant mortality rate from 200 per 1000
live-births in 1949 to 23 per 1000 in 2005, as well as increased average life
expectancy of the Chinese people from 35 years at birth in 1949 to 63.2 years and 72
years in 1970-75 and 2000-05 respectively.23 However, the occurrence and outcome
of SARS drew attention to considerably weaknesses in the diseases surveillance and
response systems and thereby brought the entire country and government to take
actions to renew an obsolete and inappropriate policies for the infection control. A
variety of general strategies consisted of improvement of the safety of blood
collection, amelioration of water supply and sanitation, and control of populations of
mosquitoes, mice and other vectors showed effectiveness of substantial lowering the
incidence of infectious diseases transmitted through food, water, blood and vectors.

The China Information System for Diseases Control and Prevention (CISDCP), which
was the worlds largest internet-based disease reporting system, was introduced by the
Chinese government after the SARS epidemic.23 Instead of intricate procedures by
firstly submitting the case report forms to local or district Center of Disease Control
(CDC) department and followed by submitting the summarized reports to the national
CDC, this innovated system could allow the diseases to be reported in real time so
that the hospitals and clinics could report the cases through the internet directly and
immediately. As a consequence, the public health officials could identify disease
outbreaks at the shortest time and implement any required strategies.

Moreover, the Ministry of Health has also developed a surveillance and response
22

system for early detection of newly emerging infectious diseases.23 For instance,
hospitals are needed to report the case within 24 hours through the CISDCP once the
patients profile meets the criteria of pneumonia of unknown cause. When the national
CDC receives and identifies the reported case, the provincial and lower-level CDC
and hospitals will be actively contacted to ensure that the case is diagnosed and
treated properly. Table 3 showed the infection control measures implemented during
pre- and post-SARS periods in China.12,23

23

Table 3. The infection control measures implemented before and after SARS in the
mainland China.12,23

Pre-SARS
China

Post-SARS

1. Same as Hong Kong

1. The China Information System for
2. Country-based monthly
Diseases Control and Prevention
reports sent by post
(CISDCP) is formed
between 1950 and 1985
2. A sophisticated surveillance and
3. Country-based monthly
response system is developed by the
reports sent by electronic
Ministry of Health
means between 1985 and 3. Hospital-based
real-time
reports
2003
exchanged through internet from 2004
4. Amendment of the Law of the PRC on
the Prevention and Treatment of
Infectious Diseases in 2004
5. Improvement in infrastructure for
infection control and public hygiene
by different levels of government
6. Increment
of
infection-specific
hospitals, clinics and number of
relevant health professionals
7. Establishment
of
system
for
supervision of infection in the society
8. Ten-times financial support increased
in 2012 compared with 2003
9. Increase vaccination programs from
2007
10. Improvement of insurance policy to
protect patients with infectious
diseases
11. Enhance multi-directional abilities in
laboratory

24

Evaluation of Efficacy of Infection Control Activities

A series of reforms after 2003 undoubtedly brought a new era and phenomenon for
infection control activities in every group of people in a society. A huge amount of
budget, human resources and time were invested in this public health practices. The
efficacy of these control measures were always encouraging and inspiring, but
sometimes the outcome were disappointed alternatively. In 2004, an Antibiotic
Guideline for the control and prevention of multi-drugs resistant organisms was
introduced by the Chinese Ministry of Health.21 In spite of the establishment of this
administrative guideline, the habit and atmosphere of the antibiotic applications
remained unchanged between 2002 and 2006, with approximately 75% and 80% of
patients suffered from seasonal influenza and inpatients respectively were prescribed
with antibiotics in the hospitals. This would exacerbate the existing problem within a
crowded Chinese population, and the worst consequence is the global emergence of
these micro-organisms which are very difficult to be treated.

On the other hand, the recent occurrence of a novel avian-origin influenza A (H7N9)
virus in eastern China during February and March 2013 gives a challenge to the
current operating surveillance and reporting system for infectious diseases. The
suspected cases were first admitted to the hospitals specific for infection, and were
identified with the Chinese surveillance system for unexplained origin of pneumonia
which was developed in 2004.13 For the first three suspected and hospitalized patients
reported in Shanghai City and Anhui Province, their demographic, epidemiologic,
virologic and clinical characteristics, including exposure to poultry or swine within 2
weeks before the onset of illness, recent visiting to a live animal market and
information provided by their relatives, were collected immediately and accurately
with a standardized surveillance reporting form. The samples by throat swab were
25

obtained and sent to Shanghai Public Health Clinical Center, the Centers for Disease
Control and Prevention (CDC) in Shanghai and Anhui.8 These specimens were then
performed with some preliminary tests for identification of respiratory agents, which
were followed by being delivered to the Chinese National Influenza Center in Beijing
on March 25, 2013 for laboratory testing.8 The cases were thereafter confirmed with
H7N9 infection by ways of isolation of H7N9 virus and full genome sequencing,
together with extraction and demonstration of viral RNA through the technique of
specific real-time reverse transcriptase polymerase chain reaction from the respiratory
specimens. While the tests were undergoing, the patients suspected with infection
were provided with antiviral treatment such as oseltamivir promptly. Meanwhile, the
control measures combined of rapid isolation of the cases, active monitoring of close
contacts for 7 days for observation of presence of symptoms as well as droplet
precautions by health care professionals were all established at the first time in
hospitals in order to prevent the risk of transmission through human-to-human for this
virus.

The same procedures were carried out in the later occurrence of cases, and each case
was announced to the public through the media and reported to the neighboring
countries and regions no matter in the period before and after confirmation. Although
the outbreak has spread to other province and regions, the diseases were
under-controlled and the number of infected individuals may even be more than the
announced cases if the appropriate strategies were not initiated rapidly. The public
health practices are conspicuously ameliorated comparing with SARS epidemic and
one of the reasons is attributed to the reinforcement of the communication,
cooperation and trusty between the governments in mainland China and Hong Kong
and other countries or regions. Because of the genomic re-assortment of the virus,
26

however, the source of the transmission is not determined and is still being
investigated.

A retrospective case-control study to investigate the effect of management system of

infection control and prevention in hospital conducted by Tang Y et al. found that
there was statistically significant lower incidence of infectious diseases of the
research group than the control group (p<0.05), in which the hospital infectious
disease management and control measures began from 2011 were performed in the
former group.22 The study also showed that the research group had a statistically
significant lower incidence of the abuse of antibiotics than the control group (p<0.05),
which reflects lower occurrence of multi-drugs resistant pathogens in case of effective
infection control measures.22

Similarly, a cross-sectional study made by Pan WL et al concluded that there was

statistically significant improvement of consciousness, knowledge and skill of
infection control in terms of methods of sterilization, main index of testing the
effectiveness of antiseptics, classification and report of infectious diseases as well as
concept and report of sudden public health event among health care professionals
after implementation of infection control management in the medical institutions and
clinics (p<0.01).17

Another study carried out by Zhang TK et al summarized that the scores obtained
before and after the introduction of the Law of the PRC on the Prevention and
Treatment of Infectious Diseases in a hospital related to training of infectious diseases
reporting and management, effectiveness of infection control and prevention,
management of appearance of sudden public health episodes and knowledge of
27

infection control were 70% vs 94.5%, 71.5% vs 93%, 69% vs 93.5% and 68.89% vs
92.07% respectively, which all showed the statistically significant difference of the
results between the pre- and post-periods of the interventions (p<0.05).27 The
summary of the evaluation of efficacy of infection control activities by these three
studies is provided in table 4.

28

Table 4. Summary of the evaluation of efficacy of infection control activities by three

studies conducted in China.

Studies

Results

A retrospective case-control study by Statistically significant lower incidence

Tang Y et al in Beijing
of infectious diseases and abuse of
antibiotics of the research group than the
control group in hospital (p<0.05)
A cross-sectional study by Pan WL et al Statistically significant improvement of
in JiangSu

consciousness, knowledge and skill of

infection control in terms of methods of
sterilization, main index of testing the
effectiveness
of
antiseptics,
classification and report of infectious
diseases as well as concept and report of
sudden public health event among health
care professionals after implementation
of infection control management in the

medical institutions and clinics (p<0.01)

A cross-sectional and retrospective Statistically significant difference of the
studies by Zhang TK et al in Hunan
scores obtained between the pre- and
post-periods of the introduction of the
Law of the PRC on the Prevention and
Treatment of Infectious Diseases in
terms of training of infectious diseases
reporting and management, effectiveness
of infection control and prevention,
management of appearance of sudden
public health episodes and knowledge of
infection control in hospital(p<0.05).

29

Strategies for Disease Prevention in the Public

The Chinese government has built up several plans to improve public hygiene within
these ten years. The general strategies are the same to those adopted in Hong Kong.
However, there are some tactics which are specific for the social and environmental
conditions in China. Figure 1 to 3 showed the conditions of improvement of the
number of grass-roots health care institutions, and drinking water supply and hygienic
toilets in rural areas from 2007 to 2011 based on the statistics by the Ministry of
Health of The Peoples Republic of China.16

Zoonosis forms a common topic since the outbreak of SARS. Similar to occurrence of
avian influenza, people are infected by contact with a source from animals, such as
those who are working or purchasing the live poultry. Close contacts between humans
and animal vectors in the southern China has been shown to take a role for several
adverse epidemics including type A influenza.2 The Chinese government recognized
that the infectious diseases can be eliminated by reduction in exposure to animal
reservoirs and thus increased introduction of laws that restrict the consumption of
wild animals in the public.2 Such measure is found particularly in restaurants, in
which wildlife consumption is prohibited and punishment will be received if food
from wildlife is seen in menus.

Inaccurate or insufficient to disseminate information or report case may hinder the

establishment of preventive strategies in the community as media in China has a
tendency to sensationalize information which give rise to misconceptions of the
disease outbreak and the development of public myths.2 For instance, boiling while
vinegar was believed to protect the people from influenza but a proportion of people
were poisoned by carbon monoxide from charcoal burning to heat the vinegar.2
30

Prior to the marketization in the health care system in China, the health services for
rural population were organized and financed through the Cooperative Medical
System (CMS), which was funded by the farmers, village Collective Welfare Fund
and subsidies from higher level governments.14 After the agricultural sector reform in
the early 1980s, the scheme collapsed, and the number of township clinics and
primary health professionals in rural districts were greatly decreased by 14.2% and
35.9% respectively.14 Because of geographical location, some villages were isolated
and people living within were poor and difficult to assess basic health care. As a result,
unsatisfied hygiene and sanitation were found, and the people were lack of infectious
diseases knowledge in these poverty areas. In recent years, the China government had
tried an effort to perform decentralization and resource reallocation so as to
ameliorate the inequality of health care access.

31

Total number of institutions

Number of grass-roots health care institutions

940000
920000
900000
880000
860000
840000
820000
800000
2007

2008

2009

2010

2011

Year

Figure 1. Condition of the number of grass-roots health care institutions in China.

Number of total beneficiaries

Condition of improvement of rural drinking water supply

92000
91000
90000
89000
88000
87000
86000
2007

2008

2009

2010

2011

Year

Figure 2. Condition of improvement of drinking water supply in China rural areas.

Cumulative number of
hygienic toilets

Condition of improvment of rural hygienic toilets

20000
15000
10000
5000
0
2007

2008

2009

2010

2011

Year

Figure 3. Condition of improvement of hygienic toilets in China rural areas.

32

Limitation of this Review

A number of limitations were encountered for this literature review. Firstly, the
published articles relevant to the reform of health care system and infection control
are limited, especially those for the mainland China as the majority of this kind of
topic is published in Chinese version medical journal. Also, there is great difference
between Hong Kong and China in terms of politics, freedom of rights, financial
support, education, cultures and living habits, and these factors may have certain level
of effects in public hygiene which has not seriously discussed in this review.

Moreover, when compare with Hong Kong, China has an overwhelming wide range
of land and a large proportion of population in the mainland are living in rural areas
and mountains. As a result, some renewed practices of infection control may not be
obtained and emphasized by these people, and the district health authorities may even
not follow the advanced instructions and policies issued by the central government.
Therefore, the infection control measures are not consistent throughout whole China,
and it may be better to use Guangzhou or Shenzhen as a city-to-city comparison with
Hong Kong. Furthermore, information collected by the studies mentioned in the
articles contains several biases due to self-selection, missed diagnoses and delayed
reporting so that the true conditions are not reflected accurately.

33

Conclusion: Future to the practices for infectious diseases in Hong Kong

The ideal health care system should be efficient, equitable, safe and patient-centered.
These criteria are also suitable to apply to the issues regarding practices for public
hygiene. Although many problems and difficulties will be inevitably faced, it is
indispensable for the successful government to establish and maintain a high quality
and cost-effective health services to the citizens.

Not only focusing on the epidemics and pandemics of the diseases that mentioned
above, but also essential for taking concern on the other nosocomial and
communicable infections. Emergence of antibiotic resistance that complicates the
restraint of infection is one of the long-standing and intricate problems that persist at
present. Rationale use of antibiotics and reduction of its reliance in clinical setting as
well as strengthening of hand hygiene practice are the basic measures that should be
publicized. Determination to prevent the use of drug in case of viral infection is one of
the professional training for the doctors. Also, unrestricted purchase of antibiotics
without prescription in the mainland China should be advised and forbidden.
Legislation for prohibiting overuse or improper use of antibiotics in livestock and
poultry feeds to avoid occurrence of antibiotic resistance is another feasible control
method.

Several studies showed that many multi-drug resistant organisms were able to live on
inanimate surfaces for prolonged periods of time, such as 5 months, 5 days to 4
months and 7 days to 7 months for clostridium difficile (spores), vancomycin-resistant
enterococci and methicillin-resistant staphylococcus aureus respectively, and many
hospital surfaces comprised of bed rails, bed linens and tabletops were heavy
contaminated with these organisms.10 Hence, it is particularly important to frequent
34

cleaning of these surfaces as well as equipments so as to break the chain of infection

and prevent the spread of micro-organisms in hospital environment. Reinforcement of
personal hygiene can decrease the risk of transmission of epidemiologically
significant organisms by direct or indirect contact.

In spite of professional training before working in clinical settings, many health care
professionals and workers may not compliant to contact precautions in actual
circumstances. A study found that only 19.5 of interviewed nurses and midwives were
compliance with precaution practices, which was low compared with more than half
of them held positive attitudes and knowledge towards the precaution items.3 It may
be due to troublesome to take gowns and gloves when only some simple works are
performed. It can be improved by more education, hand hygiene focusing and
adopting an easier procedure for personal protection. Furthermore, increment of
patient participation in infection control activities and building effective partnership
with patients and their families are necessary for handling with infectious diseases
challenges at any moment.

35

Learn from the Review

Table 5 is a summary for the most important information retrieved in the articles. The
review can provide a platform to make more understanding for the current health
system in both Hong Kong and China and also realize the importance of public health
hygiene for emerging novel infectious diseases. In this era, mutual cooperation and
communication between different regions or governments is critical and essential for
managing an outbreak of disease. Actually, recognizing an underlying etiology for a
disease is the determinant for the successful control of infection and improvement of
public health, and it depends not only on microbiological factor but also relevant to
political, epidemiological, socioeconomic, environmental and cultural reasons.
Therefore, base on this review, a future cross-sectional study may be worth to perform
to investigate the effectiveness of the control measures between urban and rural areas
as well as evaluation of the inequality to access medical services for different class of
people in the society.

36

Table 5. Summary of the key information obtained in the articles.

Articles

Information retrieved

Abdullah ASM et al, Malave A et al and Case detection, reporting, clear and
webpage of WHO.
timely dissemination of information are
essential in handling infectious disease
after the occurrence of SARS, and
recommendations are provided to face
for the future outbreaks
Askarian M et al, Pan WL et al, Song Evaluation of the knowledge, attitudes
XY et al, Tang Y et al and Zhang TK et and effectiveness of the infection control
al.
practices
among
health
care
professionals working in clinical
environment.
Chan ZCY, Hsiao WCL, Liu Y et al and Review of health care system and
The BFRCHC Study Group.
Gao R et al and Li Q et al.
Kramer A et al.

Lee SS et al and Wu JT et al.

Scientific Committee
Preventable Diseases.

on

services in Hong Kong and China

Description of H7N9 outbreak in China
Study showed that many multi-drug
resistant organisms were capable of
living on inanimate surfaces for
prolonged periods of time, which in turn
emphasized the importance of frequent
public health practices.
Demography and control measures
established during H1N1 pandemic in
2009.
Vaccine Successful vaccination programmes for
the
protection
against

Li B, Shaw K, Smith KF et al, Wang LD

et al, Yuen KY.

Web pages of Centre for Health

Protection, Chinese Center for Disease
Control and Prevention and Ministry of

pneumococcus-induced
diseases
in
children.
Description
of
infection
control
measures and public health practices
between Hong Kong and China during
pre- and post-SARS periods.
Statistical information of the infectious
diseases,
including
number
of
notification of cases recorded in the past

Health of The Peoples Republic of few years.

China.
37

References
1. Abdullah ASM, Lee A. Severe acute respiratory syndrome: a challenge for public
health practice in Hong Kong. Journal of Epidemiology & Community Health.
2003; 57: 655-658.
2. Abdullah ASM, Tomlinson B, Cockram CS and et al. Lessons from the Severe
Acute Respiratory Syndrome Outbreak in Hong Kong. Emerging Infectious
Diseases. 2003; 9(9): 1042-1045.
3. Askarian M, Shiraly R and McLaws ML. Knowledge, attitudes, and practices of
contact precautions among Iranian nurses. American Journal of Infection Control.
2005; 33(8): 486-488.
4. Centre for Health Protection. Department of Health. www.chp.gov.hk/
5. Chan ZCY. Primary Health Care in Hong Kong. Education for Health. 2006; 19(2):
229-232.
6. Chinese Center for Disease Control and Prevention. The Statistical Report of
China Health Affair and Development in 2011. http://www.chinacdc.cn/ *
7. Development and Financing of Hong Kongs Future Health Care. 2007. The
Bauhinia Foundation Research Centre Health Care Study Group.
8. Gao R, Cao B, Hu Y and et al. Human Infection with a Novel Avian-Origin
Influenza A (H7N9) Virus. The New England Journal of Medicine. 2013; 368:
1888-1897.
9. Hsiao WCL. The Chinese Health Care System: Lessons for Other Nations. Social
Science & Medicine. 1995; 41(8): 1047-1055.
10. Kramer A, Schwebke I and Kampf G. How long do nosocomial pathogens persist
on inanimate surfaces? A systematic review. BMC Infectious Diseases. 2006; 6:
130.
11. Lee SS and Wong NS. Relationship between population configuration and the
38

spatial pattern of pandemic influenza A (H1N1) 2009 in Hong Kong. Hong Kong
Medical Journal. 2012; 18: 310-317.
12. Li B. 2013.The Report of Infection Control Works and Condition of Implementing
the Law on the Prevention and Treatment of Infectious Diseases by the State
Council of the Peoples Republic of China. National Health and Family Planning
Commission of the Peoples Republic of China. http://www.moh.gov.cn/zhuzhan *
13. Li Q, Zhou L, Zhou M and et al. Preliminary Report: Epidemiology of the Avian
Influenza A (H7N9) Outbreak in China. The New England Journal of Medicine.
2013.
14. Liu Y, Hsiao WC and Eggleston K. Equity in health and health care: the Chinese
experience. Social Science & Medicine. 1999; 49: 1349-1356.
15. Malave A and Elamin EM. Severe Acute Respiratory Syndrome (SARS)
Lessons for Future Pandemics. American Medical Association Journal of Ethics.
2010; 12(9): 719-725.
16. Ministry of Health of The Peoples Republic of China. China Health Statistics
2011. http://wsb.moh.gov.cn/ *
17. Pan WL, He JP, Xu KY et al. The effectiveness of infection control and
management conducted by social medical institutions. 2004; 2(12): 55-57. *
18. Scientific Committee on Vaccine Preventable Diseases. 2011. Recommendations
on the Use of 13-valent Pneumococcal Conjugate Vaccine in Childhood
Immunisation Programme.
19. Shaw K. The 2003 SARS outbreak and its impact on infection control practices.
Public Health. 2006; 120: 8-14.
20. Smith KF, Dobson AP, McKenzie FE and et al. Ecological theory to enhance
infectious disease control and public health policy. Frontiers in Ecology and the
Environment. 2005; 3(1): 29-37.
39

21. Song XY, Wu YH and Zhou J. Finding gaps: An assessment of infection control
needs in China. International Journal of Infection Control. 2011; v7: i4.
22. Tang Y, Li YR, Guo XD et al. Hospital Infectious Disease Management and
Control Measures. Progress in Modern Biomedicine. 2012; 12(28): 5571-5573. *
23. Wang LD, Wang Y, Jin SG and et al. Emergence and control of infectious diseases
in China. Lancet. 2008; 372: 1598-1605.
24. World Health Organization. 2003. Severe acute respiratory syndrome (SARS):
Status of the outbreak and lessons for the immediate future.
25. Wu JT, Cowling BJ, Lau EHY and et al. School Closure and Mitigation of
Pandemic (H1N1) 2009, Hong Kong. Emerging Infectious Diseases. 2010;16(3):
538-541.
26. Yuen KY. Emerging infectious diseases in Hong Kong. Hong Kong Medical
Journal. 2001; 7(3): 224-226.
27. Zhang TK, Wang YS. The evaluation of effectiveness of infection control and
prevention before and after the introduction of the Law on the Prevention and
Treatment of Infectious Diseases in a hospital in XiangTan. Practical Preventive
Medicine. 2012; 19(1):62-63. *

* The articles and documents are in Chinese version

40