Wednesday, March 04, 2020

A Tale of Two Outbreaks: Hong Kong & Italy

Flattening the Curve - Credit CDC


Up until two weeks ago Italy had but 3 known COVID-19 cases.  Today the ECDC reported they had in excess of 2,500 cases, and they have also reported 80 deaths. 
By contrast, Hong Kong - which not only shares a border with Mainland China, but has been dealing with cases since mid-January - has only recently passed the 100 case mark. Across the bay, Macao has even fewer cases (n=10).  
If you had asked anybody a month ago which of these two regions would have the most cases in early March, few would have picked Italy.  Granted Italy has a much larger population than Hong Kong, but even so, the choices made by both governments have made the biggest difference.

Hong Kong has been very proactive in their response, and closed its schools when they had fewer than 40 cases - have kept them shuttered since late January - and intend to keep them closed until mid April at the earliest.
Italy, on the other hand, only today announced a limited - two week - closure of schools across the country. 
Hong Kong closed most public venues - museums, sporting events, movie theatres, bars and most  restaurants - in late January (see HK Epidemic Measures: Curbing Travel From Mainland - Closing Public Places - Work From Home Orders) and has kept them closed.
Italy - not so much. 

A few temporary cancellations of sporting events in the hardest hit regions, but nothing like the response we've seen in Hong Kong. There are signs, at least over the past couple of days, that Italy may be taking stronger actions - like canceling more sporting events, and the aforementioned closing of schools -  but they may be both too `measured' and too late to have much impact.

There appear to be two philosophies at work here.

  • In Hong Kong, they assumed the disease was already in the community, and they not only continued to work to prevent further entry, they put very tough measures in place to prevent its spread.
  • Italy, on the other hand, has been mostly reactive.  Waiting for community spread to become obvious, and then dealing with each outbreak as if it were a limited event, rather than a systemic problem. 

So far, at least outside of Asia, most countries have been following a reactive strategy. 

Hong Kong has, admittedly, taken a huge financial hit by being proactive. And not just for big corporations, but for every resident in the city. So much so that the HK government has agreed to pay out 10,000 HKD to every resident over the age of 18, to ease the economic pain.

And there are no guarantees on how long they can keep these difficult community mitigation measures intact - or that they won't see just as big of an epidemic a month or two from now - when they are eventually relaxed.

By waiting, Italy may have forestalled their economic hit by a few weeks - but any savings will likely evaporate with their worsening epidemic.
Economically, it appears to be a case of damned if you do, and damned if you don't. 
Perhaps in a year or two, we'll have enough data to know which option was least painful; at least economically.  And we won't know until it's over whether Hong Kong's strategy results in fewer cases and deaths, or simply delays the inevitable.
If there is a tiebreaker - at least for now - it has to be that Hong Kong has bought more time to prepare, and has (so far) limited the strain on their healthcare system. 
In 2017's Community Pandemic Mitigation's Primary Goal : Flattening The Curve, we look at the HHS/CDC's 2017 revised Community Mitigation Guidelines to Prevent Pandemic Influenza, which outlined ways that communities can slow the spread of an epidemic, and hopefully reduce its impact.
The downside is - if successfully implemented - it may double or even triple the length of a pandemic wave.  And that can have profound economic and societal impacts. 
You hope to trade a shorter, steeper, and more severe pandemic for a longer, but more moderate pandemic wave.  Something our society - including our healthcare delivery system - is better able to cope with. And that means more people can be saved. 
Theoretically, anyway. 
While I tend to favor a forward-leaning, proactive approach - in all honesty - I have no idea which approach will turn out the `best'.  Or at least, least-worst.  

Since we seem to be seeing both approaches being tried around the world, over the next year or two we should get a much better idea what works best.  Although results may vary depending on each country's resources and cultural norms. 

Hopefully, whatever we learn, it will help guide us in the pandemic-after-next.