From Crisis to Insight: Navigating Public Health Challenges in an Aging Society—Lessons from Hong Kong’s COVID-19 Experience

Abstract

This article critically examines the experience of Hong Kong (HK) with the COVID-19 pandemic and highlights the urgent need for effective public health responses in an aging society. As one of the world’s fastest aging societies, Hong Kong’s vulnerability to the consequences of pandemics is particularly pronounced due to low birth rates and high life expectancies. The city has experienced multiple waves of the COVID-19 virus, with the fifth wave causing some of the highest mortality rates in the world. However, through continuous learning and adaptation, HK’s public health response has evolved to combat the crisis effectively. The discussion aims to highlight the importance of drawing from both positive and negative lessons from past epidemics and the critical role of public health systems in ensuring the well-being of older adults and the wider community. It emphasizes the need for sustained efforts to maintain and strengthen public health systems to tackle the ongoing and future public health challenges in an aging society.

Impact of COVID-19 on Hong Kong

Public health systems around the world have been tested like never before by the COVID-19 pandemic. Hong Kong and Singapore are among the fastest aging societies in the world, with low birth rates and high life expectancies. This demographic trend has significant implications for their vulnerability to the consequences of pandemics, as older populations are at higher risk of severe illness and mortality. Hong Kong (HK), a densely populated city with a significant aging population, has experienced multiple waves of the COVID-19 virus since its initial outbreak on January 23, 2020 [1, 2]. In the context of a pandemic, “waves” refer to the successive peaks and valleys in the number of cases or deaths over time, often caused by the ebb and flow of infections as well as changes in public health interventions and human behavior [3]. Despite the challenges, Hong Kong’s public health response has continually evolved and learned from each wave, transforming crises into useful insights to pull itself out and setting an example on several fronts discussed in the following sections. The pandemic has had a significant, multifaceted impact on Hong Kong’s socio-economic stability, particularly with the fifth wave causing the city to record some of the highest mortality rates in the world [4]. This highlighted the need for an effective public health response in an aging society like HK, where the number of older adults is expected to double by 2041 [5] and as much as 40% of the population will be 65 or older by 2050, as forecasted by the WHO [6]. Several stern and prompt actions like closing schools, implementing zoned lockdowns, and prohibiting social gatherings during the pandemic required careful consideration of the unique circumstances of Hong Kong at the time. Given the city’s prior epidemic experience with SARS, local authorities were able to draw from both positive and negative lessons when formulating a plan to combat the COVID-19 outbreak.

The advantages and limitations of Hong Kong’s prolonged adherence to a zero-COVID strategy are well-documented and have been debated to date [7, 8]. During the first few waves of the pandemic in HK, this strategy was quite effective in limiting the rate of infections to their lowest while the rest of the world struggled to keep it under control. However, the catastrophically low vaccination rates and absence of herd immunity during the fifth wave, as discussed in the following section, led to a significant rise in new infections and fatalities [9]. As HK’s population ages, it is important to consider what can be applied to future public health crises based on what was learned during the course of the pandemic. By synthesizing and applying these insights, HK and other aging societies around the world can better prepare for future crises and safeguard the health and welfare of such vulnerable populations.

Extracting Valuable Insights from the First Seven Waves of the Pandemic

The number of cases and deaths from the COVID-19 outbreak in Hong Kong is a distinct reminder of the impact that infectious diseases can have on an aging society. It also highlights the need for continued vigilance against emerging pathogens such as the corona virus, which pose a threat to public health globally. The need for early and accurate information dissemination to the general population, particularly older persons who are more susceptible to the virus, is one of the most important lessons that were gained as a result of this experience. The public’s awareness and compliance with preventative measures can be increased through the use of communication tactics that are effective. For instance, during the pandemic, a study that was carried out in Hong Kong discovered that good communication and trust in the health messages that were communicated by the government dramatically enhanced the possibility of people adopting preventative measures [10]. Another thing that we have learned is how essential it is for organizations in different fields, such as the healthcare industry, the social service sector, and government agencies, to work together and coordinate their efforts [11]. The various requirements of older people, such as their physical and mental health, social support, and access to healthcare services, can be addressed through collaboration, which can be of great assistance. For instance, during the fifth wave, partnerships between hospitals and community care providers showcased the potential to improve care coordination and lower hospitalization rates among older people through a thorough coordination process. The pandemic has also brought to light the significance of utilizing technology as part of the response to issues pertaining to public health. Increasing access to healthcare services for older persons, particularly those who live alone or are confined to their homes, can be facilitated by the implementation of digital health technology such as telemedicine and remote monitoring. Technology can also be used to enhance attempts to trace contacts and conduct surveillance, which enables infected individuals to be identified and isolated at the earliest possible time. According to the findings of a study that was carried out in Hong Kong, the use of telemedicine services is successful in increasing access to healthcare services as well as lowering the costs associated with healthcare for older persons who suffer from chronic conditions [12, 13].

In addition to the reaction in the public health sector, the pandemic has highlighted the significance of meeting the requirements of senior citizens residing in long-term care facilities (LTCFs). In these facilities, infection prevention and control measures must be given top priority. These measures include routine cleaning and disinfection, sufficient personal protective equipment for staff members, and access to COVID-19 testing and vaccination. LTCFs should also create a comfortable and satisfactory internal atmosphere for their elderly tenants, since this can have a beneficial influence on how satisfied they feel with their living situation. It is vital to apply stringent infection control measures, improve ventilation and air quality, offer enough staffing and training, boost communication and involvement, and provide continuity of care in order to ensure the safety and wellness of older persons who reside in care homes [14]. For instance, the Hong Kong government has established guidance on infection control measures for care facilities and has increased COVID-19 testing and immunization efforts among care home residents and staff members [15]. The development of strategies and action plans to combat the COVID-19 pandemic in Hong Kong was a multi-step process that involved various stakeholders and experts. The strategies were formulated based on a series of evidence-based assessments, including risk assessments, epidemiological data, and expert advice.

Lessons Learned from the First Wave

The first wave of the COVID-19 outbreak in Hong Kong, marked by the reported first two imported cases from mainland China (who visited Wuhan) on January 23, 2020, was a wake-up call for public health officials. The number of cases quickly grew to over 1000 and spread across multiple districts [1]. The government responded with aggressive contact tracing and quarantine measures, but it took more than 3 weeks before they could declare a halt to new infections. In hindsight, there were several factors that contributed to this delay:

• The traditional approach used by local health authorities relied on paper records instead of digital health systems (DHS). This made it difficult for officials to track down patients who had been diagnosed with COVID-19 or those who had been exposed but were not yet infected.

• An overall lack of established protocol to collectively deal with across the panic state and effective means to promote awareness at the grass-roots level.

• A lack of coordination between different agencies involved in managing the outbreak.

One key lesson is the need for timely and accurate information dissemination to the public, especially older adults, who are more vulnerable to such viruses. Effective communication strategies, including multilingual and culturally sensitive messaging, can help promote public awareness and adherence to preventive measures.

Lessons Learned from the Second Wave

The second wave of the COVID-19 pandemic in Hong Kong occurred from late February to mid-June 2020 and was a stark reminder of the challenges of managing the spread of the virus. The importance of increasing testing capacity and shifting towards a community-based approach was observed. Also, a need to emphasize quarantine and isolation as a way of containing outbreaks was largely promoted. The Centre of Health Protection [15] had a very swift yet thorough contingency plan developed by then, and the infected cases were quarantined instantly to avoid further spread and contain the virus. Here are some of the key lessons learned during the period:

• The importance of a quick and targeted response: The second wave was largely driven by clusters of cases in specific areas, such as care homes and restaurants. In response, the government implemented targeted lockdown measures to contain the spread of the virus. This highlighted the importance of swift action and a targeted approach to controlling the spread of the virus.

• The need for clear and consistent communication: During the second wave, there were times when different sources sent different messages and gave confusing information. This made the public confused and less likely to trust what the government was saying. It showed that public health officials need to communicate with the public in a clear, consistent, and accurate way to build trust and make it easier for people to follow public health measures.

• The importance of preparedness: The second wave caught Hong Kong off-guard, despite its previous success in containing the virus during the first wave. This experience highlighted the importance of being prepared for potential subsequent waves of the pandemic, including having adequate testing capacity, sufficient medical supplies and personnel, and robust contact tracing and quarantine measures.

• The significance of public cooperation: The second wave demonstrated that public cooperation and adherence to public health measures such as wearing masks, practicing social distancing, and avoiding large gatherings are essential for controlling the spread of the virus. It also highlighted the importance of engaging and empowering the public in the response to the pandemic to build a sense of collective responsibility and ownership [10].

Lessons Learned from the Third Wave

The third wave of the pandemic, beginning in July 2020, was a turning point for public health in Hong Kong. The lessons learned from this experience will certainly help shape the response to future health threats and emergencies, including those related to aging. Here are some key takeaways:

• Improved public health messaging: Communication is critical during an outbreak or crisis, as it can help people understand what they need to do to stay safe and healthy. In order for communication strategies to be effective, they must be clear, concise, and consistent across different channels (e.g., social media). They should also include messages about how long individuals should remain isolated if they are sick with COVID-19; where people can go for medical care; what symptoms warrant immediate attention; how best practices should be followed (e.g., hand-washing) when caring for someone who has been exposed; how long it takes before someone becomes contagious after coming into contact with another person who has been infected by COVID-19; and so on. This was achieved through the government’s online portal with real-time case information and active 24-hour helpline support.

Lessons Learned from the Fourth Wave

• Greater Emphasis on Prevention: The fourth wave of the pandemic in late November 2020 was the first time a larger emphasis on prevention than treatment was observed. This is because it was clear that there were not enough beds available in hospitals, and patients were being turned away due to a lack of resources. In addition, many people were afraid of hospitals and did not want to go there unless absolutely necessary. Therefore, public health officials shifted their focus from treating patients with antiviral drugs and vaccines towards preventing further spread by encouraging people to avoid close contact with others who may be infected (e.g., through hand-washing), as well as isolating those who had symptoms consistent with COVID-19 infection until they tested negative for the disease, and then releasing them back into society so they could continue living their daily lives without fear or panic about being quarantined inside hospital walls indefinitely. The transition from the fourth to the fifth wave was the deadliest challenge for Hong Kong residents (refer to Fig. 1). The startling disparity in the number of infected cases reached a level that was thirty times higher than the levels seen in the prior waves. The overwhelming magnitude of this disparity caused the entire healthcare system to be severely strained and pushed to the brink of collapse.

Fig. 1.

Hong Kong’s exceptional outbreak of the fifth pandemic wave [16]

Lessons Learned from the Fifth Wave

After a rather consistent 1-year period of containing the spread of the virus to a minimum, the fifth wave of the COVID-19 pandemic in Hong Kong occurred in early January 2022. The fifth wave resulted in a devastating toll, claiming over 2000 lives. The majority of those who lost their lives during this period had not been fully vaccinated. For instance, it could be noted that 92% of the first 1153 fatalities recorded in the fifth wave did not receive the recommended 2 doses of COVID-19 vaccination [17]. The sudden surge in cases had put immense pressure on Hong Kong’s isolation facilities, which struggled to accommodate the influx of patients and hence contain the spread of the virus. A detailed discussion of policy implications for public health has been discussed in [8, 9]. Here are some of the key lessons learned from this wave:

• The importance of proactive testing: The fifth wave was largely driven by asymptomatic cases, which highlighted the importance of proactive testing to detect and isolate cases early. The government implemented widespread testing in affected areas to identify asymptomatic cases and prevent further transmission. This underscored the importance of early detection and proactive testing in controlling the spread of the virus.

• The need for flexible and adaptive responses: The fifth wave was caused by a mutation of the virus, which made it more contagious and challenging to control [8]. This experience highlighted the need for a flexible and adaptive response to new developments in the pandemic, including monitoring and responding to changes in the virus.

• The significance of community engagement: The fifth wave was also driven by clusters of cases in specific areas, which emphasized the importance of engaging with affected communities and promoting compliance with public health measures. It highlighted the need for community involvement in the response to the pandemic, including effective communication and engagement with affected communities to promote compliance with public health measures.

Lessons Learned from the Sixth Wave

The sixth wave of the COVID-19 pandemic in Hong Kong occurred during the later months of 2022, with the peak recorded in the month of September, and provided further learning experiences in managing the spread of the virus. Here are some of the key lessons learned from this wave:

• The importance of border control measures: The sixth wave was largely driven by imported cases, which highlighted the importance of border control measures to prevent the introduction and spread of the virus. The government tightened border control measures, including quarantine requirements, and testing protocols for incoming travelers, to reduce the risk of imported cases.

• The significance of public trust and confidence: The sixth wave occurred during the rollout of the government’s vaccination program, which emphasized the importance of public trust and confidence in the safety and efficacy of the vaccines. The government implemented measures to address public concerns and promote vaccine uptake, including information campaigns and transparency in vaccine safety data.

• The need for targeted outbreak control measures: The sixth wave also saw clusters of cases in specific areas, which highlighted the importance of targeted outbreak control measures to contain the spread of the virus. The government implemented targeted lockdowns and testing in affected areas to identify and isolate cases, which helped control the spread of the virus.

• The importance of risk communication: The sixth wave occurred during a period of increased public fatigue and complacency towards public health measures, which underscored the importance of effective risk communication to promote continued compliance. The government implemented targeted messaging and communication campaigns to address public complacency and promote continued adherence to public health measures [13].

Lessons Learned from the Seventh Wave

The COVID-19 pandemic’s seventh wave in Hong Kong began in early January 2023 and is currently being managed with greater effectiveness compared to the worst effects seen during the fifth wave. Policymakers have shown remarkable maturity by adapting to the situation with evidence-based measures and a willingness to learn from past experiences. This includes moving away from the zero-COVID stance that was previously adhered to and gradually implementing new policies to better control the situation. Such actions reflect policymakers’ commitment to the well-being of the public and their ability to adjust to unforeseen circumstances with the best of intentions.

• The vulnerability of aging societies: The seventh wave highlighted the vulnerability of aging societies to the ill consequences of the pandemic, including higher rates of severe illness, hospitalization, and fatalities. This underscored the need for targeted measures to protect older adults, such as prioritizing their access to vaccines and implementing measures to reduce their risk of exposure.

• The importance of vaccination: The seventh wave occurred during the rollout of the government’s continued vaccination program for taking further doses, which emphasized the importance of vaccination in protecting individuals and communities from the virus. The government implemented measures to increase vaccination uptake among older adults with multiple doses as promoted by the WHO, including targeted outreach and education campaigns.

• The need for continued adherence to public health measures: The seventh wave witnessed increased public fatigue as well, which highlighted the need for continued adherence to these measures to prevent the spread of the virus. This included measures such as wearing masks, getting vaccinated proactively, practicing social distancing, and avoiding large gatherings.

• The importance of mental health support: The seventh wave also had significant impacts on mental health, particularly for older adults who may be more socially isolated and have limited access to support services. This underscored the importance of providing mental health support to individuals and communities affected by the pandemic, including access to mental health resources and support services.

Way Forward and Its Implications on Policy Making in Aging Societies

The COVID-19 pandemic, in its entirety, has brought to light the significance of making investments in public health infrastructure, addressing health inequalities, promoting healthy aging, addressing mental health, and constructing resilient communities. Through a forward-thinking and cooperative approach to public health, Hong Kong and every other aging society globally can continue to improve their preparedness and response to future pandemics, ensuring the health and well-being of all members of the community [18]. Based on the lessons learned from the COVID-19 outbreak in Hong Kong, there are several policy implications relevant on a global scale that can be drawn to create a more robust and healthier society:

• Increased investment in public health infrastructure: The pandemic highlighted the need for a robust public health infrastructure that can respond quickly to outbreaks. The government should invest more resources in building up its public health system, including digital information systems, testing capacity, and hospital beds. To better respond to infectious disease outbreaks, public health systems must be fortified, as evidenced by the COVID-19 pandemic. Disease surveillance, laboratory capacity, and immunization programs are all areas where Hong Kong may make improvements going forward to improve the public health system.

• Improve coordination between different agencies: In the first wave of the outbreak, there was a lack of coordination between different agencies involved in managing the outbreak. It is important for the government to establish clear lines of communication and collaboration among different agencies to ensure a more effective response to future outbreaks.

• Emphasize prevention over treatment: The fourth wave of the pandemic saw a shift towards prevention rather than treatment due to the overwhelming demand for hospital beds. The government should place more emphasis on prevention strategies, such as social distancing and isolation, to prevent further outbreaks.

• Focusing on telemedicine: The pandemic has underscored the importance of leveraging technology in the public health response. Digital health technologies, such as telemedicine and remote monitoring, can help enhance access to healthcare services for older adults, especially those who are isolated or homebound [12]. Technology can also be used to support contact tracing and surveillance efforts, enabling the timely identification and isolation of infected individuals [19].

• Targeted interventions for vulnerable populations: The sixth wave of the pandemic saw an increased focus on providing targeted solutions for specific groups within society, such as seniors or children, who may be at greater risk than others. The government should continue to develop targeted interventions that can reach out to these vulnerable populations more effectively.

• Promoting healthy aging: Advancing healthy aging is important for the sake of the health and well-being of the population as a whole, which is expected to decline as the population ages. Financial resources in Hong Kong can be put towards facilitating access to preventative health services like cancer screenings and immunizations, as well as promoting healthy lifestyle choices like regular exercise and a nutritious diet.

• Greater collaboration between the public and private sectors: The sixth wave of COVID-19 saw greater collaboration between government agencies and non-governmental organizations (NGOs). This was done through information sharing and joint planning, which helped improve the effectiveness of interventions. It also allowed for more targeted interventions that were able to reach out to vulnerable populations more effectively. The pandemic has highlighted the need for an integrated and seamless approach to the public health response that involves all stakeholders.

• More targeted interventions: In addition to increased collaboration between the public and private sectors, there was also an increased focus on providing targeted solutions for specific groups within society, such as seniors or children, who may be at greater risk than others due to their age or developmental stage, respectively. Such measures can help address the complex needs of vulnerable populations, including their physical and mental health, social support, and access to healthcare services. Care homes should encourage regular communication between residents, families, and staff to provide updates on the health and well-being of residents and address any concerns. Engaging residents in activities and social events can also improve their mental health and overall well-being.

• Ensure continuity of care: The pandemic has disrupted the continuity of care for many older adults in care homes. To ensure their safety and well-being, care homes should have contingency plans in place to provide continuity of care during emergencies and disruptions.

• Addressing health inequalities: The health disparities across different demographics have been brought to light by the pandemic. The elderly and people from low-income backgrounds are disproportionately affected. Hong Kong can further take steps to address these inequalities by, for example, offering targeted health services and enhancing access to healthcare for underprivileged groups.

• Addressing mental health: The mental health of the population, especially the elderly, has been negatively impacted by the pandemic and has to be addressed. Counseling and outreach initiatives, as well as research into the mental health needs of the people, can remain high priorities in Hong Kong.

• Building community resilience: In order to effectively deal with the public health threats of the future, it will be crucial to strengthen community resilience. Hong Kong has the option of funding community-based initiatives to improve social cohesion, fortify local health services, and reinforce emergency response infrastructure.

In conclusion, the experience of the COVID-19 pandemic in Hong Kong demonstrates the crucial need for efficient public health interventions in an aging population. With each new wave of the pandemic, the city’s public health infrastructure has been put under strain, and policymakers have had to adjust their tactics accordingly. HK has been able to effectively plan for the fight against COVID-19, serving as a model for other places to emulate by giving careful thought to the particularities of the situation as well as the lessons that have been learned from prior epidemics. Public health systems in HK must be maintained and strengthened to protect the health of the aging population and the community at large. Throughout the COVID-19 pandemic, HK has faced numerous challenges, enduring a difficult and trying period since the outbreak first emerged, but the city has learned important lessons that will help it better respond to future public health crises.

Author Contributions

The author confirms being the sole contributor of this work.

Funding

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

Data availability

The manuscript does not contain such data.

Declarations

Conflict of interest

The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.