Hong Kong, for its population of around 7.5 million, has 22.5 million doses of COVID vaccines on order. And yet, Asia’s World City is falling behind, with inoculations yet to begin. Tariq Hashmat of Health Analytics Asia speaks to Dr. Siddharth Sridhar of The University of Hong Kong.
The metropolis of Hong Kong faced the pandemic amidst political tensions and protests that marred the city for much of 2019. Since its first case on January 23, 2020, Hong Kong has seen four waves of COVID infections, each bigger than the previous. But even with total cases exceeding 10,000, the city’s COVID fatalities remain low, with a total death toll of under 200.
But while pandemic management presents one picture, Hong Kong’s COVID vaccination efforts have recently been the subject of much discussion. Over 100 million doses of COVID vaccines have been administered globally, with Mainland China having started its vaccination program in July 2020. Hong Kong, for its population of around 7.5 million, has 22.5 million doses on order – 7.5 million each of three different vaccines. However, as of February 12, 2021, not one dose was administered.
Asia’s World City is lagging behind over 60 countries and several developed as well as third world cities.
“It could have been faster,” said Dr. Siddharth Sridhar in an exclusive interview with Health Analytics Asia. A clinical virologist, Dr. Sridhar is currently a clinical assistant professor at The University of Hong Kong – the institute whose researchers confirmed the world’s first case of COVID reinfections. Dr. Sridhar has been involved in path-breaking research into COVID-19 including animal models, serosurveillance studies, diagnostic tests, and infection control that crystallized the understanding of SARS-CoV-2 in the early days of the outbreak.
In the interview, Dr. Sridhar spoke of Hong Kong’s challenges in COVID vaccine rollout, the influence of politics, and the challenges of information dissemination and management.
Below are excerpts from the interview.
Given Hong Kong’s financial capabilities, are you satisfied with the efforts put in the city’s vaccination rollout?
It could have been faster, couldn’t it? Hong Kong finds itself in the middle of the queue as far as the race for vaccination is concerned, for many different reasons – among them being that we were not involved in testing any of the currently licensed vaccines. We also don’t have production capacity for any of the vaccines. We have also taken a very conservative point of view in terms of licensing vaccines as well – insisting on actually having access to the full phase 3 randomized clinical trial data before doing so. So we have that for Pfizer’s mRNA candidate and it has been accordingly approved in Hong Kong, but we’re still pending that for some of the Chinese candidates like Sinovac and CoronaVac.
The government has taken a wait-and-see approach. They have decided to look at what’s going on around the world. As you pointed out there have been millions of doses already administered, I think the promising, quite excellent short term safety data that’s being generated around the world would only increase public confidence in the vaccines in Hong Kong. So as and when vaccines do arrive, hopefully, we should have less of a problem with vaccine hesitancy.
What data are the authorities basing the decision on to approve vaccine candidates, as there are no local trials?
On the international phase 3 randomized clinical trial data. Pfizer’s interim analysis was completed at the end of last year and officially published in December, it’s a matter of public record. So that was very quickly available. AstraZeneca’s candidate also has such data publicly available.
As for the Sinovac candidate, we’ve had a press conference, a press release, from the Butantan Institute In Brazil, and also snippets of data from some of the other trials conducted globally, but the full phase 3 RCT data from Brazil has not actually been released in the public domain. So a lot of experts in the body advising the government on vaccine regulation and approval have advised that we wait for the phase 3 RCT data before doing so.
Of course, approving it doesn’t mean getting it. Supply is another obstacle in the whole process. So, it looks like we’ll have to wait till the end of February or early March before vaccinations get underway locally.
Would a public rollout happen without local trials?
Oh yes. It is not worthwhile doing trials in Hong Kong for the reason that you mentioned at the beginning – there are very few cases locally. You can’t generate good efficacy data in Hong Kong or in the region because there are just so few cases. Even the Chinese candidates have all moved overseas for their clinical trials. It’s nice to have kind of control but that also means that you don’t have enough of the virus going around to actually do the clinical trial locally.
Chief Executive of Hong Kong Carrie Lam made a statement saying there’ve been hiccups in the procurement of the approved vaccines. What’s going on that front?
(There have been) a lot of wheelings and dealings. We are publicly aware of some of them, like these spat between AstraZeneca and the European Union. They are producing massive amounts of vaccines, but the problem is you have billions of people around the world who need these vaccines, and there is a degree of vaccine nationalism.
We said at the end of 2020 that we hope for vaccinations to be as equitable and as evenly distributed as possible. But clearly, that’s not happening as was alluded to by WHO as well. Countries that have put in the resources to develop or test the vaccines have a claim to prior access. It’s not ideal, but that is what we’re seeing, which is why Hong Kong, despite having the financial capacity, finds itself behind in the queue to get the vaccines. Other countries where the vaccines were developed or tested are obviously getting a little bit ahead in their vaccination program.
When you’re producing vaccines locally, you decide what happens to those doses – it’s as simple as that. If you don’t have that involvement in the production, development, manufacturing process, then it doesn’t matter how much money you have in your pockets. There are a lot of other variables that come into play in deciding when you get there.
Hong Kong was a political crucible in 2019, and it still continues to be so. Do you think COVID or its information management in Hong Kong was, or still is, influenced by politics?
To a certain extent, yes. It’s difficult to avoid politics in any element of public discourse in Hong Kong – in most parts of the world really – but Hong Kong especially, because of recent events, has been very sensitive in this regard.
There are levels of mistrust in public sources or government sources of information. There are plenty of people in the community who are pretty jaded by recent events here. It has affected the kind of messaging around COVID-19 and COVID-19 vaccines as well.
How has data transparency fared in Hong Kong’s COVID management so far?
It’s not bad. The good thing in Hong Kong is that we have a fairly robust system of testing and tracing which means that we have high rates of testing for COVID-19 in the population. The number of cases that we report is pretty close to the actual number of people who have caught COVID-19 in Hong Kong. A lot of the information – regarding their basic demographic characteristics or where they live or where they caught the virus from, is publicly available to a certain extent. The decision-making by the government on certain aspects such as vaccine procurement has been fairly reasonable and transparent.
Nowhere is perfect. This is an unprecedented situation. No one was prepared for COVID-19, so obviously there were mistakes made along the way in all parts of the world. But all in all, the proof is in the pudding – in terms of the number of cases and hospitalizations and how the healthcare system is faring. I’d say Hong Kong deserves a fairly good grade overall on how the pandemic has been managed. Part of that goes back to the transparency of the data and public messaging on the COVID-19 situation. They’ve done quite well.
In a recent poll in Hong Kong, less than a third of the respondents said that they would take the COVID vaccine. What are your thoughts on vaccine hesitancy and the efforts to counter it?
The local universities and the government have to constantly message the public about the benefits of vaccination and the very excellent efficacy data that’s being reported for several of the (vaccine) candidates. There is tons of safety data already available and they really help to prevent severe COVID-19.
The public has to slowly come around to the fact that these vaccines are actually very well designed and are extensively tested. They have to come to an understanding that vaccination is probably the only good way out of this pandemic.
That messaging needs to be persistent and ongoing. But apart from that, I’m not overly concerned about vaccine hesitancy because we haven’t had vaccines come to Hong Kong yet. It’s not like people are at the point where they have to make that decision. It’s still something nebulous at some point in the future. Once they come to Hong Kong, once the decision has to be made and when people are generally aware of the benefits of getting the vaccination, not least that is very likely that you will need a vaccine to perhaps travel around the world in the next one or two years, I’m sure a lot of people are going to change their minds and go for the vaccine. I’m fairly optimistic about that.
The first confirmed cases of COVID reinfections came through findings by your departmental colleagues. Additionally, variants and mutants are becoming an increasing threat for resurgence of cases. Are re-infections linked to virus mutations, and do you see the infections become a bigger subject in the near future?
Reinfections of COVID-19 so far are very uncommon events. Whenever a reinfection case is detected it kind of blows up in the headlines and everybody’s talking about it. But we must remember that there is even more robust data showing that the majority of people who catch COVID-19 are actually protected against it for several months at the very least. We have follow-up data for say nine months or so from the time that they caught COVID-19. The majority of these people do not catch COVID-19 again.
However, the emergence of certain variants, especially the South African variant is concerning because it seems to escape natural immunity or vaccine-derived COVID-19 immunity to a certain extent. And what that actually means in terms of the risk of reinfection has not been elucidated yet. In the laboratory, we know that yes, people who’ve caught COVID-19 before, their antibodies don’t seem to work as well against the South African variant. However, what that actually means in the real world setting – if they’ll actually get sick from COVID-19 again due to the variant or whether they would pass it off as an asymptomatic infection or they wouldn’t get infected at all – I’d say there’s a lot of differences and we’re not sure as yet.
The same goes for the vaccines. Most of the vaccines were evaluated against the “original” type of COVID-19, if you will. But there is some data from Novavax and Johnson & Johnson saying that the efficacy does drop somewhat when they did the trials in South Africa where the South African variant was circulating. But again, they are still effective. For example, against the British variant B.117, they’re very very good indeed. For the South African variant too, yes efficacy does drop but it still clears the 50% threshold set by WHO.
And I look forward to more data from the mRNA vaccine and the inactivated vaccines in real-world trials in areas where these new variants are circulating to see how well they work but I don’t see that as an obstacle for people getting vaccinated at all. Existing vaccines are still very good against most circulating variants.
Do the vaccine developers have to always stay on their toes to be on constant check for the next variant?
The reason COVID-19 has caused so much havoc is that people have never come in contact with this virus before.
So in a situation like that, you’re going to expect a certain proportion of people who come in contact with the virus to come down with a very severe disease – because it’s something our immune systems have absolutely never dealt with before. And so we observed that this is particularly the case in elderly people or people with chronic medical conditions.
But now once you have a sufficient proportion of the population vaccinated, i.e., their immune systems get a taste of what COVID-19 looks like, they have a kind of feeling for the virus, when they encounter a variant in the future, I would speculate that they are still protected to a certain extent. So I anticipate that even if more variants crop up in the future, it’s unlikely that the entire population needs to be revaccinated with the rejigged kind of vaccine. I think having been exposed to the vaccine or natural infection once would give most people a good level of protection against variants in the future. However, that may not be the case for the elderly or people with chronic medical conditions, and they may need the repeated doses of readjusted vaccines.
The mRNA vaccines, both Pfizer and Moderna, their CEOs came up saying they can quickly adjust the vaccine in order to cover the newly circulating variants. This might be something that is relaunched for vaccination of particularly at-risk groups in the future. But I don’t anticipate that the entire human population will require revaccination at regular intervals against COVID-19 because in most age groups and most people, it is a mild infection and it will most likely continue to be a mild infection.
I want to bring focus on the issues of misinformation. Masato Kajimoto from The University of Hong Kong said, “Regulating misinformation by either introducing new legislation or by expanding the scope of existing laws has been the trend in Asia for the last few years,” and he goes on to say that the pandemic has accelerated this. What are your thoughts on the relevance of these statements for Hong Kong?
I would say we have quite a lot of freedom to say what we want about COVID-19 and vaccine-related issues at the moment. That is both good and bad. You have a lot of great, meaningful discussions, but at the same time, you have a lot of fake news and misinformation going around.
Personally, I don’t feel that the right way to tackle misinformation is by legislating against it because then there would be suspicion of any efforts to legislate or say that certain forms of information communication are illegal. There would be quite a lot of public reaction to that. It falls down to individuals to keep themselves as informed as possible. It also comes down to social media outlets like Facebook, Twitter, and YouTube to identify misinformation on COVID-19 and actually clamp down on these sources before they do much damage.
I think at the moment it’s not a very efficient process and it does depend on a lot of machine learning algorithms to weed out this form of misinformation on social media. So that’s up to the tech people to figure out the best way of dealing with this.
We still see a lot of these spurious claims going around. The only way to tackle it is by constant messaging with the right information from trusted sources. So yeah, it’s a challenge.
What misinformation challenges do you feel are unique to Hong Kong? And how do you see those trends evolving?
That’s a good question. I think we are lucky in some ways. Anti-vaccination or the anti-vaxxer movement is not a massive thing in Hong Kong. We still have excellent rates of vaccination against things like measles, for example, where vaccination rates have really dropped in places like the US or Japan. They still remain relatively high in Hong Kong.
But we do have other sources of misunderstanding, in particular about the different vaccine types, their efficacies, where they come from, where they are made. And then claims are made relating to that. But all in all, I have to say that it’s probably much less than is encountered in, for example, the West. You won’t have people saying, “They’re putting the vaccines in to track you,” or some kind of “mind control”. Those kinds of theories are relatively still very fringe in Hong Kong.
You have been pretty active in fighting misinformation in getting the facts out about COVID-19 and vaccinations on your social media platforms. Give us an insight into your experiences as a virologist attempting to put the facts out there. What are the challenges that you face?
I think the main challenge is to communicate data from, say randomized control trials or phase 3 clinical trials, in a way that is easily understandable. I think something that’s frequently misunderstood is concepts like vaccine efficacy. So, if somebody says my vaccine has an efficacy of 50 percent or 60 percent – it is not intuitive what that really means. A layperson looking at the data would say, “Oh I get this vaccine. It’s still a coin toss whether I catch COVID-19 or not.” But that’s not what it means. It means that a person who receives the vaccine is half as likely, or 60 percent or 90 percent less likely to catch COVID-19 than a person who doesn’t have the vaccine. We often see these percentages just being thrown about in the press without a clear explanation of what it means. For people who don’t have training in terms of understanding these figures, it can be extremely difficult to comprehend. That’s one example of the kind of things that I have to digest or think about it from a non-specialist point of view and put it out there.
The other challenge is – it’s very easy to go out and say that vaccines are great, vaccines will solve everything, that this is absolutely the best thing for you to do. But real life is more nuanced. For example, there is a realistic risk of having an allergic reaction from an mRNA vaccine than another type. People need to be informed of that as well. We need to qualify our recommendations with both pros and cons, so I can say vaccination is probably the right decision for the majority of people but what vaccine you received will require careful consideration for your underlying health status, your age, your risk tolerance, your tolerance of side effects.
In this age of instant headlines, it is very difficult to communicate this kind of nuance, especially on different social media platforms. Facebook is a bit easier because there’s no character limit. With Twitter, you need to make a thread, and threads are highly non-intuitive ways of communicating information. Different platforms come with their own challenges. So it’s been quite an interesting experience.
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