Publications by authors named "Francisco Tsz Tsun Lai"

24 Publications

  • Page 1 of 1

Consumption of home-prepared meal at workplace as a predictor of glycated haemoglobin among people with type 2 diabetes in Hong Kong: a mixed-methods study.

Nutr Diabetes 2022 Apr 4;12(1):16. Epub 2022 Apr 4.

Centre for Health Systems and Policy Research, The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong SAR, China.

Objectives: There is increasing attention on association between eating patterns and diabetes control following global changes in eating patterns. There had been very limited research on the eating patterns of diabetic patients with employment, although working age population has seen the highest increase in diabetes incidence. This study aimed to identify workplace eating patterns in relation to glycaemic control among type 2 diabetic patients with employment.

Methods: This is a sequential mixed-methods study. The exploratory qualitative study involved focus group interviews with 31 type 2 diabetic patients with employment, which guided the design of a subsequent cross-sectional investigation involving 185 patients with employment. Thematic analysis was conducted on the qualitative data to identify workplace eating patterns most relevant to glycaemic control. Hierarchical multiple linear regression was performed to examine association between workplace eating pattern and glycaemic control, proxied by HbA1c.

Results: The focus group interviews identified frequency in the consumption of home-prepared meals (HPM) and meal hours as the major workplace eating patterns that affected glycaemic control. The cross-sectional study confirmed that regular consumption of HPM at workplace could explain variance of HbA1c, independent of socio-demographic factors, lifestyle factors and disease condition, with R = 0.146, F(14, 170) = 2.075, p = 0.015; adjusted R = 0.076. Patients who were female, in non-skilled occupation, on shift, with fixed work location and had break during work were more likely to consume HPM.

Conclusions: Consumption of HPM at workplace should be promoted to facilitate better glycaemic control by type 2 diabetic patients with employment, possibly through more practical dietary advice, and workplace accommodation in terms of space and facilities. In the context of COVID-19 pandemic, consumption of HPM also meant additional protection for diabetic patients through reducing close contact exposures in restaurants.
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http://dx.doi.org/10.1038/s41387-022-00188-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8979147PMC
April 2022

Impact of a delayed second dose of mRNA vaccine (BNT162b2) and inactivated SARS-CoV-2 vaccine (CoronaVac) on risks of all-cause mortality, emergency department visit, and unscheduled hospitalization.

BMC Med 2022 03 17;20(1):119. Epub 2022 Mar 17.

Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong SAR, China.

Background: Safety after the second dose of the SARS-CoV-2 vaccine remains to be elucidated, especially among individuals reporting adverse events after their first dose. This study aims to evaluate the impact of a delayed second dose on all-cause mortality and emergency services.

Methods: A territory-wide, retrospective cohort of people who had completed two doses of mRNA (BNT162b2) or inactivated SARS-CoV-2 (CoronaVac) vaccine between February 23 and July 3, 2021, in Hong Kong was analyzed, with linkage to electronic health records retrieved from the Hong Kong Hospital Authority. Vaccine recipients were classified as receiving a second dose within recommended intervals (21-28 days for BNT162b2; 14-28 days for CoronaVac) or delayed. Study outcomes were all-cause mortality, emergency department (ED) visits, and unscheduled hospitalizations within 28 days after the second dose of vaccination.

Results: Among 417,497 BNT162b2 and 354,283 CoronaVac second dose recipients, 3.8% and 28.5% received the second dose beyond the recommended intervals (mean 34.4 and 31.8 days), respectively. During the study period, there were < 5 daily new cases of COVID-19 infections in the community. Delaying the second dose was not associated with all-cause mortality (hazard ratio [HR] = 1.185, 95% CI 0.478-2.937, P = 0.714), risk of ED visit (HR = 0.966, 95% CI 0.926-1.008, P = 0.113), and risk of unscheduled hospitalization (HR = 0.956, 95% CI 0.878-1.040, P = 0.294) compared to that within the recommended interval for CoronaVac recipients. No statistically significant differences in all-cause mortality (HR = 4.438, 95% CI 0.951-20.701, P = 0.058), ED visit (HR = 1.037, 95% CI 0.951-1.130, P = 0.411), and unscheduled hospitalization (HR = 1.054, 95% CI 0.867-1.281, P = 0.597) were identified between people who received a second dose of BNT162b2 within and beyond the recommended intervals.

Conclusions: No significant association between delayed second dose of BNT162b2 or CoronaVac and all-cause mortality, ED visit, and unscheduled hospitalization was observed in the present cohort. Regardless of the recommended or delayed schedule for SARS-CoV-2 vaccination, a second dose of both vaccines should be administered to obtain better protection against infection and serious disease. The second dose should be administered within the recommended interval following the manufacturer's product information, until further studies support the benefits of delaying vaccination outweighing the risks.
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http://dx.doi.org/10.1186/s12916-022-02321-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8926447PMC
March 2022

Adverse events of special interest following the use of BNT162b2 in adolescents: a population-based retrospective cohort study.

Emerg Microbes Infect 2022 Dec;11(1):885-893

Department of Paediatrics and Adolescent Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China.

Accruing evidence suggests an increased risk of myocarditis in adolescents from messenger RNA COVID-19 vaccines. However, other potential adverse events remain under-researched. We conducted a retrospective cohort study of adolescents aged 12-18 with a territory-wide electronic healthcare database of the Hong Kong population linked with population-based vaccination records and supplemented with age- and sex-specific population numbers. Two age- and sex-matched retrospective cohorts were formed to observe 28 days following the first and second doses of BNT162b2 and estimate the age- and sex-adjusted incidence rate ratios between the vaccinated and unvaccinated. Thirty AESIs adapted from the World Health Organization's Global Advisory Committee on Vaccine Safety were examined. Eventually, the first-dose cohort comprised 274,881 adolescents (50.25% received the first dose) and the second-dose cohort 237,964 (50.29% received the second dose). Ninety-four (34.2 per 100,000 persons) adolescents in the first-dose cohort and 130 (54.6 per 100,000 persons) in the second-dose cohort experienced ≥1 AESIs. There were no statistically significant differences in the risk of any AESI associated with BNT162b2 except myocarditis [first-dose cohort: incidence rate ratio (IRR) = 9.15, 95% confidence interval (CI) 1.14-73.16; second-dose cohort: IRR = 29.61, 95% CI 4.04-217.07] and sleeping disturbances/disorders after the second dose (IRR = 2.06, 95% CI 1.01-4.24). Sensitivity analysis showed that, with myocarditis excluded as AESIs, no significantly elevated risk of AESIs as a composite outcome associated with vaccination was observed (= 0.195). To conclude, the overall absolute risk of AESIs was low with no evidence of an increased risk of AESIs except myocarditis and sleeping disturbances/disorders.
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http://dx.doi.org/10.1080/22221751.2022.2050952DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8942549PMC
December 2022

Safety of Inactivated and mRNA COVID-19 Vaccination Among Patients Treated for Hypothyroidism: A Population-Based Cohort Study.

Thyroid 2022 May 7;32(5):505-514. Epub 2022 Apr 7.

Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.

Thyroiditis and Graves' disease have been reported after coronavirus disease 2019 (COVID-19) vaccination. We evaluated the risks of adverse events after COVID-19 vaccination among patients treated for hypothyroidism. In this retrospective population-based cohort study of Hong Kong Hospital Authority electronic health records with the Department of Health vaccination records linkage, levothyroxine (LT4) users were categorized into unvaccinated, vaccinated with BNT162b2 (mRNA vaccine), or CoronaVac (inactivated vaccine) between February 23, 2021, and September 9, 2021. Study outcomes were dosage reduction or escalation in LT4, emergency department (ED) visit, unscheduled hospitalization, adverse events of special interest (AESI) according to the World Health Organization's Global Advisory Committee on Vaccine Safety, and all-cause mortality. Inverse probability of treatment weighting for propensity score was applied to balance baseline patient characteristics among the three groups. Hazard ratios (HR) were estimated using Cox regression models. Patients were observed from the index date until the occurrence of study outcome, death, or censored on September 30, 2021, whichever came first. In total, 47,086 LT4 users were identified (BNT162b2:  = 12,310; CoronaVac:  = 11,353; and unvaccinated:  = 23,423). COVID-19 vaccination was not associated with increased risks of LT4 dosage reduction (BNT162b2: HR = 0.971 [confidence interval; CI 0.892-1.058]; CoronaVac: HR = 0.968 [CI 0.904-1.037]) or escalation (BNT162b2: HR = 0.779 [CI 0.519-1.169]; CoronaVac: HR = 0.715 [CI 0.481-1.062]). Besides, COVID-19 vaccination was not associated with a higher risk of ED visits (BNT162b2: HR = 0.944 [CI 0.700-1.273]; CoronaVac: HR = 0.851 [CI 0.647-1.120]) or unscheduled hospitalization (BNT162b2: HR = 0.905 [CI 0.539-1.520]; CoronaVac: HR = 0.735 [CI 0.448-1.207]). There were two (0.016%) deaths and six (0.062%) AESI recorded for BNT162b2 recipients, and one (0.009%) and three (0.035%) for CoronaVac recipients, respectively. BNT162b2 or CoronaVac vaccination is not associated with unstable thyroid status or an increased risk of adverse outcomes among patients treated for hypothyroidism in general. These reassuring data should encourage them to get vaccinated against COVID-19 for protection from potentially worse COVID-19-related outcomes.
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http://dx.doi.org/10.1089/thy.2021.0684DOI Listing
May 2022

Myocarditis Following COVID-19 BNT162b2 Vaccination Among Adolescents in Hong Kong.

JAMA Pediatr 2022 Feb 25. Epub 2022 Feb 25.

Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong.

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http://dx.doi.org/10.1001/jamapediatrics.2022.0101DOI Listing
February 2022

Self-reported reactogenicity of CoronaVac (Sinovac) compared with Comirnaty (Pfizer-BioNTech): A prospective cohort study with intensive monitoring.

Vaccine 2022 03 7;40(10):1390-1396. Epub 2022 Feb 7.

Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong, China; Laboratory of Data Discovery for. Health (D(2)4H), Hong Kong Science and Technology Park, Hong Kong, China. Electronic address:

Objective: CoronaVac (Sinovac) Covid-19 vaccine has recently been approved for emergency use by the World Health Organization. However, data on its reactogenicity in real-world settings is scant. This study aimed to compare self-reported post-vaccination adverse reactions between CoronaVac and Comirnaty (Pfizer-BioNTech).

Methods: We adopted a prospective cohort study design using online surveys from the day of first-dose vaccination with intensive follow-up through two weeks after the second dose (11 time points). The primary outcome was adverse reactions (any versus none) and secondary outcomes were the sub-categories of adverse reactions (local, systemic, and severe allergic reactions). Potential effect modification across multimorbidity status, older age, and sex was examined.

Results: In total, 2,098 participants who were scheduled to complete the 14th-day survey were included, with 46.2% receiving Comirnaty. Retention rate two weeks after the second dose was 81.0% for the CoronaVac group and 83.6% for the Comirnaty group. Throughout the follow-up period, 801 (82.7%) of those receiving Comirnaty and 543 (48.1%) of those receiving CoronaVac reported adverse reactions. Adjusted analysis suggested that compared with Comirnaty, CoronaVac was associated with 83%-reduced odds of any adverse reactions [adjusted odds ratio (AOR) = 0.17, 95% confidence interval (CI) 0.15-0.20], 92%-reduced odds of local adverse reactions (AOR = 0.08, 95% CI 0.06-0.09), and 76%-reduced odds of systemic adverse reactions (AOR = 0.24, 95% CI 0.16-0.28). No significant effect modification was identified.

Conclusion: This post-marketing study comparing the reactogenicity of Covid-19 vaccines suggests a lower risk of self-reported adverse reactions following vaccination with CoronaVac compared with Comirnaty.
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http://dx.doi.org/10.1016/j.vaccine.2022.01.062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8818394PMC
March 2022

Lack of inflammatory bowel disease flare-up following two-dose BNT162b2 vaccine: a population-based cohort study.

Gut 2022 Feb 8. Epub 2022 Feb 8.

Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China

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http://dx.doi.org/10.1136/gutjnl-2021-326860DOI Listing
February 2022

Herpes zoster related hospitalization after inactivated (CoronaVac) and mRNA (BNT162b2) SARS-CoV-2 vaccination: A self-controlled case series and nested case-control study.

Lancet Reg Health West Pac 2022 Apr 2;21:100393. Epub 2022 Feb 2.

Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China.

Background: Stimulation of immunity by vaccination may elicit adverse events. There is currently inconclusive evidence on the relationship between herpes zoster related hospitalization and COVID-19 vaccination. This study aimed to evaluate the effect of inactivated virus (CoronaVac, Sinovac) and mRNA (BNT162b2, BioNTech/Fosun Pharma) COVID-19 vaccine on the risk of herpes zoster related hospitalization.

Methods: Self-controlled case series (SCCS) analysis was conducted using the data from the electronic health records in Hospital Authority and COVID-19 vaccination records in the Department of Health in Hong Kong. We conducted the SCCS analysis including patients with a first primary diagnosis of herpes zoster in the hospital inpatient setting between February 23 and July 31, 2021. A confirmatory analysis by nested case-control method was also conducted. Each herpes zoster case was randomly matched with ten controls according to sex, age, Charlson comorbidity index, and date of hospital admission. Conditional Poisson regression and logistic regression models were used to assess the potential excess rates of herpes zoster after vaccination.

Findings: From February 23 to July 31, 2021, a total of 16 and 27 patients were identified with a first primary hospital diagnosis of herpes zoster within 28 days after CoronaVac and BNT162b2 vaccinations. The incidence of herpes zoster was 7.9 (95% Confidence interval [CI]: 5.2-11.5) for CoronaVac and 7.1 (95% CI: 4.1-11.5) for BNT162b2 per 1,000,000 doses administered. In SCCS analysis, CoronaVac vaccination was associated with significantly higher risk of herpes zoster within 14 days after first dose (adjusted incidence rate ratio [aIRR]=2.67, 95% CI: 1.08-6.59) but not in other periods afterwards compared to the baseline period. Regarding BNT162b2 vaccination, a significantly increased risk of herpes zoster was observed after first dose up to 14 days after second dose (0-13 days after first dose: aIRR=5.23, 95% CI: 1.61-17.03; 14-27 days after first dose: aIRR=5.82, 95% CI: 1.62-20.91; 0-13 days after second dose: aIRR=5.14, 95% CI: 1.29-20.47). Using these relative rates, we estimated that there has been an excess of approximately 5 and 7 cases of hospitalization as a result of herpes zoster after every 1,000,000 doses of CoronaVac and BNT162b2 vaccination, respectively. The findings in the nested case control analysis showed similar results.

Interpretation: We identified an increased risk of herpes zoster related hospitalization after CoronaVac and BNT162b2 vaccinations. However, the absolute risks of such adverse event after CoronaVac and BNT162b2 vaccinations were very low. In locations where COVID-19 is prevalent, the protective effects on COVID-19 from vaccinations will greatly outweigh the potential side effects of vaccination.

Funding: The project was funded by Research Grant from the Food and Health Bureau, The Government of the Hong Kong Special Administrative Region (Ref. No.COVID19F01). FTTL (Francisco Tsz Tsun Lai) and ICKW (Ian Chi Kei Wong)'s posts were partly funded by D4H; hence this work was partly supported by [email protected] administered by Innovation and Technology Commission.
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http://dx.doi.org/10.1016/j.lanwpc.2022.100393DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8808060PMC
April 2022

Association of volunteer-administered home care with reduced emergency room visits and hospitalization among older adults with chronic conditions: A propensity-score-matched cohort study.

Int J Nurs Stud 2022 Mar 17;127:104158. Epub 2021 Dec 17.

The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong. 2/F Postgraduate Education Centre, Prince of Wales Hospital, 30-32 Ngan Shing Street, Sha Tin, New Territories, Hong Kong Special Administration Region, China. Electronic address:

Objectives: The objective of this study was to examine the association of receiving care from a volunteer-administered outreach program with emergency room utilization and hospitalization among older people with chronic conditions in Hong Kong.

Methods: Volunteers consisting of retired healthcare professionals, university students, and openly recruited citizens received training to provide home care services to hospital-discharged older Chinese adults aged 65+ with chronic conditions who were identified as high-risk patients of hospital admission and referred by public healthcare providers. Several home visits were made to enhance the patients' self-care capacity. For comparison, a 4:1-propensity score matching based on age, sex, the month of discharge, length of stay for the index episode, and 14 common chronic conditions was conducted to select a comparison group from a territory-wide inpatient database. Poisson regression was used to compare emergency room utilization and the number of hospitalized days.

Results: In total, 775 patients were analyzed, including 155 home care recipients and 620 extracted from the inpatient database as a matched comparison with similar baseline characteristics. Regression analysis showed that home care recipients had 21% fewer overall emergency room visits [95% confidence interval (CI): 3%-35%], 22% fewer such visits which led to hospitalization (95% CI: 1%-39%) and 22% fewer overall hospitalized days (95% CI: 16%-28%). Nevertheless, the number of hospitalized days admitted through the emergency room was 10% higher among home care recipients (95% CI: 0%-20%).

Conclusions: Volunteer-administered home care might be effective in reducing emergency room visits and non-acute hospitalization, as well as early detection of acute problems warranting tertiary care. Further randomized studies are needed to substantiate this finding.
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http://dx.doi.org/10.1016/j.ijnurstu.2021.104158DOI Listing
March 2022

COVID-19 vaccines and risks of hematological abnormalities: Nested case-control and self-controlled case series study.

Am J Hematol 2022 04 9;97(4):470-480. Epub 2022 Feb 9.

Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Hong Kong Special Administrative Region, China.

Several studies reported hematological abnormalities after vaccination against the coronavirus disease 2019 (COVID-19). We evaluated the association between COVID-19 vaccines (CoronaVac and BNT162b2) and hematological abnormalities. We conducted nested case-control and self-controlled case series analyses using the data from the Hong Kong Hospital Authority and the Department of Health, HKSAR. Outcomes of interest were thrombocytopenia, leukopenia, and neutropenia. Adjusted odds ratios (aORs), incidence rate ratios (IRRs), and 95% confidence intervals (CIs) were estimated using conditional logistic regression. In total, 1 643 419 people received COVID-19 vaccination (738 609 CoronaVac; 904 810 BNT162b2). We identified 457 and 422 cases after CoronaVac and BNT162b2 vaccination, respectively. For CoronaVac, the incidence of thrombocytopenia, leukopenia, and neutropenia was 2.51, 1.08, and 0.15 per 10 000 doses. For BNT162b2, the corresponding incidence was 1.39, 1.17, and 0.26 per 10 000 doses. The incidence per 10 000 COVID-19 cases were 1254, 2341, and 884, respectively. We only observed an increased risk of leukopenia following the second dose of BNT162b2 (aOR 1.58, 95% CI 1.24-2.02; day 0-14, IRR 2.21; 95% CI 1.59-3.08). There was no increased risk of any hematological abnormalities after CoronaVac vaccination. We observed an increased risk of leukopenia shortly after the second dose of BNT162b2. However, the incidence was much lower than the incidence following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections. There was no association between CoronaVac and hematological abnormalities. The benefits of vaccination against COVID-19 still outweigh the risk of hematological abnormalities.
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http://dx.doi.org/10.1002/ajh.26478DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9011752PMC
April 2022

Carditis After COVID-19 Vaccination With a Messenger RNA Vaccine and an Inactivated Virus Vaccine : A Case-Control Study.

Ann Intern Med 2022 03 25;175(3):362-370. Epub 2022 Jan 25.

Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, and Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Hong Kong Science and Technology Park, Hong Kong Special Administrative Region, China, and Research Department of Practice and Policy, School of Pharmacy, University College London, London, United Kingdom (I.C.K.).

Background: Case reports of carditis after BNT162b2 vaccination are accruing worldwide.

Objective: To examine the association of BNT162b2 and CoronaVac (Sinovac) vaccination with carditis.

Design: Case-control study with hospital control participants.

Setting: Territory-wide, public health care database with linkage to population-based vaccination records in Hong Kong.

Patients: Inpatients aged 12 years or older first diagnosed with carditis were selected as case patients. All other hospitalized patients without carditis were treated as control participants. Ten control participants were randomly matched with each case patient by age, sex, and admission date.

Intervention: Vaccination with BNT162b2 or CoronaVac.

Measurements: Incident diagnosis of carditis based on the International Classification of Diseases, Ninth Revision, and elevated troponin levels.

Results: A total of 160 case patients and 1533 control participants were included. Incidence of carditis per 100 000 doses of CoronaVac and BNT162b2 administered was estimated to be 0.31 (95% CI, 0.13 to 0.66) and 0.57 (CI, 0.36 to 0.90), respectively. Multivariable analyses showed that recipients of the BNT162b2 vaccine had higher odds of carditis (adjusted odds ratio [OR], 3.57 [CI, 1.93 to 6.60]) than unvaccinated persons. Stratified by sex, the OR was 4.68 (CI, 2.25 to 9.71) for males and 2.22 (CI, 0.57 to 8.69) for females receiving the BNT162b2 vaccine. The ORs for adults and adolescents receiving the BNT162b2 vaccine were 2.41 (CI, 1.18 to 4.90) and 13.79 (CI, 2.86 to 110.38), respectively. Subanalysis showed an OR of 9.29 (CI, 3.94 to 21.91) for myocarditis and 1.06 (CI, 0.35 to 3.22) for pericarditis associated with BNT162b2. The risk was mainly seen after the second dose of BNT162b2 rather than the first. No association between CoronaVac and carditis with a magnitude similar to that for BNT162b2 was seen.

Limitation: Limited sample size, absence of electrocardiography and other clinical investigative data, and unrecorded overseas vaccination exposure.

Conclusion: Despite a low absolute risk, there is an increased risk for carditis associated with BNT162b2 vaccination. This elevated risk should be weighed against the benefits of vaccination.

Primary Funding Source: Health and Medical Research Fund.
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http://dx.doi.org/10.7326/M21-3700DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8814917PMC
March 2022

Multimorbidity and adverse events of special interest associated with Covid-19 vaccines in Hong Kong.

Nat Commun 2022 01 20;13(1):411. Epub 2022 Jan 20.

Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China.

Prior research using electronic health records for Covid-19 vaccine safety monitoring typically focuses on specific disease groups and excludes individuals with multimorbidity, defined as ≥2 chronic conditions. We examine the potential additional risk of adverse events 28 days after the first dose of CoronaVac or Comirnaty imposed by multimorbidity. Using a territory-wide public healthcare database with population-based vaccination records in Hong Kong, we analyze a retrospective cohort of patients with chronic conditions. Thirty adverse events of special interest according to the World Health Organization are examined. In total, 883,416 patients are included and 2,807 (0.3%) develop adverse events. Results suggest vaccinated patients have lower risks of adverse events than unvaccinated individuals, multimorbidity is associated with increased risks regardless of vaccination, and the association of vaccination with adverse events is not modified by multimorbidity. To conclude, we find no evidence that multimorbidity imposes extra risks of adverse events following Covid-19 vaccination.
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http://dx.doi.org/10.1038/s41467-022-28068-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8776841PMC
January 2022

Post-Covid-19-vaccination adverse events and healthcare utilization among individuals with or without previous SARS-CoV-2 infection.

J Intern Med 2022 Jun 1;291(6):864-869. Epub 2022 Feb 1.

Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.

Background: Post-marketing pharmacovigilance data are scant on the safety of Covid-19 vaccines among people with previous SARS-CoV-2 infection compared with ordinary vaccine recipients. We compared the post-vaccination adverse events of special interests (AESI), accident and emergency room (A&E) visit, and hospitalization between these two groups.

Methods: We conducted a retrospective cohort study using a territory-wide public healthcare database with population-based vaccination records in Hong Kong.

Results: In total, 3922 vaccine recipients with previous SARS-CoV-2 infection and 1,137,583 vaccine recipients without previous SARS-CoV-2 infection were included. No significant association was observed between previous SARS-CoV-2 infection and AESI or hospitalization. Previous SARS-CoV-2 infection was significantly associated with a lower risk of A&E visit (CoronaVac: hazard ratios [HR] = 0.56, 95% confidence intervals [CI]: 0.32-0.99; Comirnaty: HR = 0.62, 95% CI: 0.47-0.82).

Conclusion: No safety signal of Covid-19 vaccination was detected from the comparison between vaccine recipients with previous SARS-CoV-2 infection and those without infection.
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http://dx.doi.org/10.1111/joim.13453DOI Listing
June 2022

Comparing self-reported reactogenicity between adolescents and adults following the use of BNT162b2 (Pfizer-BioNTech) messenger RNA COVID-19 vaccine: a prospective cohort study.

Int J Infect Dis 2022 Mar 26;116:47-50. Epub 2021 Dec 26.

Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong, China; Laboratory of Data Discovery for Health (D²4H), Hong Kong Science and Technology Park, Hong Kong, China. Electronic address:

Objectives: Although clinical data have shown that the BNT162b2 vaccine, which is widely used in many countries, is safe and effective as a protection against the SARS-CoV-2 infection, extant research in adverse reactions using real-world data of various sociodemographic characteristics is scant.

Methods: We conducted a prospective cohort study to compare age differences in self-reported reactogenicity of BNT162b2 in Hong Kong. A total of 1,516 participants were intensively followed up for two weeks following both doses of BNT162b2 vaccination, during which their basic demographic, health conditions, and medication information were collected.

Results: Results from the generalized mixed model showed that compared with adults aged 18 to 59 years, older adults aged 60 years or above had a lower risk of adverse reactions and adolescents aged 12 to 17 years had a moderately higher risk.

Conclusions: Results of this study should be informative to parents considering BNT162b2 vaccination for their children in that moderately increased reactogenicity compared with adults is anticipated.
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http://dx.doi.org/10.1016/j.ijid.2021.12.354DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8710238PMC
March 2022

Two-dose COVID-19 vaccination and possible arthritis flare among patients with rheumatoid arthritis in Hong Kong.

Ann Rheum Dis 2022 04 22;81(4):564-568. Epub 2021 Oct 22.

Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China

Objectives: To investigate the relationship between COVID-19 full vaccination (two completed doses) and possible arthritis flare.

Methods: Patients with rheumatoid arthritis (RA) were identified from population-based electronic medical records with vaccination linkage and categorised into BNT162b2 (mRNA vaccine), CoronaVac (inactive virus vaccine) and non-vaccinated groups. The risk of possible arthritis flare after vaccination was compared using a propensity-weighted cohort study design. We defined possible arthritis flare as hospitalisation and outpatient consultation related to RA or reactive arthritis, based on diagnosis records during the episode. Weekly prescriptions of rheumatic drugs since the launch of COVID-19 vaccination programme were compared to complement the findings from a diagnosis-based analysis.

Results: Among 5493 patients with RA (BNT162b2: 653; CoronaVac: 671; non-vaccinated: 4169), propensity-scored weighted Poisson regression showed no significant association between arthritis flare and COVID-19 vaccination ((BNT162b2: adjusted incidence rate ratio 0.86, 95% Confidence Interval 0.73 to 1.01); CoronaVac: 0.87 (0.74 to 1.02)). The distribution of weekly rheumatic drug prescriptions showed no significant differences among the three groups since the launch of the mass vaccination programme (all p values >0.1 from Kruskal-Wallis test).

Conclusions: Current evidence does not support that full vaccination of mRNA or inactivated virus COVID-19 vaccines is associated with possible arthritis flare.
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http://dx.doi.org/10.1136/annrheumdis-2021-221571DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8550868PMC
April 2022

Disrupted daily routines mediate the socioeconomic gradient of depression amid public health crises: A repeated cross-sectional study.

Aust N Z J Psychiatry 2021 Oct 22:48674211051271. Epub 2021 Oct 22.

Centre for Psychosocial Health, The Education University of Hong Kong, Hong Kong SAR, China.

Objective: There is a socioeconomic gradient to depression risks, with more pronounced inequality amid macroenvironmental potential traumatic events. Between mid-2019 and mid-2020, the Hong Kong population experienced drastic societal changes, including the escalating civil unrest and the COVID-19 pandemic. We examined the change of the socioeconomic gradient in depression and the potential intermediary role of daily routine disruptions.

Method: We conducted repeated territory-wide telephone surveys in July 2019 and July 2020 with 1112 and 2034 population-representative Cantonese-speaking Hong Kong citizens above 15 years old, respectively. Stratified by year, we examined the association between socioeconomic indicators (education attainment, household income, employment status and marital status) and probable depression (nine-item Patient Health Questionnaire [PHQ-9] ⩾ 10) using logistic regression. Differences in the socioeconomic gradient between 2019 and 2020 were tested. Finally, we performed a path analysis to test for the mediating role of daily routine disruptions.

Results: Logistic regression showed that higher education attainment in 2019 and being married in 2020 were protective against probable depression. Interaction analysis showed that the inverse association of higher education attainment with probable depression attenuated in 2020 but that of being married increased. Path analysis showed that the mediated effects through daily routine disruptions accounted for 95.9% of the socioeconomic gradient of probable depression in 2020, compared with 13.1% in 2019.

Conclusion: From July 2019 to July 2020, the mediating role of daily routine disruptions in the socioeconomic gradient of depression in Hong Kong increased. It is thus implied that infection control measures should consider the relevant potential mental health impacts accordingly.
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http://dx.doi.org/10.1177/00048674211051271DOI Listing
October 2021

Gender-specific trends of educational inequality in diagnosed diabetes from 1999 to 2014 in Hong Kong: a serial cross-sectional study of 97,481 community-dwelling Chinese adults.

Popul Health Metr 2021 10 10;19(1):37. Epub 2021 Oct 10.

The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China.

Background: Gender differences in the trend of educational inequality in diabetes have been widely observed in the Western populations, indicating the increasing importance of educational attainment as a social determinant of diabetes among women. Nonetheless, relevant evidence is scarce in developed Asian settings for comparisons. This study examined the gender-specific trends of educational inequality in diagnosed diabetes in Hong Kong between 1999 and 2014.

Methods: A series of eight territory-wide population-representative samples of 97,481 community-dwelling Hong Kong Chinese adults aged 45 or above were surveyed between 1999 and 2014. Regression-based Relative Index of Inequality (RII) and age-standardized Slope Index of Inequality (SII) were adopted to examine the extent and trend of gender-specific educational inequality in self-reported physician-diagnosed diabetes.

Results: Age-standardized prevalence of diabetes increased in both genders over time, with a steeper surge among men. In addition, educational inequalities in diabetes, in both relative and absolute terms, significantly widened among women over the study period (annual RII change = 1.04; 95% CI = 1.02-1.07, annual SII change = 0.36%; 95% CI = 0.16-0.56%), with the peak in 2011 (RII = 2.44; 95% CI = 1.83-3.24, SII = 9.21%; 95% CI = 6.47-11.96%). However, no significant widening inequality was found among men. Further adjustment for household income level did not attenuate the observed educational inequality.

Conclusions: Despite a greater increase in diabetes prevalence among men, disparity in diabetes substantially widened across education levels among women in the past decade in Hong Kong. The gender perspective should be taken into considerations for policy making to alleviate the prevalence surge and rising educational inequality in diabetes.
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http://dx.doi.org/10.1186/s12963-021-00268-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8504033PMC
October 2021

Characterization of Unlinked Cases of COVID-19 and Implications for Contact Tracing Measures: Retrospective Analysis of Surveillance Data.

JMIR Public Health Surveill 2021 11 16;7(11):e30968. Epub 2021 Nov 16.

Centre for Health Systems and Policy Research, Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, Hong Kong.

Background: Contact tracing and intensive testing programs are essential for controlling the spread of COVID-19. However, conventional contact tracing is resource intensive and may not result in the tracing of all cases due to recall bias and cases not knowing the identity of some close contacts. Few studies have reported the epidemiological features of cases not identified by contact tracing ("unlinked cases") or described their potential roles in seeding community outbreaks.

Objective: For this study, we characterized the role of unlinked cases in the epidemic by comparing their epidemiological profile with the linked cases; we also estimated their transmission potential across different settings.

Methods: We obtained rapid surveillance data from the government, which contained the line listing of COVID-19 confirmed cases during the first three waves in Hong Kong. We compared the demographics, history of chronic illnesses, epidemiological characteristics, clinical characteristics, and outcomes of linked and unlinked cases. Transmission potentials in different settings were assessed by fitting a negative binomial distribution to the observed offspring distribution.

Results: Time interval from illness onset to hospital admission was longer among unlinked cases than linked cases (median 5.00 days versus 3.78 days; P<.001), with a higher proportion of cases whose condition was critical or serious (13.0% versus 8.2%; P<.001). The proportion of unlinked cases was associated with an increase in the weekly number of local cases (P=.049). Cluster transmissions from the unlinked cases were most frequently identified in household settings, followed by eateries and workplaces, with the estimated probability of cluster transmissions being around 0.4 for households and 0.1-0.3 for the latter two settings.

Conclusions: The unlinked cases were positively associated with time to hospital admission, severity of infection, and epidemic size-implying a need to design and implement digital tracing methods to complement current conventional testing and tracing. To minimize the risk of cluster transmissions from unlinked cases, digital tracing approaches should be effectively applied in high-risk socioeconomic settings, and risk assessments should be conducted to review and adjust the policies.
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http://dx.doi.org/10.2196/30968DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8598156PMC
November 2021

Bell's palsy following vaccination with mRNA (BNT162b2) and inactivated (CoronaVac) SARS-CoV-2 vaccines: a case series and nested case-control study.

Lancet Infect Dis 2022 01 16;22(1):64-72. Epub 2021 Aug 16.

Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China; Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, Sha Tin, Hong Kong Special Administrative Region, China; Expert Committee on Clinical Events Assessment Following COVID-19 Immunization, Department of Health, The Government of the Hong Kong Special Administrative Region, Hong Kong Special Administrative Region, China; Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK. Electronic address:

Background: Bell's palsy is a rare adverse event reported in clinical trials of COVID-19 vaccines. However, to our knowledge no population-based study has assessed the association between the inactivated SARS-CoV-2 vaccines and Bell's palsy. The aim of this study was to evaluate the risk of Bell's palsy after BNT162b2 and CoronaVac vaccination.

Methods: In this case series and nested case-control study done in Hong Kong, we assessed the risk of Bell's palsy within 42 days following vaccination with BNT162b2 (Fosun-BioNTech [equivalent to Pfizer-BioNTech]) or CoronaVac (from Sinovac Biotech, Hong Kong) using data from voluntary surveillance reporting with the Hospital Authority, the COVID-19 Vaccine Adverse Event Online Reporting system for all health-care professionals, and the Hospital Authority's territory-wide electronic health records from the Clinical Data Analysis and Reporting System. We described reported cases of Bell's palsy among vaccine recipients (aged 18-110 years for CoronaVac and aged 16-110 years for BNT162b2). We compared the estimated age-standardised incidence of clinically confirmed cases among individuals who had received the CoronaVac or BNT162b2 vaccination (up to 42 days before presentation) with the background incidence in the population. A nested case-control study was also done using conditional logistic regression to estimate the odds ratio (OR) for risk of Bell's palsy and vaccination. Cases and controls were matched (1:4) by age, sex, admission setting, and admission date.

Findings: Between February 23 and May 4, 2021, 451 939 individuals received the first dose of CoronaVac and 537 205 individuals received the first dose of BNT162b2. 28 clinically confirmed cases of Bell's palsy were reported following CoronaVac and 16 cases were reported following BNT162b2. The age-standardised incidence of clinically confirmed Bell's palsy was 66·9 cases per 100 000 person-years (95% CI 37·2 to 96·6) following CoronaVac vaccination and 42·8 per 100 000 person-years (19·4 to 66·1) for BNT162b2 vaccination. The age-standardised difference for the incidence compared with the background population was 41·5 (95% CI 11·7 to 71·4) for CoronaVac and 17·0 (-6·6 to 40·6) for BNT162b2, equivalent to an additional 4·8 cases per 100 000 people vaccinated for CoronaVac and 2·0 cases per 100 000 people vaccinated for BNT162b2. In the nested case-control analysis, 298 cases were matched to 1181 controls, and the adjusted ORs were 2·385 (95% CI 1·415 to 4·022) for CoronaVac and 1·755 (0·886 to 3·477) for BNT162b2.

Interpretation: Our findings suggest an overall increased risk of Bell's palsy after CoronaVac vaccination. However, the beneficial and protective effects of the inactivated COVID-19 vaccine far outweigh the risk of this generally self-limiting adverse event. Additional studies are needed in other regions to confirm our findings.

Funding: The Food and Health Bureau of the Government of the Hong Kong Special Administrative Region, China.

Translation: For the Chinese translation of the abstract see Supplementary Materials section.
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http://dx.doi.org/10.1016/S1473-3099(21)00451-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8367195PMC
January 2022

Socioeconomic determinants of depression amid the anti-extradition bill protests in Hong Kong: the mediating role of daily routine disruptions.

J Epidemiol Community Health 2020 12 11;74(12):988-994. Epub 2020 Aug 11.

Centre for Psychosocial Health, The Education University of Hong Kong, Hong Kong SAR, China

Background: Previous research has suggested a socioeconomic gradient of mental health in the face of potentially traumatic events. Nevertheless, few studies examined the intermediary mechanisms of this gradient. This study tested a hypothesised mediating effect of disruptions to daily routines (eg, eating/sleeping habits) between socioeconomic status (SES) and depression among participants and non-participants of the anti-extradition bill protests in summer 2019 in Hong Kong.

Methods: A territory-wide telephone survey was conducted during the movement in the first 3 weeks of July 2019 to collect self-report data from 1112 Cantonese-speaking Hong Kong citizens. Stratified by participation in the anti-extradition bill protests, logistic regression was conducted to examine the inverse relationship between SES and depression. Subsequently, path analysis was conducted to test the hypothesised indirect effect through daily routine disruptions.

Results: In total, 581 (52.2%) respondents participated in the anti-extradition bill protests. Logistic regression showed that higher educational attainment was protective of depression among both participants and non-participants, while the protective effect of household income level HK$40 000-HK$79 999 (compared with
Conclusions: Daily routine disruptions partially explain the association between low SES and depression, especially among participants of the anti-extradition bill protests. To improve population mental health, such disruptions should be mitigated.
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http://dx.doi.org/10.1136/jech-2019-213693DOI Listing
December 2020

Association between time from SARS-CoV-2 onset to case confirmation and time to recovery across sociodemographic strata in Singapore.

J Epidemiol Community Health 2020 08 7;74(8):678. Epub 2020 Jun 7.

The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Sha Tin, Hong Kong

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http://dx.doi.org/10.1136/jech-2020-214516DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7320746PMC
August 2020

Housing affordability effects on physical and mental health: household survey in a population with the world's greatest housing affordability stress.

J Epidemiol Community Health 2020 02 5;74(2):164-172. Epub 2019 Nov 5.

JC School of Public Health and Primary Care, The Chinese University of Hong Kong, New Territories, Hong Kong.

Background: We examined the association of housing affordability with physical and mental health in Hong Kong, where there is a lack of related research despite having the worst housing affordability problem in the world, considering potential mediating effect of deprivation.

Methods: A stratified random sample of 1978 Hong Kong adults were surveyed. Housing affordability was defined using the residual-income (after housing costs) approach. Health-related quality of life was assessed by the Short-Form Health Survey version 2 (SF-12v2), from which the physical component summary (PCS) and mental component summary (MCS) measures were derived. Multivariable linear regressions were performed to assess associations of housing affordability with PCS and MCS scores, adjusting for sociodemographic, socioeconomic and lifestyle factors. Mediation analyses were also conducted to assess the mediating role of deprivation on the effect of housing affordability on PCS or MCS.

Results: Dose-response relationships were observed between housing affordability and mean PCS score ( (95% CI) compared with the highest affordable fourth quartile: -2.53 (-4.05 to -1.01), -2.23 (-3.54 to -0.92), -0.64 (-1.80 to 0.51) for the first, second and third quartiles, respectively) and mean MCS score ( (95% CI): -3.87 (-5.30 to -2.45), -2.35 (-3.59 to -1.11), -1.28 (-2.40 to -0.17) for the first, second and third quartiles, respectively). Deprivation mediated 34.3% of the impact of housing unaffordability on PCS and 15.8% of that on MCS.

Conclusions: Housing affordability affects physical and mental health, partially through deprivation, suggesting that housing policies targeting deprived individuals may help reduce health inequality in addition to targeting the housing affordability problem.
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http://dx.doi.org/10.1136/jech-2019-212286DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6993018PMC
February 2020

Measuring everyday processes and mechanisms of stress resilience: Development and initial validation of the Sustainability of Living Inventory (SOLI).

Psychol Assess 2019 Jun 10;31(6):715-729. Epub 2019 Jan 10.

Department of Behavioral Sciences, Rush University Medical Center.

Sustainment of daily routines requires greater psychological resilience and may lead to greater resilience in the face of stressors. Existing scales tend only to focus on emotions and engagement, rather than how well individuals sustain routine behaviors. To address this gap in the literature, we developed the Sustainability of Living Inventory (SOLI). A pool of 46 Likert-type items were developed to indicate how regularly respondents performed a variety of specific routines. Four separate study samples were collected through online surveys with community-dwelling American adults (N = 1,109). The final model evidenced excellent goodness-of-fit and consisted of 42 items, which loaded on eight dimensions: hygiene, eating, sleep, duties at home, leisure at home, exercising, social activities, and work/study involvement (α = .73-.93). These eight dimensions further loaded on two second-order factors, primary and secondary daily routines. Convergent validity was demonstrated in the correlations with Lawton Instrumental Activities of Daily Living Scale, Perceived Ability to Cope with Trauma Scale, Savoring Beliefs Inventory, and Conservation of Resources-Evaluation. Discriminant validity was demonstrated in the correlations with the List of Threatening Experiences, Life Events Checklist for DSM-5, and items on chronic financial strain. Criterion-related validity was demonstrated in the correlations with established outcome measures including State-Trait Anxiety Inventory, Patient Health Questionnaire, PTSD Checklist-Civilian Version, Positive and Negative Affect Schedule, Satisfaction with Life Scale, and Perceived Stress Scale. Incremental validity was shown in the correlations with outcome measures independent of common coping and resource variables. Implications of the SOLI on mental health screening and intervention were discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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http://dx.doi.org/10.1037/pas0000692DOI Listing
June 2019

The independent role of deprivation in abdominal obesity beyond income poverty. A population-based household survey in Chinese adults.

J Public Health (Oxf) 2019 09;41(3):476-486

The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong.

Background: Individual-level deprivation takes into account the non-monetary aspects of poverty that neither income poverty nor socio-economic factors could fully capture; however, it has rarely been considered in existing studies on social inequality in obesity. Therefore, we examined the associations of deprivation, beyond income poverty, with both general and abdominal obesity.

Methods: A territory-wide two-stage stratified random sample of 2282 community-dwelling Hong Kong adults was surveyed via face-to-face household interviews between 2014 and 2015. Deprivation was assessed by a Deprivation Index specific to the Hong Kong population. General obesity was defined as body mass index (BMI) ≥ 25 kg/m2, while abdominal obesity was defined as waist circumference (WC) ≥ 90 cm/80 cm for male/female. Multivariable binary logistic regressions were performed.

Results: Deprivation was independently associated with abdominal obesity (odds ratios (OR) = 1.68; 95% confidence intervals (CI): 1.27-2.22); however, no significant association was found with general obesity (OR=1.03; CI: 0.77-1.38). After additional adjustment for BMI, deprivation remained strongly associated with abdominal obesity (OR=2.00; CI: 1.41-2.83); and after further adjustment for WC, deprivation had a marginal inverse association with general obesity (OR=0.72; CI: 0.51-1.01).

Conclusions: Deprivation is an important risk factor of abdominal obesity and plays a critical role in capturing the preferential abdominal fat deposition beyond income poverty.
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http://dx.doi.org/10.1093/pubmed/fdy161DOI Listing
September 2019
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