Publications by authors named "Gabriel M Leung"

425 Publications

Health State Utility Values for Type 2 Diabetes and Related Complications in East and Southeast Asia: A Systematic Review and Meta-Analysis.

Value Health 2021 Jul 10;24(7):1059-1067. Epub 2021 Apr 10.

Division of Health Economics, Policy, and Management, School of Public Health, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China. Electronic address:

Objectives: East and Southeast Asia has the greatest burden of diabetes in the world. We sought to derive a reference set of utility values for type 2 diabetes without complication and disutility (utility decrement) values for important diabetes-related complications to better inform economic evaluation.

Methods: A systematic review to identify utility values for diabetes and related complications reported in East and Southeast Asia. We searched MEDLINE (OVID) from inception to May 26, 2020 for utility values elicited using direct and indirect methods. Identified studies were assessed for quality based on the National Institute of Health and Care Excellence guidelines. Utility and disutility estimates were pooled by meta-analyses with subgroup analyses to evaluate differences by nationality and valuation instrument. (PROSPERO: CRD42020191075).

Results: We identified 17 studies for the systematic review from a total of 13 035 studies in the initial search, of which 13 studies met the quality criteria for inclusion in the meta-analyses. The pooled utility value for diabetes without complication was 0.88 (95% CI 0.83-0.93), with the pooled utility decrement for associated complications ranged from 0.00 (for excess BMI) to 0.18 (for amputation). The utility values were consistently more conservative than previous estimates derived in Western populations. Utility decrements were comparable for SF-6D and EQ-5D valuation instruments and for Chinese and other Asian groups.

Conclusions: A reference set of pooled disutility and utility values for type 2 diabetes and its complications in East and Southeast Asian populations yielded more conservative estimates than Western populations.
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http://dx.doi.org/10.1016/j.jval.2020.12.019DOI Listing
July 2021

Learning from crisis: building resilient systems to combat future pandemics.

Lancet 2021 Jul;398(10294):e2-e6

Department of Infectious Diseases, Imperial College London, London, UK.

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http://dx.doi.org/10.1016/S0140-6736(21)00665-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8248923PMC
July 2021

SARS-CoV-2 under an elimination strategy in Hong Kong.

medRxiv 2021 Jun 23. Epub 2021 Jun 23.

Hong Kong utilized an elimination strategy with intermittent use of public health and social measures and increasingly stringent travel regulations to control SARS-CoV-2 transmission. By analyzing >1700 genome sequences representing 17% of confirmed cases from 23-January-2020 to 26-January-2021, we reveal the effects of fluctuating control measures on the evolution and epidemiology of SARS-CoV-2 lineages in Hong Kong. Despite numerous importations, only three introductions were responsible for 90% of locally-acquired cases, two of which circulated cryptically for weeks while less stringent measures were in place. We found that SARS-CoV-2 within-host diversity was most similar among transmission pairs and epidemiological clusters due to a strong transmission bottleneck through which similar genetic background generates similar within-host diversity.

One Sentence Summary: Out of the 170 detected introductions of SARS-CoV-2 in Hong Kong during 2020, three introductions caused 90% of community cases.
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http://dx.doi.org/10.1101/2021.06.19.21259169DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8240692PMC
June 2021

Development and validation of the CHIME simulation model to assess lifetime health outcomes of prediabetes and type 2 diabetes in Chinese populations: A modeling study.

PLoS Med 2021 Jun 24;18(6):e1003692. Epub 2021 Jun 24.

School of Public Health, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.

Background: Existing predictive outcomes models for type 2 diabetes developed and validated in historical European populations may not be applicable for East Asian populations due to differences in the epidemiology and complications. Despite the continuum of risk across the spectrum of risk factor values, existing models are typically limited to diabetes alone and ignore the progression from prediabetes to diabetes. The objective of this study is to develop and externally validate a patient-level simulation model for prediabetes and type 2 diabetes in the East Asian population for predicting lifetime health outcomes.

Methods And Findings: We developed a health outcomes model from a population-based cohort of individuals with prediabetes or type 2 diabetes: Hong Kong Clinical Management System (CMS, 97,628 participants) from 2006 to 2017. The Chinese Hong Kong Integrated Modeling and Evaluation (CHIME) simulation model comprises of 13 risk equations to predict mortality, micro- and macrovascular complications, and development of diabetes. Risk equations were derived using parametric proportional hazard models. External validation of the CHIME model was assessed in the China Health and Retirement Longitudinal Study (CHARLS, 4,567 participants) from 2011 to 2018 for mortality, ischemic heart disease, cerebrovascular disease, renal failure, cataract, and development of diabetes; and against 80 observed endpoints from 9 published trials using 100,000 simulated individuals per trial. The CHIME model was compared to United Kingdom Prospective Diabetes Study Outcomes Model 2 (UKPDS-OM2) and Risk Equations for Complications Of type 2 Diabetes (RECODe) by assessing model discrimination (C-statistics), calibration slope/intercept, root mean square percentage error (RMSPE), and R2. CHIME risk equations had C-statistics for discrimination from 0.636 to 0.813 internally and 0.702 to 0.770 externally for diabetes participants. Calibration slopes between deciles of expected and observed risk in CMS ranged from 0.680 to 1.333 for mortality, myocardial infarction, ischemic heart disease, retinopathy, neuropathy, ulcer of the skin, cataract, renal failure, and heart failure; 0.591 for peripheral vascular disease; 1.599 for cerebrovascular disease; and 2.247 for amputation; and in CHARLS outcomes from 0.709 to 1.035. CHIME had better discrimination and calibration than UKPDS-OM2 in CMS (C-statistics 0.548 to 0.772, slopes 0.130 to 3.846) and CHARLS (C-statistics 0.514 to 0.750, slopes -0.589 to 11.411); and small improvements in discrimination and better calibration than RECODe in CMS (C-statistics 0.615 to 0.793, slopes 0.138 to 1.514). Predictive error was smaller for CHIME in CMS (RSMPE 3.53% versus 10.82% for UKPDS-OM2 and 11.16% for RECODe) and CHARLS (RSMPE 4.49% versus 14.80% for UKPDS-OM2). Calibration performance of CHIME was generally better for trials with Asian participants (RMSPE 0.48% to 3.66%) than for non-Asian trials (RMPSE 0.81% to 8.50%). Main limitations include the limited number of outcomes recorded in the CHARLS cohort, and the generalizability of simulated cohorts derived from trial participants.

Conclusions: Our study shows that the CHIME model is a new validated tool for predicting progression of diabetes and its outcomes, particularly among Chinese and East Asian populations that has been lacking thus far. The CHIME model can be used by health service planners and policy makers to develop population-level strategies, for example, setting HbA1c and lipid targets, to optimize health outcomes.
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http://dx.doi.org/10.1371/journal.pmed.1003692DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8270422PMC
June 2021

Linking cohort-based data with electronic health records: a proof-of-concept methodological study in Hong Kong.

BMJ Open 2021 06 22;11(6):e045868. Epub 2021 Jun 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, Hong Kong

Objectives: Data linkage of cohort-based data and electronic health records (EHRs) has been practised in many countries, but in Hong Kong there is still a lack of such research. To expand the use of multisource data, we aimed to identify a feasible way of linking two cohorts with EHRs in Hong Kong.

Methods: Participants in the 'Children of 1997' birth cohort and the Chinese Early Development Instrument (CEDI) cohort were separated into several batches. The Hong Kong Identity Card Numbers (HKIDs) of each batch were then uploaded to the Hong Kong Clinical Data Analysis and Reporting System (CDARS) to retrieve EHRs. Within the same batch, each participant has a unique combination of date of birth and sex which can then be used for exact matching, as no HKID will be returned from CDARS. Raw data collected for the two cohorts were checked for the mismatched cases. After the matching, we conducted a simple descriptive analysis of attention deficit hyperactivity disorder (ADHD) information collected in the CEDI cohort via the Strengths and Weaknesses of ADHD Symptoms and Normal Behaviour Scale (SWAN) and EHRs.

Results: In total, 3473 and 910 HKIDs in the birth cohort and CEDI cohort were separated into 44 and 5 batches, respectively, and then submitted to the CDARS, with 100% and 97% being valid HKIDs respectively. The match rates were confirmed to be 100% and 99.75% after checking the cohort data. From our illustration using the ADHD information in the CEDI cohort, 36 (4.47%) individuals had ADHD-Combined score over the clinical cut-off in the SWAN survey, and 68 (8.31%) individuals had ADHD records in EHRs.

Conclusions: Using date of birth and sex as identifiable variables, we were able to link the cohort data and EHRs with high match rates. This method will assist in the generation of databases for future multidisciplinary research using both cohort data and EHRs.
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http://dx.doi.org/10.1136/bmjopen-2020-045868DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8220454PMC
June 2021

The first case study of wastewater-based epidemiology of COVID-19 in Hong Kong.

Sci Total Environ 2021 May 24;790:148000. Epub 2021 May 24.

Environmental Microbiome Engineering and Biotechnology Laboratory, Department of Civil Engineering, The University of Hong Kong, Pok Fu Lam Road, Hong Kong SAR, China. Electronic address:

Early detection and surveillance of severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) virus are key pre-requisites for the effective control of coronavirus disease (COVID-19). So far, sewage testing has been increasingly employed as an alternative surveillance tool for this disease. However, sampling site characteristics impact the testing results and should be addressed in the early use stage of this emerging tool. In this study, we implemented the sewage testing for SARS-CoV-2 virus across sampling sites with different sewage system characteristics. We first validated a testing method using "positive" samples from a hospital treating COVID-19 patients. This method was used to test 107 sewage samples collected during the third wave of the COVID-19 outbreak in Hong Kong (from June 8 to September 29, 2020), covering sampling sites associated with a COVID-19 hospital, public housing estates, and conventional sewage treatment facilities. The highest viral titer of 1975 copy/mL in sewage was observed in a sample collected from the isolation ward of the COVID-19 hospital. Sewage sampling at individual buildings detected the virus 2 days before the first cases were identified. Sequencing of the detected viral fragment confirmed an identical nucleotide sequence to that of the SARS-CoV-2 isolated from human samples. The virus was also detected in sewage treatment facilities, which serve populations of approximately 40,000 to more than one million people.
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http://dx.doi.org/10.1016/j.scitotenv.2021.148000DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8142803PMC
May 2021

Optic disc and peripapillary vessel density measured with optical coherence tomography angiography and its associations in Chinese adults: a large population-based study.

Br J Ophthalmol 2021 May 20. Epub 2021 May 20.

Ophthalmology, University of Hong Kong, Hong Kong, Hong Kong

Purpose: To investigate the optic disc and peripapillary vessel density, as well as its ocular and systemic associations, in healthy eyes among adult Chinese population.

Methods: A population-based cross-sectional eye survey was conducted on Chinese adults residing in Hong Kong. 1891 eyes from 1891 participants who completed 4.5×4.5 mm optical coherence tomography angiography scans were recruited. Among the 1891 eyes, 404 were excluded due to low scan quality, optic disc or retinal disorders and non-Chinese ethnicity. The vessel densities (VDs) at nerve fibre layer plexus (NFLP) at both optic disc and peripapillary were collected for analysis. Multiple linear regression analysis was performed to determine the ocular and systemic associations of NFLP VD.

Results: The study included 1487 participants (men: 41.2%) with a mean age of 48.8±15.4 years. The mean NFLP VD of the whole , inside disc and peripapillary region was 53.8%, 42.7% and 60.3%, respectively. In the multivariable model, decreased NFLP VDs were significantly associated with older age, male gender, longer axial length (AL) and lower Signal Strength Index.

Conclusions: This large population-based cross-sectional study provided quantitative data of optic disc and peripapillary NFLP VD which may serve as a normative reference for clinical use. Apart from age, gender and AL, the scan signal strength also should be taken into consideration during the assessment of NFLP VD.
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http://dx.doi.org/10.1136/bjophthalmol-2020-318199DOI Listing
May 2021

COVID-19 transmission in Hong Kong despite universal masking.

J Infect 2021 07 22;83(1):92-95. Epub 2021 Apr 22.

WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China; Laboratory of Data Discovery for Health, Hong Kong Science and Technology Park, Hong Kong Special Administrative Region, China. Electronic address:

Objectives: mask-wearing outside the home has been almost universal in Hong Kong since late January 2020 with very high compliance. Nevertheless, community spread of COVID-19 has still occurred. We aimed to assess the settings where COVID-19 transmission occurred and determine the fraction of transmission events that occurred in settings where masks are not usually worn.

Methods: we reviewed detailed information provided by the Hong Kong Department of Health on local COVID-19 cases diagnosed up to 30 September 2020 to determine the most likely settings in which transmission occurred. We classified them in probably mask-on or mask-of and compared the prevalence of asymptomatic infections in these settings.

Results: among the 2425 cases (65.3%, 2425/3711) with information on transmission setting, 77.6% of the transmission occurred in household and social settings where face masks are not usually worn. Infections that occurred in mask-on settings were more likely to be asymptomatic (adjusted odds ratio 1.33; 95% confidence interval: 1.04, 1.68).

Conclusions: we conclude that universal mask-wearing can reduce transmission, but transmission can continue to occur in settings where face masks are not usually worn. The higher proportion of asymptomatic cases in mask-on settings could be related to a milder disease presentation or earlier case detection.
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http://dx.doi.org/10.1016/j.jinf.2021.04.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8061183PMC
July 2021

Diagnostic performance of different sampling approaches for SARS-CoV-2 RT-PCR testing: a systematic review and meta-analysis.

Lancet Infect Dis 2021 Apr 12. Epub 2021 Apr 12.

WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China. Electronic address:

Background: The comparative performance of different clinical sampling methods for diagnosis of SARS-CoV-2 infection by RT-PCR among populations with suspected infection remains unclear. This meta-analysis aims to systematically compare the diagnostic performance of different clinical specimen collection methods.

Methods: In this systematic review and meta-analysis, we systematically searched PubMed, Embase, MEDLINE, Web of Science, medRxiv, bioRxiv, SSRN, and Research Square from Jan 1, 2000, to Nov 16, 2020. We included original clinical studies that examined the performance of nasopharyngeal swabs and any additional respiratory specimens for the diagnosis of SARS-CoV-2 infection among individuals presenting in ambulatory care. Studies without data on paired samples, or those that only examined different samples from confirmed SARS-CoV-2 cases were not useful for examining diagnostic performance of a test and were excluded. Diagnostic performance, including sensitivity, specificity, positive predictive value, and negative predictive value, was examined using random effects models and double arcsine transformation.

Findings: Of the 5577 studies identified in our search, 23 studies including 7973 participants with 16 762 respiratory samples were included. Respiratory specimens examined in these studies included 7973 nasopharyngeal swabs, 1622 nasal swabs, 6110 saliva samples, 338 throat swabs, and 719 pooled nasal and throat swabs. Using nasopharyngeal swabs as the gold standard, pooled nasal and throat swabs gave the highest sensitivity of 97% (95% CI 93-100), whereas lower sensitivities were achieved by saliva (85%, 75-93) and nasal swabs (86%, 77-93) and a much lower sensitivity by throat swabs (68%, 35-94). A comparably high positive predictive value was obtained by pooled nasal and throat (97%, 90-100) and nasal swabs (96%, 87-100) and a slightly lower positive predictive value by saliva (93%, 88-97). Throat swabs have the lowest positive predictive value of 75% (95% CI 45-96). Comparably high specificities (range 97-99%) and negative predictive value (range 95-99%) were observed among different clinical specimens. Comparison between health-care-worker collection and self-collection for pooled nasal and throat swabs and nasal swabs showed comparable diagnostic performance. No significant heterogeneity was observed in the analysis of pooled nasal and throat swabs and throat swabs, whereas moderate to substantial heterogeneity (I ≥30%) was observed in studies on saliva and nasal swabs.

Interpretation: Our review suggests that, compared with the gold standard of nasopharyngeal swabs, pooled nasal and throat swabs offered the best diagnostic performance of the alternative sampling approaches for diagnosis of SARS-CoV-2 infection in ambulatory care. Saliva and nasal swabs gave comparable and very good diagnostic performance and are clinically acceptable alternative specimen collection methods. Throat swabs gave a much lower sensitivity and positive predictive value and should not be recommended. Self-collection for pooled nasal and throat swabs and nasal swabs was not associated with any significant impairment of diagnostic accuracy. Our results also provide a useful reference framework for the proper interpretation of SARS-CoV-2 testing results using different clinical specimens.

Funding: Hong Kong Research Grants Council.
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http://dx.doi.org/10.1016/S1473-3099(21)00146-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8041361PMC
April 2021

Modelling COVID-19.

Nat Rev Phys 2020 May 6:1-3. Epub 2020 May 6.

WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.

As the COVID-19 pandemic continues, mathematical epidemiologists share their views on what models reveal about how the disease has spread, the current state of play and what work still needs to be done.
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http://dx.doi.org/10.1038/s42254-020-0178-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7201389PMC
May 2020

Nowcasting epidemics of novel pathogens: lessons from COVID-19.

Nat Med 2021 03 15;27(3):388-395. Epub 2021 Mar 15.

WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China.

Epidemic nowcasting broadly refers to assessing the current state by understanding key pathogenic, epidemiologic, clinical and socio-behavioral characteristics of an ongoing outbreak. Its primary objective is to provide situational awareness and inform decisions on control responses. In the event of large-scale sustained emergencies, such as the COVID-19 pandemic, scientists need to constantly update their aims and analytics with respect to the rapidly evolving emergence of new questions, data and findings in order to synthesize real-time evidence for policy decisions. In this Perspective, we share our views on the functional aims, rationale, data requirements and challenges of nowcasting at different stages of an epidemic, drawing on the ongoing COVID-19 experience. We highlight how recent advances in the computational and laboratory sciences could be harnessed to complement traditional approaches to enhance the scope, timeliness, reliability and utility of epidemic nowcasting.
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http://dx.doi.org/10.1038/s41591-021-01278-wDOI Listing
March 2021

How the lessons of previous epidemics helped successful countries fight covid-19.

BMJ 2021 03 11;372:n486. Epub 2021 Mar 11.

Bioinformatics Institute, Agency for Science, Technology and Research, Singapore.

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http://dx.doi.org/10.1136/bmj.n486DOI Listing
March 2021

Real-time tracking and prediction of COVID-19 infection using digital proxies of population mobility and mixing.

Nat Commun 2021 03 8;12(1):1501. Epub 2021 Mar 8.

WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, SAR, China.

Digital proxies of human mobility and physical mixing have been used to monitor viral transmissibility and effectiveness of social distancing interventions in the ongoing COVID-19 pandemic. We develop a new framework that parameterizes disease transmission models with age-specific digital mobility data. By fitting the model to case data in Hong Kong, we are able to accurately track the local effective reproduction number of COVID-19 in near real time (i.e., no longer constrained by the delay of around 9 days between infection and reporting of cases) which is essential for quick assessment of the effectiveness of interventions on reducing transmissibility. Our findings show that accurate nowcast and forecast of COVID-19 epidemics can be obtained by integrating valid digital proxies of physical mixing into conventional epidemic models.
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http://dx.doi.org/10.1038/s41467-021-21776-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7940469PMC
March 2021

Clinical outcomes of different therapeutic options for COVID-19 in two Chinese case cohorts: A propensity-score analysis.

EClinicalMedicine 2021 Feb 13;32:100743. Epub 2021 Feb 13.

WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.

Background: The timing of administration of agents and use of combination treatments in COVID-19 remain unclear. We assessed the effectiveness of therapeutics in cohorts in Hong Kong SAR and Anhui, China.

Methods: We conducted propensity-score analysis of 4771 symptomatic patients from Hong Kong between 21st January and 6th December 2020, and 648 symptomatic patients from Anhui between 1st January and 27th February 2020. We censored all observations as at 13st December 2020. Time from hospital admission to discharge, and composite outcome of death, invasive mechanical ventilation or intensive care unit admission across 1) all therapeutic options including lopinavir-ritonavir, ribavirin, umifenovir, interferon-alpha-2b, interferon-beta-1b, corticosteroids, antibiotics, and Chinese medicines, and 2) four interferon-beta-1b combination treatment groups were investigated.

Findings: Interferon-beta-1b was associated with an improved composite outcome (OR=0.55, 95%CI 0.38, 0.80) and earlier discharge (-8.8 days, 95%CI -9.7, -7.9) compared to those not administered interferon-beta-1b. Oral ribavirin initiated within 7 days from onset was associated with lower risk of the composite outcome in Hong Kong (OR=0.51, 95%CI 0.29, 0.90). Lopinavir-ritonavir, intravenous ribavirin, umifenovir, corticosteroids, interferon-alpha-2b, antibiotics or Chinese medicines failed to show consistent clinical benefit. Interferon-beta-1b co-administered with ribavirin was associated with improved composite outcome (OR=0.50, 95%CI 0.32, 0.78) and earlier discharge (-2.35 days, 95%CI -3.65, -1.06) compared to interferon-beta-1b monotherapy.

Interpretation: Our findings support the early administration of interferon-beta-1b alone or in combination with oral ribavirin for COVID-19 patients.

Funding: Hong Kong Health and Medical Research Fund; Hong Kong Innovation and Technology Commission; Chinese Fundamental Research Funds for the Central Universities.
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http://dx.doi.org/10.1016/j.eclinm.2021.100743DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7881744PMC
February 2021

Co-producing the covid-19 response in Germany, Hong Kong, Lebanon, and Pakistan.

BMJ 2021 02 15;372:n243. Epub 2021 Feb 15.

Alliance for Health Policy and Systems Research, World Health Organization, Geneva, Switzerland.

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http://dx.doi.org/10.1136/bmj.n243DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7879266PMC
February 2021

Early transmissibility assessment of the N501Y mutant strains of SARS-CoV-2 in the United Kingdom, October to November 2020.

Euro Surveill 2021 01;26(1)

Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, New Territories, Hong Kong SAR, China.

Two new SARS-CoV-2 lineages with the N501Y mutation in the receptor-binding domain of the spike protein spread rapidly in the United Kingdom. We estimated that the earlier 501Y lineage without amino acid deletion Δ69/Δ70, circulating mainly between early September and mid-November, was 10% (6-13%) more transmissible than the 501N lineage, and the 501Y lineage with amino acid deletion Δ69/Δ70, circulating since late September, was 75% (70-80%) more transmissible than the 501N lineage.
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http://dx.doi.org/10.2807/1560-7917.ES.2020.26.1.2002106DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7791602PMC
January 2021

Changing disparities in COVID-19 burden in the ethnically homogeneous population of Hong Kong through pandemic waves: an observational study.

Clin Infect Dis 2021 Jan 6. Epub 2021 Jan 6.

WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China.

Background: Disparities were marked in previous pandemics, usually with higher attack rates reported for those in lower socioeconomic positions and for ethnic minorities.

Methods: We examined characteristics of laboratory-confirmed COVID-19 cases in Hong Kong, assessed associations between incidence and population-level characteristics at the level of small geographic areas, and evaluated relations between socioeconomics and work-from-home (WFH) arrangements.

Results: The largest source of COVID-19 importations switched from students studying overseas in the second wave to foreign domestic helpers in the third. The local cases were mostly individuals not in formal employment (retirees and homemakers) and production workers who were unable to WFH. For every 10% increase in the proportion of population employed as executives or professionals in a given geographic region, there was an 84% (95% confidence interval (CI): 1% to 97%) reduction in the incidence of COVID-19 during the third wave. In contrast, in the first two waves, the same was associated with 3.69 times (95% CI: 1.02 to 13.33) higher incidence. Executives and professionals were more likely to implement WFH and experienced frequent changes in WFH practice, compared to production workers.

Conclusions: Consistent findings on the reversed socioeconomic patterning of COVID-19 burden between infection waves in Hong Kong at both individual and population level analyses indicated that risks of infections may be related to occupations involving high exposure frequency and WFH flexibility. Contextual determinants should be taken into account in policy planning aiming at mitigating such disparities.
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http://dx.doi.org/10.1093/cid/ciab002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7929139PMC
January 2021

Public perception and performance of different sampling approaches for the diagnosis of COVID-19.

Influenza Other Respir Viruses 2021 05 4;15(3):420-422. Epub 2021 Jan 4.

WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.

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http://dx.doi.org/10.1111/irv.12834DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8051699PMC
May 2021

Face masks and COVID-19: don't let perfect be the enemy of good.

Euro Surveill 2020 12;25(49)

Laboratory of Data Discovery for Health, Hong Kong Science and Technology Park, Hong Kong Special Administrative Region, China.

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http://dx.doi.org/10.2807/1560-7917.ES.2020.25.49.2001998DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7730488PMC
December 2020

The epidemiology of population mental wellbeing in China.

Lancet Public Health 2020 12;5(12):e631-e632

School of Public Health, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China; Laboratory of Data Discovery for Health (D(2)4H), Hong Kong Science and Technology Park, Hong Kong Special Administrative Region, China.

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http://dx.doi.org/10.1016/S2468-2667(20)30265-6DOI Listing
December 2020

Using genetics to understand the role of antihypertensive drugs modulating angiotensin-converting enzyme in immune function and inflammation.

Br J Clin Pharmacol 2021 04 23;87(4):1839-1846. Epub 2020 Oct 23.

School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China.

Aim: Angiotensin-converting enzyme 2 (ACE 2) is the binding domain for severe acute respiratory syndrome coronavirus (SARS-CoV) and SARSCoV-2. Some antihypertensive drugs affect ACE2 expression or activity (ACE inhibitors and angiotensin II receptor blockers [ARBs]), suggesting use of other hypertensives might be preferable, such as calcium channel blockers (CCBs). Given the limited evidence, the International Society of Hypertension does not support such a policy.

Methods: We used a Mendelian randomization study to obtain unconfounded associations of antihypertensives, instrumented by published genetic variants in genes regulating target proteins of these drugs, with immune (lymphocyte and neutrophil percentage) and inflammatory (tumour necrosis factor alpha [TNF-α]) markers in the largest available genome-wide association studies.

Results: Genetically predicted effects of ACE inhibitors increased lymphocyte percentage (0.78, 95% confidence interval [CI] 0.35, 1.22), decreased neutrophil percentage (-0.64, 95% CI -1.09, -0.20) and possibly lowered TNF-α (-4.92, 95% CI -8.50, -1.33). CCBs showed a similar pattern for immune function (lymphocyte percentage 0.21, 95% CI 0.05 to 0.36; neutrophil percentage -0.23, 95% CI -0.39 to -0.08) but had no effect on TNF-α, as did potassium-sparing diuretics and aldosterone antagonists, and vasodilator antihypertensives. ARBs and other classes of hypertensives had no effect on immune function or TNF-α.

Conclusion: Varying effects of different classes of antihypertensives on immune and inflammatory markers do not suggest antihypertensive use based on their role in ACE2 expression, but instead suggest investigation of the role of antihypertensives in immune function and inflammation might reveal important information that could optimize their use in SARSCoV-2.
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http://dx.doi.org/10.1111/bcp.14572DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7675404PMC
April 2021

Lessons learnt from easing COVID-19 restrictions: an analysis of countries and regions in Asia Pacific and Europe.

Lancet 2020 11 24;396(10261):1525-1534. Epub 2020 Sep 24.

Saw Swee Hock School of Public Health, National University of Singapore, Singapore; Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK. Electronic address:

The COVID-19 pandemic is an unprecedented global crisis. Many countries have implemented restrictions on population movement to slow the spread of severe acute respiratory syndrome coronavirus 2 and prevent health systems from becoming overwhelmed; some have instituted full or partial lockdowns. However, lockdowns and other extreme restrictions cannot be sustained for the long term in the hope that there will be an effective vaccine or treatment for COVID-19. Governments worldwide now face the common challenge of easing lockdowns and restrictions while balancing various health, social, and economic concerns. To facilitate cross-country learning, this Health Policy paper uses an adapted framework to examine the approaches taken by nine high-income countries and regions that have started to ease COVID-19 restrictions: five in the Asia Pacific region (ie, Hong Kong [Special Administrative Region], Japan, New Zealand, Singapore, and South Korea) and four in Europe (ie, Germany, Norway, Spain, and the UK). This comparative analysis presents important lessons to be learnt from the experiences of these countries and regions. Although the future of the virus is unknown at present, countries should continue to share their experiences, shield populations who are at risk, and suppress transmission to save lives.
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http://dx.doi.org/10.1016/S0140-6736(20)32007-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7515628PMC
November 2020

What can we expect from first-generation COVID-19 vaccines?

Lancet 2020 11 21;396(10261):1467-1469. Epub 2020 Sep 21.

School of Public Health, LKS Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China. Electronic address:

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http://dx.doi.org/10.1016/S0140-6736(20)31976-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7505651PMC
November 2020

Clustering and superspreading potential of SARS-CoV-2 infections in Hong Kong.

Nat Med 2020 11 17;26(11):1714-1719. Epub 2020 Sep 17.

WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, Hong Kong, China.

Superspreading events (SSEs) have characterized previous epidemics of severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV) infections. For SARS-CoV-2, the degree to which SSEs are involved in transmission remains unclear, but there is growing evidence that SSEs might be a typical feature of COVID-19. Using contact tracing data from 1,038 SARS-CoV-2 cases confirmed between 23 January and 28 April 2020 in Hong Kong, we identified and characterized all local clusters of infection. We identified 4-7 SSEs across 51 clusters (n = 309 cases) and estimated that 19% (95% confidence interval, 15-24%) of cases seeded 80% of all local transmission. Transmission in social settings was associated with more secondary cases than households when controlling for age (P = 0.002). Decreasing the delay between symptom onset and case confirmation did not result in fewer secondary cases (P = 0.98), although the odds that an individual being quarantined as a contact interrupted transmission was 14.4 (95% CI, 1.9-107.2). Public health authorities should focus on rapidly tracing and quarantining contacts, along with implementing restrictions targeting social settings to reduce the risk of SSEs and suppress SARS-CoV-2 transmission.
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http://dx.doi.org/10.1038/s41591-020-1092-0DOI Listing
November 2020

Reply to: Is presymptomatic spread a major contributor to COVID-19 transmission?

Nat Med 2020 10 17;26(10):1534-1535. Epub 2020 Aug 17.

World Health Organization Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, University of Hong Kong, Hong Kong SAR, China.

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http://dx.doi.org/10.1038/s41591-020-1049-3DOI Listing
October 2020

Author Correction: Temporal dynamics in viral shedding and transmissibility of COVID-19.

Nat Med 2020 Sep;26(9):1491-1493

World Health Organization Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, University of Hong Kong, Hong Kong, SAR, China.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.
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http://dx.doi.org/10.1038/s41591-020-1016-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7413015PMC
September 2020

The impact of the Syrian conflict on population well-being.

Nat Commun 2020 08 6;11(1):3899. Epub 2020 Aug 6.

School of Public Health, LKS Faculty of Medicine, University of Hong Kong, 1/F Patrick Manson Building (North Wing), 7 Sassoon Road, Pokfulam, Hong Kong, China.

The United Nations described the Syrian conflict as the worst man-made disaster since World War II. We adopted a global perspective in examining the impact of the Syrian conflict on Syrians' physical, mental, and social well-being using the Gallup World Poll. Face-to-face interview data of 11,452 Syrian participants from 2008 to 2015 show that Syrians' physical (e.g., access to shelter), mental (e.g., life satisfaction), and social (e.g., social support) well-being decline substantially. Syrians who reported being exposed to the conflict are similarly affected compared to those without direct exposure, suggesting country-wide spillover effects. Global data covering 1.7 million participants across 163 countries from 2006 to 2016 show during the conflict, Syria's precipitous decline in well-being is unparalleled in the world, even when compared to countries similarly experiencing war, protests, and disasters. Our findings reinforce the vital importance of an accelerated peace process to restore well-being in Syria.
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http://dx.doi.org/10.1038/s41467-020-17369-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7411009PMC
August 2020

Evolution of effective serial interval of SARS-CoV-2 by non-pharmaceutical interventions.

Res Sq 2020 Jun 1. Epub 2020 Jun 1.

The University of Hong Kong.

Studies of novel coronavirus disease (COVID-19) have reported varying estimates of epidemiological parameters such as serial intervals and reproduction numbers. By compiling a unique line-list database of transmission pairs in mainland China, we demonstrated that serial intervals of COVID-19 have shortened substantially from a mean of 7.8 days to 2.6 days within a month. This change is driven by enhanced non-pharmaceutical interventions, in particular case isolation. We also demonstrated that using real-time estimation of serial intervals allowing for variation over time would provide more accurate estimates of reproduction numbers, than by using conventional definition of fixed serial interval distributions. These findings are essential to improve the assessment of transmission dynamics, forecasting future incidence, and estimating the impact of control measures.
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http://dx.doi.org/10.21203/rs.3.rs-32486/v1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7336698PMC
June 2020

Serial interval of SARS-CoV-2 was shortened over time by nonpharmaceutical interventions.

Science 2020 08 21;369(6507):1106-1109. Epub 2020 Jul 21.

WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China.

Studies of novel coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), have reported varying estimates of epidemiological parameters, including serial interval distributions-i.e., the time between illness onset in successive cases in a transmission chain-and reproduction numbers. By compiling a line-list database of transmission pairs in mainland China, we show that mean serial intervals of COVID-19 shortened substantially from 7.8 to 2.6 days within a month (9 January to 13 February 2020). This change was driven by enhanced nonpharmaceutical interventions, particularly case isolation. We also show that using real-time estimation of serial intervals allowing for variation over time provides more accurate estimates of reproduction numbers than using conventionally fixed serial interval distributions. These findings could improve our ability to assess transmission dynamics, forecast future incidence, and estimate the impact of control measures.
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http://dx.doi.org/10.1126/science.abc9004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7402628PMC
August 2020
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