Panel on Health Services (Minutes) 17 Jul 98

Legislative Council

LC Paper No. CB(2) 239/98-99
(These minutes have been seen
by the Administration)

Ref : CB2/PL/HS

LegCo Panel on Health Services

Minutes of Special Meeting
Held on Friday, 17 July 1998 at 8:30 am
in Conference Room A of the Legislative Council Building
Members Present:

Hon Michael HO Mun-ka (Chairman)
Dr Hon LEONG Che-hung, JP (Deputy Chairman)
Hon HO Sai-chu, JP
Hon Cyd HO Sau-lan
Hon CHAN Yuen-han
Hon Mrs Sophie LEUNG LAU Yau-fun, JP
Hon YEUNG Yiu-chung
Dr Hon TANG Siu-tong, JP
Hon LAW Chi-kwong, JP

Member Absent :

Dr Hon YEUNG Sum

Member Attending:

Hon WONG Yung-kan

Public Officers Attending:

Health and Welfare Bureau
Mr Gregory LEUNG: Deputy Secretary for Health and Welfare (1)
Mr Stephen NG: Deputy Secretary for Health and Welfare (4)
Miss Winnie TSE: Assistant Secretary for Health and Welfare
Department of Health
Dr T A SAW: Acting Director of Health
Dr K H MAK: Consultant (Community Medicine)
Dr W L LIM: Consultant Medical Microbiologist
Hospital Authority
Dr W M KO: Deputy Director of Operations
Dr K M CHOY: Executive Manager (Professional Services)

Clerk in Attendance :

Ms Doris CHAN: Chief Assistant Secretary (2) 4

Staff in Attendance :

Ms Joanne MAK: Senior Assistant Secretary (2) 4

I. Discussion with the Administration
(LC Paper No. CB(2) 62/98-99)

Acting Director of Health (DH(Atg)) said that "enterovirus" was a generic term for some 70 viruses that replicated in the guts of men. Enterovirus infection was found worldwide and not new. This disease entity was first described as far back as 1969. The recent interest in enterovirus 71 (EV 71) was in relation to the outbreak in Taiwan in which EV 71 had been associated with complications leading sometimes to death. A certain percentage of enterovirus infections presented as mild fever which would pass off in a few days. A proportion of them ended up as Hand Foot Mouth Disease (HFMD). A case of HFMD was invariably due to enterovirus infection. A small percentage of such HFMD might end up in complicated forms such as myocardities and aseptic meningitis.

2. DH(Atg) said that when the Department of Health (DH) first learnt of the outbreak in Taiwan, it had set up regular contact with the National Quarantine Service in Taiwan in late May through phone calls, fax and e-mail. An action plan had also been formulated. DH(Atg) said that there was no need for panic, but there was a need to remain vigilant through extended surveillance for the complicated forms of EV 71. DH(Atg) briefed members on the following actions which had been / would be undertaken by the Administration to contain the problem of EV 71 infection in Hong Kong -

Setting up since 14 June 1998 a sentinel surveillance system which involved 63 General Outpatient Clinics and 16 private practitioners.
Stepping up since 21 June 1998 monitoring of the number of hospital admissions due to HFMD and/or complications associated with enterovirus infection.
Redeploying manpower and resources to support the laboratory work required for the surveillance programme. The Government Virus Unit was able to cope with 2 000 specimens in June 1998 as compared with around 850 specimens in June 1997.
DH had investigated all cases reported from institutions like child care centres and nurseries, and all suspected and confirmed cases of EV 71 were being investigated.

3. DH(Atg) further informed members that since the Interdepartmental Working Group on Enterovirus Infection (the Working Group) was set up in July 1998 and conducted its first meeting on 7 July 1998, the Working Group had taken the following actions to prevent the spread of EV 71 in Hong Kong -

As at 13 July 1998, 92% of all child care centres ( i.e. 350 out of 382) had been inspected and 100% would be covered by 18 July 1998. 30% of all kindergartens (i.e. 272 out of some 700) had been inspected so far.
In terms of environmental hygiene in children playgrounds and amusement centres, the two municipal councils had been advised on the method to clean and disinfect toys, play equipment and facilities at these amenities.
On the maintenance of swimming pools, the Working Group had reviewed the preventive measures in all public and private swimming pools. Staff there were required to strictly prohibit persons with obvious skin diseases, particularly HFMD, from using the pools. Posters presenting skin diseases particularly HFMD would be displayed. Proper maintenance of the pools would be ensured and the free residual chlorine content of all swimming pools would be maintained at the levels of 1 ppm for chlorinated pools and 0.5 ppm for pools where chlorine and ozone were used. Sampling of the pool water would be done on an hourly basis.
In terms of public education and publicity, pamphlets had been produced and distributed through clinics, District Offices and were made available in public places. Hotlines had been set up and, since 10 June 1998, data on enterovirus infection had been uploaded for professionals. Press conferences had been held and briefings for the press had been conducted almost on a daily basis.
Briefings for operators of child care centres on how to prevent the disease were held on 14 and 16 July 1998. For operators of kindergartens, such seminars were planned for 28 July 1998 and 5 August 1998. DH medical staff had also participated in television programmes to provide information on enterovirus infection upon request.
Consultant Medical Microbiologist (CMM) of DH had been sent to Taiwan to collect first hand information on EV 71.

4. DH(Atg) added that most of the operators of the inspected premises and members of the public were very co-operative. He also thanked members of the press for their responsible reporting of the efforts made to control the spread of the disease and messages concerning this illness. He said that at present, there was no need for closures of any swimming pools and child care centres. If there were reasons to believe that there ought to be certain cleansing procedures to be taken at these premises, the procedures could be undertaken at night, at the end of a day or during weekend. Closure for the purpose of cleaning and disinfection might be considered on a case by case basis but there was no case at the moment for an outright ban of institutions where children congregated throughout the territory on health grounds.

5. DH(Atg) said that as at 16 July 1998, there were eight confirmed and 14 suspected cases of EV 71 infection.

6. The Chairman referred to the letter issued by the Panel to the Administration dated 14 July 1998 and said that the information provided in the Administration's paper fell short of the requirements as stated in the said letter. While he appreciated that the Administration had limited time to prepare the information paper, he requested that in future all the information papers provided by the Administration should be as detailed as possible in order to save time for discussion. Deputy Secretary for Health and Welfare (1) (DS(HW)(1)) agreed to take note of the request.

Admin.

7. In response to Mr LAW Chi-kwong's enquiries, DH(Atg) said that among the confirmed and suspected cases, there was only one adult found to have contracted EV 71 and the symptoms shown were milder than in children's cases.

8. Mr YEUNG Yiu-chung was concerned about the ways of infection of EV 71. In reply, DH(Atg) said that in the eight confirmed cases, the disease was transmitted by the faecal oral route.

9. Mrs Sophie LEUNG enquired whether DH had kept a close watch on the development of the outbreak in Taiwan since it was first reported in late May. She considered that it was important for DH to know the factors leading to the outbreak in Taiwan so that it could devise the appropriate measures to prevent a similar outbreak in Hong Kong. In response, DH(Atg) said that the Administration had tried to obtain updated information from the Government of Taiwan almost on a daily basis since late May. The experience of Taiwan was no different from those outbreaks that had been reported in the past 30 years. He assured members that the Working Group was hopeful that it would be able to contain the problem of EV 71 with all the preventive measures in place, the publicity and public education underway and with the co-operation of the community. DH(Atg) considered that the crux of the matter was how well the Administration could prevent the spread of the disease and the complicated cases associated with it.

10. Dr LEONG Che-hung took the view that it was necessary for the Administration to find out the factors leading to the outbreak in Taiwan or else it could not really devise effective preventive measures against an outbreak in Hong Kong. However, DH(Atg) said that it was impossible now to tell what precipitating factors had led to the outbreak in Taiwan as the causes of the deaths during the outbreak were still under investigation.

11. Miss CHAN Yuen-han enquired about the reasons for the large increase in number of enterovirus infections in Hong Kong in 1998 as compared with the previous years from 1994 to 1997. In reply, DH(Atg) said that it was because DH had been undertaking more tests on the viruses. The number of the tests undertaken in the first half of 1998 was 12 418 as compared with 5 500-odd tests undertaken in the same period last year. DH(Atg) pointed out that there had been more specimens sent to DH from clinicians and other doctors. In addition, there was a seasonal pattern of increased activity of enteroviruses in this part of the world. Miss CHAN considered that the increase in the number of enterovirus infections from 32 in 1997 to 154 in 1998 was alarming and urged the Administration to explore the reasons behind. DH(Atg) said that it was due to increased activity of enteroviruses. Deputy Secretary for Health and Welfare (4) (DS(HW)(4)) confirmed that this year there was an increase in enterovirus infections in Hong Kong and the neighbouring regions.

12. Dr LEONG Che-hung asked the Administration whether the case of the adult contracting EV 71 suggested that the EV 71 discovered in Hong Kong had shown signs of mutation. DH(Atg) responded that EV 71 had been identified for 30 years and in all the outbreaks so far, DH had been mindful of the possibility of mutation. DH(Atg) said that so far with all the investigations done, he was not aware of any report suggesting that mutation of this virus had taken place. In short, this virus was relatively stable compared with flu virus. Among all the outbreaks so far, DH staff had not seen any mutation of the scale and the versatility which were normally seen in flu virus.

13. In response to Miss Cyd HO's enquiry, DH(Atg) said that the equipment for gene sequencing was being purchased. In the interim, DH had made arrangements to send the virus to Taiwan and Holland for gene sequencing. The results would be known early next week, which would be one week from the day of sending out the isolates. The results could show whether the virus found in Hong Kong was similar to the Taiwan strain or not. DH(Atg) said that the department also intended to collaborate with the University of Hong Kong and the Chinese University of Hong Kong for the gene sequencing work. He said that it was not possible to compare the length of time required to do gene sequencing by overseas and local institutions because it would depend on various factors such as the individual expertise of the persons doing the test. DH(Atg) said that when the gene sequencing equipment was available, DH would do the gene sequencing itself.

14. Dr LEONG Che-hung considered that the Administration should have learnt from previous incidents like bird flu and should have placed an order then to purchase the gene-sequencing equipment. He pointed out that as EV 71 had now affected adults, there was a possibility of mutation of the virus. The way to prove it was by gene sequencing and he regretted that the equipment had not yet been purchased. In reply, DH(Atg) said that as the department had sent specimens to overseas for gene sequencing, the results would be available soon. He emphasized that even with gene sequencing, DH could not predict the potential of the virus in causing fatal cases. He pointed out that it had been shown in all the outbreaks over the past 30 years that there was no way to predict the potential of the virus in causing fatal cases nor in this case even if the equipment was in place. He explained that gene sequencing was only used to look for changes in the structure of the virus which, however, had no bearing on the diagnosis or identity of the virus itself. It was only for academic purpose to know the gene sequences of a virus isolated. As far as gene sequencing was concerned, it had no impact on the contingency plan of the Working Group and how it would manage with an outbreak.

15. CMM said that the case of H5N1 was different because it was a new virus and gene sequencing was required at that time to ascertain the mode of transmission of the virus and whether the virus found in human beings was the same as that found in chicken. As for EV 71, one did not need gene sequencing to confirm the identity of it which could be done by other techniques. Gene sequencing was now needed only to identify whether the EV 71 found in Hong Kong was the same as that isolated in Taiwan or in other places where outbreaks of the disease had been reported.

16. In response to Mrs Sophie LEUNG's enquiry about details of the EV 71 discovered in Taiwan and Japan, CMM said that the virus isolated in Taiwan was closely related to that in Japan although the virus in Japan had only caused HFMD whereas the fatality in Taiwan was known to have been caused by EV 71. However, some EV 71 cases in Taiwan had also only caused HFMD and not any fatalities. Therefore, these factors proved that from gene sequencing itself, one could not predict the potential of the disease in causing fatal cases.

17. In view of the similarities in structure between the viruses found in Taiwan and Japan, Dr TANG Siu-tong considered that it was essential for DH to find out why EV 71 had caused death in Taiwan but not in Japan. In response, DH(Atg) said that the reasons for this were still under investigation.

18. Deputy Director (Operations) (DD(O)) of the Hospital Authority (HA) said that HA would try to obtain more information from Taiwan on the clinical symptoms of the fatal case(s) caused by EV 71. The information would be useful for the clinical management of EV 71 cases.

19. In response to Miss CHAN Yuen-han's enquiry about details of the rapid tests being conducted by HA, DD(O) said that there were three laboratories under HA responsible for conducting the rapid tests and each test would usually take one to four days to complete. He said that the technique of rapid tests was not new but it was the first time for them to be applied in testing EV 71 in Hong Kong. Thus, their sensitivity and specificity had yet to be monitored and evaluated. In view of this, DH and HA had agreed that all results on rapid tests obtained in HA hospitals should be followed up by confirmatory tests undertaken by DH. One type of rapid tests used was the Polymerase Chain Reaction technique. DD(O) said that the reliability of this technique in being applied to clinical management of EV 71 cases would be monitored. CMM added that another kind of the rapid tests which was Shell vial culture was more established with higher sensitivity and specificity than the Polymerase Chain Reaction technique. DD(O) said that both rapid tests would be done for patients who showed signs of severe complications and the results would be followed up by the confirmatory tests of DH.

20. Dr LEONG Che-hung noted that many enterovirus cases had been detected in Taiwan in May 1998. He queried why it had taken so long for DH to set up the sentinel surveillance system which was only available in June 1998. He also asked why only 16 private medical practitioners were involved in the surveillance system since private medical practitioners were important in helping to collect data on the virus. In response, DH(Atg) said that there was not any delay because the announcement of the outbreak in Taiwan was only made in late May. In fact, DH had reacted promptly and established contact with the National Quarantine Service in Taiwan by e-mail almost at the end of May. He considered that it was reasonable to have the surveillance system set up in two weeks. In response to Dr LEONG's second question, DH(Atg) said that the Working Group had planned to enlist more doctors in private practice to take part in the surveillance system and arrangements were being made to invite more of them to participate. At the Chairman's request, DH(Atg) agreed to provide a progress report within one month on the improvements made to the surveillance system.

Admin.

21. Dr TANG Siu-tong was concerned about the capability of the Working Group in monitoring and co-ordinating effectively the two municipal councils' performance of their assigned tasks. In response, DH(Atg) said that the participating departments of the Working Group had been very co-operative and taking up assigned tasks very promptly. In response to Dr TANG's enquiry, DH(Atg) clarified that the Working Group was not the Hygiene Services Committee under DH nor the former co-ordinating committee on H5N1. Rather, it was a new interdepartmental working group set up solely for preventing the spread of enterovirus in Hong Kong.

22. Dr LEONG Che-hung enquired as to why the Working Group had targetted child care centres first instead of kindergartens in the inspections carried out by DH despite the fact that the EV 71 cases were largely reported from kindergartens. DH(Atg) explained that it was because most of the kindergartens had closed for summer vacation. The kindergartens would be inspected when the new academic year commenced in mid August.

23. Dr LEONG Che-hung considered that the Education Department (ED), instead of the Urban Services Department or DH, should be responsible for inspecting cleanliness of kindergartens and teaching the students about hand washing. Dr LEONG further took the view that health education should be included as part of the curriculum of schools. In response DH(Atg) said that ED was actually involved and it had arranged the first seminar for staff of schools on 28 July 1998. DS(HW)(4) added that there was actually clear division of work between DH and ED. For examples, ED had issued guidelines to schools and kindergartens and provided health advice to the staff on observing personal and environmental hygiene. He understood that ED had targetted to promote students' awareness of personal hygiene and help them to develop practices of good personal hygiene starting from kindergarten education. In response to the Chairman's enquiries, DH(Atg) said that following the seminar held on 28 July 1998 for staff of schools, the next one would be held on 5 August 1998. In addition, a briefing session had been organized for operators of child care centres on 16 July 1998.

24. The Chairman suggested that DH should work out in conjunction with ED more specific guidelines to advise the staff of schools on what they should do in order to prevent the infection of HFMD and/or EV 71. In reply, DH(Atg) said that school staff had been advised of these during the seminars organized for them. Nevertheless, DH(Atg) agreed to consider including the advice in letters to be issued to the staff of schools.

Admin.

25. Responding to the Chairman's further enquiry, DH(Atg) assured that there was no duplication of resources by the present arrangement of engaging both HA and the two Universities in laboratory work for testing EV 71. He explained that DH provided all the laboratory support to the 44 hospitals of HA. On the other hand, the two academic institutions were able to do the initial part of culture and testing. They still had to send it to DH for the confirmatory test. Thus, the Virus Unit of DH was the only place to do the virus studies for all the hospitals in Hong Kong and all the other patients if there was a need to do tests on them on an outpatient basis.

26. Dr LEONG Che-hung was concerned about whether the redeployment of manpower and other resources to support the increased laboratory work had posed manpower problems to DH. In response, DH(Atg) said that DH would ensure that no services would be affected because of the redeployment. In view of the growth in number of infectious communicable diseases in Hong Kong, Dr LEONG Che-hung suggested that the Administration should consider establishing its policy on public health and setting up a department responsible for overseeing public health, taking precautionary measures, collecting data and tackling any outbreak of disease. This would be better than redeploying manpower on an ad hoc basis to combat any outbreak of disease. DS(HW)(1) responded that the Administration would strengthen the manpower of the team under DH which was responsible for communicable disease control. Consideration was also given to enhancing the professional training of the staff concerned and purchasing additional equipment for them.

27. The Chairman noted that there had been wide concerns about the levels of hygiene of ball pools and swimming pools. He enquired what measures the Working Group would take to monitor the level of hygiene of these amenities. DH(Atg) replied that the two municipal councils had issued guidelines to operators of all public and private children' playgrounds which would be followed up by visits conducted by health inspectors. At the Chairman's request, DH(Atg) agreed that the Working Group should provide, after conducting its second meeting in next week, a progress report on the inspections of the playgrounds and swimming pools. The Chairman stressed that it was inadequate just to issue guidelines to the operators of the private amusement centres/swimming pools and he was concerned whether there were adequate health inspectors to cover all these premises. In response, DS(HW)(4) said that he had learnt from the Assistant Directors of the two municipal councils that they had been closely monitoring progress of the inspections. In addition, the government would take full responsibility for any inefficiency in the course of work undertaken by the Working Group.

Admin.

28. At Mrs Sophie LEUNG's enquiry, DH(Atg) explained the amount of residue chlorine required for swimming pools for killing the virus. He assured members that operators of swimming pools were required by law to keep log books to record the levels of the residue chlorine which should be taken at hourly intervals. The results would also be checked by health inspectors.

29. In response to Miss CHAN Yuen-han's concern about the effectiveness of the working group in controlling the spread of enterovirus infection and in monitoring the work of the participating departments, DS(HW)(1) said that the Working Group would be vigilant of the work of the two municipal councils. DS(HW)(1) informed members that the Health and Welfare Bureau also had representatives in the Working Group and the Bureau was closely monitoring the situation. He said that over the past month, the participating departments had been very co-operative and active in performing their assigned tasks.

30. Mrs Sophie LEUNG considered that the Administration should adopt a proactive approach to educate the public on personal and environmental hygiene. DS(HW)(4) agreed and said that the Working Group had stepped up publicity on public hygiene since commencement of the "Healthy Living into the Twenty-first Century" campaign in June 1998 which would be long-term work undertaken by the Administration. In addition, the two Municipal Councils had stepped up prosecutions of food premises and market stalls failing to comply with the relevant hygienic regulations and requirements. He said that the Working Group was focusing on the promotion of personal hygiene to minimize the spread of the diseases. As the HFMD / EV 71 were more active in summer, more attention would be paid to cleanliness of swimming pools and recreation centres.

31. The Chairman quoted two recent incidents to show that there was room for improvement in the news release of the Working Group. In particular, the Chairman considered that the Working Group should avoid giving the mass media an impression that the Working Group was trying to hide any news from the public. Furthermore, the Working Group should take measures to improve its arrangements for press release to avoid giving the mass media fragmented or inaccurate information. DS(HW)(1) agreed to take note of the Chairman's observations and to seek improvements.

Admin.

32. CMM briefed members on her visit to Taipei conducted on 9 July 1998 and the institutions she had visited. She had been briefed on the surveillance system, the data collected and the measures taken to prevent the outbreak from spreading in Taiwan. The findings of this visit included -

Taiwan had been experiencing an outbreak of HFMD since April 1998 and its surveillance system had been strengthened since then.
As at 10 July 1998, there were 52 deaths suspected to be related to enterovirus infection. However, investigation into the causes of death was still underway. Of the six autopsies performed, EV 71 was isolated in one of them.
Among children under the age of five, the mortality associated with suspected enteroviruses in spring and summer did not show any change in the last three years.
There was no significant increase in mortality corresponding to the upsurge of HFMD.
The number of HFMD cases had now abated. The situation was under control.

33. The Chairman said that it would have facilitated the discussion at the meeting if the presented information had been included in the Administration's paper. He requested CMM to provide the information in writing to the Panel afterwards.

Admin.

34. Dr LEONG Che-hung considered that the trip taken by CMM fruitless without being able to collect useful information to enhance understanding of the disease. In response to Dr LEONG's enquiries, CMM said that in Taiwan only one child had been confirmed carrying EV 71 during the autopsy. The virus was not found in the other five victims. In addition, she said that there was no vaccine being developed for enterovirus in Taiwan and she did not know if any country was developing vaccine for enterovirus. DD(O) took this opportunity to clarify that the proposed use of immunoglobulin as recently reported in the newspapers was not in any way a vaccine for prevention of EV 71.

35. Miss Cyd HO asked whether the failure of CMM in collecting useful information on EV 71 was due to any difficulties she had encountered in Taiwan or due to inadequate preparation work prior to the trip. In response, CMM said that the people in Taiwan had been very co-operative and she did not think that her trip was unsuccessful. She said that it was important to know that the actual causes of deaths of the some 50 children in Taiwan were still under investigation. She also clarified that she had not asked for specimens of virus from the Taiwan authorities and it was wrong for the newspapers to have reported that such a request had been rejected. In response to the Chairman's question, CMM said that the purposes of her trip included -

to confirm if it was true that there were so many children in Taiwan whose deaths were related to EV 71;
to confirm whether there was any increase in mortality associated with HFMD; and
to visit the laboratory in Taiwan and to see if there was anything DH should learn from them.

36. The Chairman commented that DH could actually collect data on items (a) and (b) by e-mail and fax. CMM explained that it would enhance her understanding by paying a visit to Taiwan to see the actual situation. At the Chairman's enquiry, DD(O) said that HA was considering whether it would be advisable to send medical staff to Taiwan to observe the management of the cases in Taiwan, to discuss the clinical features and to collect first hand information on the virus.

37. The Chairman requested the Working Group to provide a progress report to the Panel as soon as possible after it had convened its second meeting.

Admin.

Legislative Council Secretariat
21 August 1998