Intended for healthcare professionals


Covid-19: Hong Kong reports world’s highest death rate as zero covid strategy fails

BMJ 2022; 376 doi: (Published 17 March 2022) Cite this as: BMJ 2022;376:o707
  1. Luke Taylor
  1. Bogotá

Coronavirus infections are surging in Hong Kong as the city has reported the highest number of covid-19 deaths for population size in the world.

Previously a global model for covid containment, transmission of SARS-CoV-2 has soared as Hong Kong’s zero covid strategy has failed to contain the more contagious omicron variant. The city’s low vaccine coverage is also aiding transmission and leading to more fatalities, said epidemiologists.

Hong Kong’s isolation centres, hospitals, and morgues are overflowing, and some shops have empty shelves as residents are hoarding supplies in anticipation of a potential city-wide lockdown, the news agency Reuters has reported.1

The covid death rate in Hong Kong is now above 25 per 100 000 residents—higher than in the UK last December when the omicron variant first appeared.

In Hong Kong’s largely unvaccinated elderly population the death rate is comparable to that in the UK during the first wave of coronavirus infections before vaccines were rolled out, said Julian Tang, clinical virologist at the University of Leicester, UK.

“The enforced [isolation] in Hong Kong worked really well in the early pandemic before there was widespread community transmission of the virus—but now, under the ongoing zero covid strategy, it is impossible to do this for all new cases,” he said.

Vaccination catch-up

Residents of Hong Kong with confirmed covid-19 were previously required to quarantine in hospitals, while close contacts were required to isolate in designated facilities. As cases have spiked the hospital discharge criteria have loosened, however, allowing for shorter hospital stays. Close contacts can now quarantine at home.2

Most vaccines administered in Hong Kong are manufactured in China. Some of these vaccines, such as CoronaVac, have been shown to be less effective than mRNA vaccines at preventing infection and serious illness.3 Boosting with mRNA vaccines could help bring down transmission, said Tang.

But many Hong Kong citizens are not yet fully jabbed. Over 90% of those dying from covid-19 had not received the full vaccination scheme, said Hong Kong’s chief executive, Carrie Lam, on 11 March. “We need to catch up and vaccinate every Hong Kong citizen,” she said as she faced increasing pressure from China to bring infections under control.

Lam said that her government would target elderly people with more medical resources and hold a mass testing scheme in March. She has ruled out using lockdowns to bring down cases.4

Around 40% of Hong Kong’s population are not fully vaccinated, and more than half of over 70s have yet to receive a single vaccine. In the most vulnerable group—over 80s—that number rises further: 56% have received a single dose, 37% have had two doses, and only 2% have received three doses.5


Hong Kong is a semi-autonomous region, but the Chinese government has clamped down on its freedoms in recent years, increasing people’s distrust in authority and vaccines, said local experts.6 The fact that most of the vaccines administered are made in China adds to this mistrust, as well as misinformation on western manufactured jabs, such as Pfizer-BioNtech.

China’s president, Xi Jinping, ordered Hong Kong’s leaders to get a grip on covid-19 last month, but the public health crisis is no longer limited to 7.4 million strong Hong Kong: China recorded its biggest one day increase in covid cases on 14 March, with new infections more than doubling.7

Infection rates in China remain relatively low at 2.35 infections per million people, but strict measures aimed at slowing down transmission are not working against omicron and suggest that the country’s elimination policy is now untenable. Over 80 million people in China are locked down, including international manufacturing hubs such as Shenzhen.

“The chance of a major outbreak in China is reasonably high,” said Jin Dong-Yan, a virologist at the University of Hong Kong.

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