COVID-19 response and issues in Japan
By Dr.Yasuhiro Kanatani, MD, PhD
COVID-19, a biological weapon?
Anthrax, Ebola, Plague, Smallpox, and Botulinum are considered extremely high-risk pathogens to be used as biological weapons. As a consequence, the development of vaccines and therapeutic agents has been more focused on countering other kinds of pathogens. Using micro-organisms as biological weapons requires appropriate measures (detection, prevention, treatment). Therefore, coronaviruses causing SARS (Severe Acute Respiratory Syndrome) or MERS (Middle East Respiratory Syndrome), for which there are no effective preventive measures, are unlikely to be used as biological weapons.
First development of the COVID-19 response in Japan
The first step in responding to COVID-19 in Japan was to quarantine passengers on the massive Diamond Princess cruise ship, which arrived in Yokohama on February 3, 2020. The Ministry of Defense dispatched Self-Defense Forces personnel to the vessel from February 6. A total of 2,700 JGSDF personnel were dispatched during 46 days for medical support activity, but none of them got infected through this mission. The reason for this low infection-rate is that (1) everyone was using protective clothing, (2) it was mandatory to wear goggles, and (3) action was organized by groups of two. Moreover, the use of a passenger boat as a base allowed to secure infection control by reducing the risk of exposure and gave also the opportunity to have a 14-days isolation facility for JGSDF members after the activity was completed. Above all, it is important to mention that staff was promptly supported by the equipment necessary for infection control. It was also essential to secure communications for support activities onboard the cruise ship, and to prevent any failure from the communication equipment due to the robust structure of the cruise ship. This situation convinced the government of the importance of having a hospital ship.
Preventive measures and testing
The next step was to control the spread of the COVID-19 in the community. Countermeasures have been implemented regarding emergency medical transportation, diagnosis, treatment, and prevention of infected persons. When it comes to emergency transportation measures for patients suspected of COVID-19 infection, standard infectious disease preventive measures are taken in cooperation with the public health center and the patient is transported to the designated infectious disease medical institution. Some ambulances are equipped with ozone gas decontamination equipment, but the exact effects on COVID-19 are still unknown. Thus, decontamination is done with 0.1% sodium hypochlorite and wiped with ethanol. Furthermore, prompt screening and isolation of suspected infected people minimize the spread of the infection. Therefore, PCR tests were widely used in Japan at an early stage while antibody test are now considered for surveillance in the epidemic phase. However, the antibody test kits have not been approved yet by the authorities as in vitro diagnostics. As for treatment, Favipiravir1 is offered under compassionate use to patients with COVID-19. Currently, the use of Favipiravir is kept under medication control and is limited to hospitalization. Since it is known that Favipiravir suppresses intracellular growth of COVID-19, the intake of this medication should occur at the early stage of infection. Therefore, from March 31, the phase III of clinical trials for the approval of Favipiravir as a COVID-19 treatment has been initiated. However, since this drug is usually taken orally, in the case of COVID-19 patients attached to artificial ventilators it it should be dissolved and administered via the gastric tube. Thus, in the most severe cases, its effectiveness is reduced.
Current issues and state of play in Japan
One on the main outcomes of this crisis in Japan is that there is an urgent need to build a domestic procurement system and to reduce Japan’s dependence on China: indeed, due to the disruption of the supply chain, Japan faced a shortage on diethyl malonate, which is the raw material needed for the production of the Favipiravir drug. Currently, domestic manufacturers have started to develop a DNA vaccine targeting the Spike protein in the COVID-19 virus. Concerning the spread of the virus, as of April 22, the number of infected people in Japan was 11,350, but the death toll was 277, which is relatively low compared to the Western countries. However, due to the increasing number of infected people in metropolitan areas, there is concern that the infection will spread further, and medical disruption will follow. According to the direction of infectious disease crisis management in Japan, up to now we have aimed to delay the domestic epidemic by establishing thorough measures such as the quarantine and by creating a treatment provision system specialized for the seriously ill people. Besides, the rate of positive PCR test results in the Tokyo metropolitan area is about 4 times higher than the national average (40.1% vs. 10.9%). The higher the rate of positive PCR is, the higher the infectious risks for hospital is, which could then accelerate the collapse of medical services. As a preventive response to this scenario, online medical services have been implemented to reduce the infectious risk for medical staff. The Council of Governmental Experts in Japan estimates the number of infected people to reach 400,000 in the future, and over 7,000 beds to be required for severely infected people. Medical institutions specialized in infectious disease are designated to welcome the COVID-19 patients; however, the number of beds required for COVID-19 highly exceeds their present capacity (5,373 beds, including beds for tuberculosis). Therefore, local governments have been centrally managing infectious patients at the public health centers or at the local government's task force and have been deciding of the need for hospitalization according to the gravity of the symptoms of the patients. With this system, the medical staff could therefore concentrate on the treatment of moderate to severely ill patients. However, the consequence of this organization is that we saw some mild patients forced to stay at home, which have then seen a rapid worsening of their symptoms. Therefore, it is an urgent issue to secure devices such as pulse oximeters that would evaluate patients’ health at home in real-time. In some medical institutions accepting severely ill patients, it has been pointed out that the use of ventilators in severe cases increases the risk of secondary infection of medical personnel through the creation of mist. For this reason, some university hospitals in the suburbs of Tokyo have built a system that can remotely monitor patients inside a highly contaminated area. During this crisis, the use of VR (Virtual Reality) or AR (Augmented Reality) should be taken into consideration during treatments such as the ECMO (Extracorporeal Membrane Oxygenation) which requires management by a highly skilled medical team.
After the declaration of the national emergency, peoples' movement decreased by about 50%, but the Government experts' committee had requested a movement restriction of about 80% until the end of the infection. The delayed development of digitization in Japanese society is an obstacle for remote work or telework, which makes it difficult to completely restrict the movement of people. Despite the fact that the government has announced its objective to end the state of emergency on May 6, people are already getting tired of living at home. Last but not least, previous budget restrictions have contributed to worsen this crisis situation in Japan. To achieve fiscal discipline in the past, Japanese finance authorities have cut down public resources. Additionally, the reserve resources for crisis management, which are not essential during peacetime, have also been reduced. Therefore, the hope is that this “corona pandemic” can proof how important it is for the government to continuously secure the necessary resources needed for proper crisis management.
Dr. Yasuhiro Kanatani is a Professor of Clinical Pharmacology at the Tokai University School of Medicine and is the former Director of the Department of Health Crisis Management at the National Institute of Public Health (NIPH) in Japan. His research interests focus on health risk assessment and management. Graduated from the National Defense Medical College (NDMC) in 1989, he received a PhD in medicine from NDMC in 1994. Later, he worked as a medical officer at the Ministry of Health, Labor and Welfare from 1999 to 2002 and at the Ministry of Defense from 2002 to 2004. From 2004 to 2010, he worked as an associate professor in the Division of Environmental Medicine at the NDMC Research Institute, after which he became the Director of the Department of Health Crisis Management of the NIPH.