SitRep: Japan

On 16 January, Japan officially confirmed their first case of COVID-19. There were less than 500 known cases worldwide, most of which were in China, making Japan one of the first countries outside of China with a known case. Although cases remained low throughout the month, a tour bus driver hosting a group from Wuhan would be Japan’s first case of community transmission on 28 January, raising alarm and speculation about the ease of human-to-human transmission. February started with 26 cases and the month ended with 230. In March, cases grew from 242 to just over two thousand. 

COVID19 remained a mystery in Japan throughout much of the Spring, with cases rising just enough to suspect community outbreak but the numbers never quite being as high as they should be for that scenario. There was widespread speculation that the Abe government was intentionally under-testing to keep numbers low in hopes that the 2020 Summer Olympics could stay on schedule. Yet there were reports that the percentage of confirmed cases was shrinking even as testing slowly expanded. Then it exploded in April, going from about two thousand cases to ten thousand in eighteen days. In many ways, though, the scale of the epidemic remains a mystery due to intentionally low testing rates and not know exactly when the outbreak(s) began.

The limited genetic data submitted to NextStrain shows community infections from Chinese strains of the virus until March 9th, 2020. A strain from Hangzhou was submitted on March 9th, roughly a month after Japan enacted travel restrictions on Zhejiang province. From there, most samples have unclear but mostly European lineage. The genetic data also shows strains closely related to Africa, where some confirmed cases had travel history. Basic SIER modeling would fit a hypothesis of a small First Wave outbreak that either fizzled out or rapidly shadowed by several dozen imports in March. Japan was unusually exposed to non-Wuhan China exports through February and did not restrict European imports until late March.

Prime Minister Shinzo Abe declared a state of emergency until 7 April  for Tokyo, then a nationwide state of emergency on 16 April. Even more confounding, in the light of the early alerts Japan had compared to the rest of the world, and with the comparatively low number of cases to date (approximately 14k at time of writing) the country is on the brink of a medical system collapse.

There are several compounding factors that have pushed Japan to the precipice – and likely soon over – of a national disaster. The most glaring errors are based on a flawed and overly optimistic approach to the rate of spread that influenced a lack of producing a testing kit, ordering test kits, and thus a lack of testing. With only 1,500 tests per 1,000,000 people, or 141,600 overall, Japan is woefully behind other nations in testing. Logistically, there is also the lack of medical facility and equipment preparation that medical officials have warned about and Prime Minister Abe has received harsh scrutiny for.           

The beginnings of Japan’s controversial COVID-19 handling can be traced back to the mishandling of the Diamond Princess cruise ship outbreak. Recent revelations, however, do put a share of the blame on the cruise operator – Carnival – as they missed an alert from Hong Kong that a passenger who disembarked there tested positive. Even after issuing the warning, the cruise ship continued to let passengers mingle until docking in Yokohama, Japan. Japanese officials quarantined passengers in their individual rooms on the cruise liner while allowing the crew to continue intermixing, eating together, and serving the passengers on board, thus passing the virus between themselves and incidentally passengers. Furthermore, only those with fever or severe symptoms were tested. There are genetic hints that the virus might have escaped the ship.

The Diamond Princess incident is a microcosm of how Japan has managed, or not managed, social distancing and large-scale testing. The lockdown of prefectures not being ordered until early April was based on the overly optimistic, and premature, hypothesis that spread was isolated to clusters and key individuals, not necessarily to each infected individual. The premise operated under the assumption if those within clusters could be traced and quarantined, then the country could avoid a larger lockdown. This overlooked a potentially high reproduction rate (R0) of 5.7 without distancing interventions and the possibility viral shedding could be most prevalent during the pre-symptomatic stage. All of these assumptions came in spite of the 28 January case which was, again, early evidence there was a high transmission rate for even mild cases.

Estimated R0 from CMMID

A high rate of reproduction in the pre-symptomatic stage has thoroughly debunked Japan’s operating hypothesis to only test the severely symptomatic. Akin to Singapore’s situation, an early halt on travel from Wuhan prevented too many First Wave cases coming in (though the door to Hangzou was shut fairly late); however, the Second Wave coming from Europe, the United States, and neighboring Southeast Asian nations creating community spread has ensured those early efforts are for naught. Singapore, at the time of writing, has a similar number of cases at (17k vs 14.5k) but Japan was far slower and less systemic in their response by by failing to implement strong social distancing, centralized quarantine, internal travel restrictions, or scale up testing to adequate levels given their capacity. Google Community Reports from 17 April – only days after the lockdown – do show a drop-in retail and recreation by 31 percent but show a decrease in workplaces by only 23 percent and an increase in grocery and pharmacy traffic by four percent. By mid-April, it took one expat a hospital ride, two hospital visits, and five hours waiting on the phone to get a PCR test.

Due to the strict requirements to be administered a test, latent reporting until symptom development has also implicated some businesses and schools have remained open with an employee being an unknown COVID-19 case. Hospitals have also been spots for infection spread due to late training for doctors and nurses. Eiju General Hospital, a primary care facility, has been a recent hotspot after being unprepared to identify and isolate potentially infected or pre-symptomatic patients. Dr. Kentaro Iwata, who was one of the first to raise the alarm about the Diamond Princess, recently did an extended interview with the Foreign Correspondents Club in Japan, in which he included concern about the lack of epidemic training. He also rose concern about Japan’s lack of willingness to move to a new plan and rose alarm over a steadily declining Personal Protective Equipment (PPE) stock. One of the key reasons for concern is the lack of ICU beds – which ranks below Italy and Spain – or the ability to transition entire hospitals into effective COVID-19 wards. The lack of PPE for hospital staff, and their inevitable may be one of the biggest risks as Japan is still in the early stages of outbreak.

Earlier criticism of Japan also surrounded their unwillingness to cancel the 2020 Summer Olympics. Some health officials were adamant that there was a cover-up, giving rise to extreme criticism when the Olympics were delayed until 2021 on 30 March. Despite the timing being suspicious, Japan is following a similar timeline to Singapore with community spread and the the timing of the Olympic cancellation and a rise in cases is likely coincidence; a coincidence, however, that will not be forgotten as hospitals are quickly running out of room.

The downturn in business overseas has also been a causeway for more panic in Japan. A slowdown in major exports due to overseas economic declines has pushed Japan’s government to deploy a nearly one trillion USD stimulus bill, equivalent to 20 percent of the GDP. In a world-first move, Japan has also allotted 2.2 billion USD of this bill to incentivize corporations to move out of China, and back into Japan. The timetable for this move has also been moved up due as relations with China business becomes more tense. Further concern for Japan is the lack of food self-sufficiency, with Japan being one of the least self-sufficient nations in the United Nations index.

Critics of the economic stimulus, which per a Reuters Poll is a majority, state the money going directly to individuals is not enough. Much of the stimulus is rolled up in tax and loan delays, giving rise to concern that businesses and individuals will not be able to survive the contracted economic downturn. Prime Minister Abe has stated that the stimulus bill will result in a GDP increase of 3.8 percent, as each business may receive up to 18,600 USD (2 million Yen). The rules for obtaining one of these loans, however, are incredibly strict. Individual companies may have success turning to domestic demand, creating an internal economy for Japan. The pivot for companies will be shocking and take time; time which companies may not have to fiscally survive.  

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