SCIENCE

COVID-19: Guidelines for the New Normal

As Japan heads into the winter, the number of COVID-19 infections is rising again. Mizuno Tetsu analyzes the present situation and the government’s ongoing response.

Due to the COVID-19 pandemic, Japan has recorded its greatest economic decline since WWII. From the end of June the spread of infection across Japan started to reduce, but now it is rising again. The bottom of the decline occurred during the first week of August and then infections seemed to be more or less constant. But from October new positive cases seemed to be on a slightly increasing trend, and from November shifted to a definite increase. On November 9, Omi Shigeru, Chairman of the New Coronavirus Infectious Diseases Control Subcommittee, sounded a warning bell, saying that unless Japan takes strong measures, “there is a high possibility a trend of rapidly increasing cases will develop.” With winter soon approaching, there is concern that seasonal influenza will spread widely alongside COVID-19.

Meanwhile, Prime Minister Suga Yoshihide—who has taken over from the Abe administration—delivered a general policy speech to an extraordinary session of the Diet on October 26, saying that the government will absolutely prevent explosive spread of disease, that the lives and health of citizens will be securely protected, that socioeconomic activities will be resumed, and that the economy will be restored.

Examples of the measures against infection indicated by Prime Minister Suga are: securing the capacity to conduct an average 200,000 tests per day at regional medical institutions; carefully testing the elderly, those with underlying conditions, and others at high risk of developing severe symptoms; and focusing investment of health funds on the seriously ill. Regarding a vaccine, Prime Minster Suga said, “While ascertaining safety and effectiveness will be the absolute priority, by mid 2021 we will secure sufficient vaccine to offer to all Japanese citizens, prioritizing the elderly, those with underlying medical conditions, and medical workers, and vaccinating them without charge.” Economic measures have centered on regional revitalization, including through the Go To Travel Campaign and the Go To Eat Campaign.

Into the Winter

Tokyo has seen the largest number of infected people. A large-scale testing program in Shinjuku’s entertainment district during the summer period of infection spread led to a drop in infections, but since October there seems to be a slightly increasing trend centered on people in their 20s to 40s. At the beginning of the COVID-19 outbreak, Hokkaido issued its own state of emergency declaration and, as winter approaches, it has more than 100 infections every day.

Based on lessons so far, the government has closely cooperated with municipalities to dispatch teams of government specialists when a cluster develops, then contain the outbreak through large-scale and focused testing. Although 27,000 beds and 23,000 rooms in residential medical facilities have already been secured, the winter influenza season is approaching and all efforts must be made to prevent infection spreading.

During the seasonal influenza period, there will be a significant increase in the number of people experiencing symptoms such as fever, resulting in a rapid increase in demand for testing and medical care. 

The former Prime Minister Abe formulated a new direction for COVID-19 countermeasures at the 42nd meeting of the Novel Coronavirus Response Headquarters and he announced his resignation on August 28. Abe said, “we will review the authority set out in the Act on the Prevention of Infectious Diseases and Medical Care for Patients with Infectious Diseases, from the perspective of prioritizing medical resources for patients with severe symptoms. […] In order to reduce the burden on public health centers and medical institutions, and to ensure the more efficient use of hospital beds, we will review the application of the current arrangement [for COVID-19], including amending the relevant government ordinances. Regarding screening structures, in order to simultaneously screen for COVID-19 and influenza, we intend to fundamentally enhance the structures, including securing the capacity to conduct an average of 200,000 tests per day at regional medical institutions.

The New Normal

In order to prevent spread of infection and the collapse of the healthcare provision system, in April the government declared a state of emergency, while calling for the people to adopt a “new normal,” including basic infection spread countermeasures such as avoiding the 3Cs (closed spaces, crowded places, and close contact settings), avoiding places where people shout, mask-wearing, careful physical social distancing, hand sanitization and air ventilation, and also the use of contact tracing applications. At the same time, to try and also maintain socioeconomic activities, it has produced infection-spread prevention guidelines by industrial sector and asked companies to follow them closely.

Some things have become clear as these measures are implemented. While 80% of those infected recover with mild or no symptoms, in 20% pneumonia symptoms worsen, with around 5% of severely affected patients requiring artificial respiration and other measures. Although the proportion of people in younger age groups who develop severe symptoms is low, the risk of severe symptoms is high for the elderly over the age of 65, those with chronic respiratory disease, diabetics, and the obese.

There is also the possibility of new testing methods becoming available, such as saliva-based PCR screening, and treatment drugs such as remdesivir and dexamethasone coming into standard use, thus contributing to a drop in the frequency of severe cases.

Making use of this knowledge, measures put in place by the government are ensuring the necessary testing system by greatly expanding testing through simple antigen test kits (an average 200,000 a day) and installing PCR and antigen level testing equipment, so that regional medical institutions can first easily and quickly test for both seasonal influenza and COVID-19.

Secondly, there are measures to deal with regions that have large numbers or clusters of infected people. The government will request administrative districts to implement mass testing of all those residing and working in their medical facilities and homes for the elderly, as well as implement the widespread testing that is necessary to prevent the spread of infection in their regions. Thirdly, the government is putting in place a system to support elderly people and those with underlying conditions who wish to be tested. Fourthly, the government is securing systems of healthcare provision. Administrative districts are systematically securing hospital beds and residential medical facilities, basing their response on residential treatment for low-risk patients with light or no symptoms (or at-home treatment when appropriate), and focusing healthcare funds on those with severe symptoms. Fifthly, in the case of administrative districts, the government is securing hospital beds and residential medical facilities for those infected with COVID-19, strengthening support to ensure stable management of medical facilities, and setting up a consultation, examination, and testing system in local medical facilities to prepare for seasonal influenza. 

Additionally, it is securing enough vaccine for all Japanese citizens to be immunized by the first half of 2021, preparing the health care center system and infection crisis management system, and expanding the testing capacity and system for people from abroad traveling into and out of Japan.

As stated above, the number of infections is not bottoming out, and on October 23, 2020, the New Coronavirus Infectious Diseases Control Subcommittee put together two documents that urge the public to be even more careful: “Five situations in which infection risk increases” and “Ways to enjoy eating together while decreasing infection risk.”

Five situations in which infection risk increases

Situation 1: Social occasions where alcohol is drunk

  • ・Under the influence of alcohol people get excited and at the same time less careful. Also, hearing becomes less acute and it’s easy to start shouting.
  • ・When large groups are together for long periods of time, particularly small spaces separated by partitions, the infection risk increases.
  • ・Sharing bottles, drinking utensils, and chopsticks also increases risk.

Situation 2: Eating and drinking in large groups or for long periods of time

  • Compared to quick meals, the infection risk is higher for long periods of eating and drinking, taking clients out for food and drink, and moving from bar to bar at night.
  • In the case of eating and drinking in large groups, for example five or more people, the infection risk increases due to talking loudly and higher likelihood of droplet infection.

Situation 3: Conversation without masks

  • Conversation at close distance without masks increases the risk of droplet infection and microdroplet infection.
  • Using karaoke boxes during the day has been identified as one example of infection while not using masks.
  • Care is needed when traveling in cars and buses.

Situation 4: Living together in small spaces

  • The infection risk increases when living together in small spaces due to sharing closed spaces for long periods of time.
  • Examples of suspected infection in dormitory rooms and shared areas such as toilets have been reported.

Situation 5: Changes of location

  • In situations such as breaks during the workday when people change their location, the infection risk may increase due to relaxation and changed environment.
  • Examples of suspected infection in break rooms, smoking areas, and changing rooms have been reported.

The subcommittee has also urged both service users and providers to implement the below:

 

Ways to enjoy eating together while decreasing infection risk

For users

  • If you will be eating and drinking: 1) Do so in small numbers for a short time; 2) As much as possible, do so with people you are normally together with; 3) Refrain from drinking late at night or moving from bar to bar; and enjoy alcohol in moderation.
  • Use only your own chopsticks and cups, without sharing.
  • Position seats diagonally across from each other, and as much as possible avoid being directly opposite or alongside someone else. (Cases have been reported where people sitting directly opposite or alongside one another while eating were infected, but those sitting diagonally across were not.)
  • As much as possible, wear a mask when talking. (It is necessary to bear in mind that face and mouth shields are less effective than masks.)
  • Use establishments that have devised appropriate ventilation etc., and which closely follow the guidelines.
  • Those who feel ill should not attend.

For establishments

  • Establishments must follow the guidelines closely.
  • (For example, this also includes measures such as monitoring the health of employees and mask wearing, the effective positioning of acrylic screens between seats, and devising the appropriate use of fans in conjunction with ventilation.)
  • Users are urged to stick closely to the above guidelines, and also to download the COVID-19 Contact-Confirming Application (COCOA.)

Furthermore, the subcommittee is urging the continuing observance of various measures, not just when eating and drinking, but in all situations. These include: mask wearing and basic avoidance of the “3Cs” (closed spaces, crowded places and close-contact settings), ventilation of indoor spaces, keeping gatherings short and with few members, conversing as quietly as possible without raising voices, cleaning and disinfection of shared facilities, and hand washing and alcohol disinfection. 

As part of the summary, the example of a particular restaurant is given. According to that account, although there was infection among restaurant employees, it had closely followed the guidelines, including by keeping windows open, always ensuring ventilation, and having customers sit at a set distance apart from each other. Thanks to this, of over 100 customers who used the restaurant, there was not one case of infection.

Even in winter it is possible to ventilate spaces at set intervals. As infection prevention becomes a habit, it may be that the various ways we devise to overcome COVID-19 turn into knowledge we can pass on to future generations. Looking at history, it doesn’t seem that infectious disease disappears.

MIZUNO Tetsu is a freelance writer.

Note: This article first appeared in the November/December issue of the Japan Journal. Data in figures up to November 10, 2020.

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