Science’s COVID-19 reporting is supported by the Pulitzer Center.
Japan yesterday declared at least a temporary victory in its battle with COVID-19, and it triumphed by following its own playbook. It drove down the number of daily new cases to near target levels of 0.5 per 100,000 people with voluntary and not very restrictive social distancing and without large-scale testing. Instead, the country focused on finding clusters of infections and attacking the underlying causes, which often proved to be overcrowded gathering spots such as gyms and nightclubs.
“With this unique Japanese approach, we were able to control this [infection] trend in just 1.5 months; I think this has shown the power of the Japanese model,” Prime Minister Shinzo Abe declared at a press conference yesterday evening announcing the lifting of the state of emergency.
The number of daily new cases peaked at 743 on 12 April but has varied between 90 and 14 for the past week, according to the World Health Organization. At yesterday’s press conference, Abe noted the number of hospitalized COVID-19 patients has dropped from 10,000 about 1 month ago to 2000.
The positive outcome has even convinced some skeptics of the nation’s cluster strategy. Japan has prevented an outbreak “on the scale seen in many Western countries,” says Kenji Shibuya, a global health specialist at King’s College London who previously warned of undetected community spread. He credits the public’s cooperation with stay-at-home directives and the fortuitous timing of the emergency.
Despite the lifting of the emergency, the outbreak “is not over,” says Hitoshi Oshitani, a virologist and public health expert at Tohoku University. “I’m expecting small outbreaks from time to time,” he says. Although the government may consider reimposing restrictions, he believes “we can manage these smaller outbreaks.”
Japan got off to a bad start dealing with the pandemic when it quarantined the Diamond Princess cruise ship for 2 weeks in Yokohama after passengers were infected with COVID-19. Eventually, 712 of the 3711 people on board tested positive for the novel coronavirus; 14 died.
Then, whereas much of the rest of the world built its response to the pandemic on widespread contact tracing, isolation, and testing, Japan adopted a “quite different” strategy, Oshitani says. “We try to identify the clusters and [determine] their common characteristics.”
Not surprisingly, they found that most clusters originated in gyms, pubs, live music venues, karaoke rooms, and similar establishments where people gather, eat and drink, chat, sing, and work out or dance, rubbing shoulders for relatively extended periods of time. They also concluded that most of the primary cases that touched off large clusters were either asymptomatic or had very mild symptoms. “It is impossible to stop the emergence of clusters just by testing many people,” Oshitani says. This led them to urge people to avoid what they dubbed the “three Cs”—closed spaces, crowds, and close-contact settings in which people are talking face-to-face. It sounds simple. But, “This has been the most important component of the strategy,” Oshitani says.
(Reassuringly, they did not trace any clusters to Japan’s notoriously packed commuter trains. Oshitani says riders are usually alone and not talking to other passengers. And lately, they are all wearing masks. “An infected individual can infect others in such an environment, but it must be rare,” he says. He says Japan would have seen large outbreaks traced to trains if airborne transmission of the virus was possible.)
But through March, cases climbed as authorities ramped up efforts to explain the importance of the three Cs; researchers believe the rise was partly driven by citizens returning home from overseas and travelers. Then, on 7 April, concern about the strains being imposed on the health care system prompted the government to declare a state of emergency in several key prefectures. On 16 April, it extended the emergency order nationwide.
Japan’s national and local governments do not have the legal power to impose lockdown measures. But authorities urged people to stay home as much as possible, companies to allow working from home, and bars and restaurants to close or serve only take out. Based on modeling, members of the advisory committee urged people to reduce their interactions with others by 80% in order to bend the curve.
Oshitani doubts the 80% goal was achieved. But there was fairly extensive voluntary compliance. “Surprisingly, Japan’s mild lockdown seemed to have a real lockdown effect,” Shibuya says.
Most importantly, the state of emergency bought time to educate the public about risky behavior and environments. Masks now are nearly ubiquitous. There were bars and restaurants that ignored requests to close or restrict hours, but they are typically not as crowded as they once were. “Now people know much better the risks of the virus,” Oshitani says.
Though acknowledging that the numbers are down, Shibuya still questions the focus on clusters, which did not work well in the big cities and did not prevent outbreaks in hospitals and nursing homes. “The health care system managed to cope with COVID this time,” he says, but it stretched facilities to the point of collapse.
Meanwhile, the government never made testing the priority it became in other countries. Japan has conducted 2.2 tests per 1000 people. For comparison, the rate in neighboring South Korea is 16; and in the United States, 43.
The dwindling numbers of new cases led the government to start to lift the state of emergency for much of Japan on 14 May, ahead of the intended 31 May schedule. Yesterday’s announcement completed the lift, relieving Tokyo and four other prefectures.
Although the state of emergency has been lifted, there are still extensive and detailed governmental guidelines for different sectors of the economy. Yesterday, Abe said the government will gradually ease restrictions on events. Next month professional baseball will start with empty stands, gradually allowing increasing numbers of spectators. Concerts and cultural events will be allowed to start with 100 attendees, with numbers increasing step by step up to 50% of a venue’s capacity.
Abe warned these steps will not reduce the risk of infection to zero. “We must be prepared for trial and error, it will take a considerable amount of time to completely restore daily life,” he said.
*Correction, 27 May, 8 a.m.: This story has been updated to remove an erroneous reference to 400,000 daily new cases at the time of the lockdown in the United Kingdom. The figure came from a disease model projection, not reported cases.