Safecast

Uncertainties about Japan’s COVID-19 data

Tue, 04/28/2020 - 06:49

In our earlier posts (here and here) we tried to clarify the actual policies being implemented in Japan with regard to COVID-19 testing. We pointed out inconsistencies and other official data issues that make it difficult for the public to get a good grasp of the actual number of tests being done and how many people are probably infected now. Four weeks have passed since our last post on this issue. At the time, 20,340 tests had been reported in Japan, with 1214 positive cases nationwide, 171 in Tokyo. Nationwide there were fewer than 100 new cases reported daily. At the time of writing today, the most recent data available shows 150,692 people tested, 13,448 total positive cases nationwide, and 3,908 cases in Tokyo. The highest daily count was reported on April 11, with 700 cases, compared to the current average of about 400 per day.

These counts, of course, represent a notable increase over February and March, which should have silenced the voices that insisted that Japan had already “beaten” the coronavirus. At the same time, while the increase is large, and the health care system already shows worrying signs of overloading, the country does not yet appear to have entered a phase of devastating exponential growth like that seen already in many places in the world. As we frequently point out, it is very difficult for even symptomatic people in Japan to get tested. We found this to be of such concern that we created an online map where people can report their experiences. Considering the small number of tests being done, as gauged by the percentage of the population which has been tested (roughly 0.008%), how soon would we know that a larger outbreak was happening? We must ask the same questions we asked in March: How many cases are being missed by the current “cluster countermeasures” approach, which intentionally limits testing? How dangerous might the situation become if a much larger proportion of COVID-19 positive people, specifically those who are asymptomatic or pre-symptomatic (and so not likely to qualify for testing under current guidelines), is not identified and quickly isolated to slow down the spread of the virus?

Dr. Kenji Shibuya, Director of the Institute of Population Health at Kings College in London, gave an online presentation to the Tokyo Foreign Correspondents Club (FCCJ) last week in which he laid out the implications he sees in the available data and clarified areas of concern. As we noted previously, he has raised cautions about the risks of relying exclusively on the “cluster countermeasures” approach, and has urged a much larger expansion of testing in Japan. We encourage everyone to watch the video of his presentation. Specifically, he estimated that the actual number of infections in Japan is likely to be at least ten times higher than the number currently being reported through official channels, for a number of reasons. The following day, Hokkaido University professor Hiroshi Nishiura, a key member of the Ministry of Health, Labor, and Welfare’s task force on coronavirus clusters, gave a press conference in Tokyo in which he concurred with Dr. Shibuya’s estimate, adding, in fact, that it may be even higher. At the same time, Nishiura reiterated several times that data now shows a decreasing trend of cases in the nation. The most recent data graphs seem to show that as well.

Nationwide case count for Japan as of April 27, 2020 (source: https://covid19japan.com/) Tokyo COVID-19 case data, as of April 27, 2020 (source: https://stopcovid19.metro.tokyo.lg.jp/en/)

As Dr. Shibuya pointed out in his presentation, there are many caveats that should be kept in mind when looking at the numbers reported by Japanese government sources. For several reasons, he believes it is difficult to draw firm epidemiological conclusions from the data we are given. The implications of the two-week delay between the onset of a COVID-19 infection and symptoms becoming serious enough that the patient fulfills Japan’s stringent PCR testing criteria are very important and should be understood. The daily numbers for positive cases we are given only indicate the date of compilation or reporting of cases which have already existed for weeks. These numbers are a lagging indicator, a narrow snapshot of the spread of infection two weeks prior. If much more extensive testing were being done, Shibuya says, particularly of asymptomatic and pre-symptomatic cases, we would have a fuller and more current picture of the spread.

Another caveat is that results for tests done at private laboratories are not fully represented, due to delayed and inconsistent reporting. As an example, although the bilingual online dashboard provided by the Tokyo Metropolitan Government is one of the better official communication efforts, data from private labs is only included as a weekly total added every Friday, as opposed to the daily reporting from public institutions. Consequently the case numbers appear to spike mysteriously every Friday. Similar spikes affect the testing total graphs. The explanation for this is not evident anywhere on the city’s webpage.

Very little of Japan’s testing and case reporting system is automated or fully online. Unbelievably, all of the data is still sent by fax, and needs to be manually transcribed, entered, and compiled. This introduces unnecessary delays and makes the likelihood of data entry errors higher. Considering the inefficient data compilation process, the difference between what the data categories actually represent as opposed to what they appear to represent, and ongoing inconsistencies regarding the number of tests reported, it is hard to evaluate what is actually going on based on these numbers alone. Most concerningly, none of this data is publicly available, so outside researchers have no way to independently validate, replicate, or scrutinize it. Shibuya related his experience trying to obtain COVID-19 data from Japan’s National Institute for Infectious Diseases (NIID) to analyze, which should be a very straightforward process, particularly for a researcher of his status and reputation. He was told that he would need to fill out a number of specific forms, and that the process could take months. Without access to the background dataset held by the NIID we can tell very little from the publicly available data.

A recent study based on a large Italian data sample from Lombardy indicated that 43% of the COVID-19 transmissions seen there arose from asymptomatic infections. Also, most new infections occurred before the lockdown, from asymptomatic infections in the same household. Other studies reinforce similar conclusions regarding the predominance of asymptomatic infections in the population. Despite the reassuring recent Japan case graph curves, there remains a strong possibility that Japan has entered an explosive phase of COVID-19 transmission which the current national disease surveillance system has not yet detected because asymptomatic and pre-symptomatic cases, which form the majority, are almost entirely excluded from the testing criteria. This is bolstered by recent reports from Keio University Hospital that of 67 patients admitted to the hospital for non-respiratory reasons who were screened for COVID-19, four of them (6%) were found to be positive. Shibuya and others note that this is neither a large nor representative sample, but the prevalence is unexpectedly high and should not be ignored.

Based on known asymptomatic-to-symptomatic case ratios from other countries, both Shibuya and Nishiura consider ten times the reported Japanese cases to be a low-end estimate of actual infections, while noting that in other countries it has been as high as a factor of 20 to 50. Assuming that the Keio findings of 6% prevalence represent an overestimate, but that an infection rate of 3-4% of the Tokyo population is plausible based on other evidence, Shibuya noted that, “A simple calculation will give you a figure how many people are infected right now.” Taking 13 million as the population of the Tokyo Prefecture, 3% is 390,000 people. The operative term here is “plausible.” Results of modeling done by Dr. Nishiura reported two weeks ago estimated that without strong countermeasures the number of serious COVID-19 cases in Japan could reach 850,000, and the death toll as high as 400,000.  These two sets of estimates are in general agreement on the possible magnitude of the outbreak here. The effectiveness of the voluntary social distancing and other countermeasures that have been implemented remain a relatively uncertain variable.

Large numbers of deaths, however, still do not appear to be evident. We previously noted concern that due to the lack of testing, many observers have suspected that deaths recorded simply as pneumonia may in fact be due to COVID-19, in effect “hiding” them from being properly counted. Influenza mortality, however, is difficult to quantify even under normal conditions, Shibuya points out, with many variations, co-morbidities, and other contributing factors. For various reasons, none of them duplicitous, deaths from contagious diseases are often underestimated. Because in the case of influenza it is impossible to test everyone, we must often rely on an excess mortality estimation process instead. A recent paper from Tokyo University researchers shows that seasonal influenza activity in Japan was markedly lower in 2020 than in previous years, and suggests that measures taken to constrain COVID-19 may be one reason.

2019-2020 Japan influenza mortality. The blue points indicate increased mortality in March-April 2020 (source : NIID)

Recent mortality rate data from NIID indeed shows a statistical increase in influenza mortality in Tokyo in March and early April, 2020. Shibuya and others conclude that this may include some undiagnosed coronavirus deaths. Again, this does not mean deaths are being intentionally hidden, but that the reporting system sometimes makes it difficult to determine with full confidence actual causes of death.

The success South Korea has had so far in minimizing the spread of COVID-19 within its borders, according to Shibuya, is because they focused on basics: to test and isolate. Because of their unfortunate experiences with MERS and SARS in earlier years, they were well prepared for this outbreak. We can say that the same is true for Taiwan. Japan’s focus on border control and identifying clusters of major symptoms — “cluster countermeasures” which will miss asymptomatic or pre-symptomatic mild cases being transmitted within the community, and has already led to dangerous hospital transmission — has left the country vulnerable. The country needs to be conducting 100,000 tests per day, and Shibuya believes this goal is achievable. Nishiura is more sanguine. His personal stated opinion is that even if testing is increased to 20,000 per day, response will still be limited by the capacity of health care facilities. Because of personnel issues, logistics, and other issues, he noted, “The reality is we do not have the capacity to do what Korea has been doing with intensive testing and tracing.”

A key point to keep in mind, Shibuya explained, is that the perspectives of physicians and public health specialists are different, and sometimes opposite. For physicians, the primary objective is to reduce disability and save patient lives. Therefore it is natural to want to focus on cases with major symptoms, and not on asymptomatic ones, in order to prioritize resources for severe cases. If only limited testing is available, consequently, this thinking suggests that it is best to focus on those who have symptoms. From a clinical standpoint this seems reasonable. “But from a public health perspective,” Shibuya says, “unless you tackle quite a few asymptomatic and pre-symptomatic cases, we cannot contain the epidemic.” The apparently unshakeable focus on the “cluster countermeasures” policy in Japan, despite the clear looming risks, is an indication of how strongly the physician viewpoint dominates the typical Japanese approach to epidemics..

What should we expect in coming weeks? Nobody knows. Perhaps social distancing and the cooperative discipline of the population is truly helping, and the apparent bending of the curve we’ve seen over the past week will continue. It’s clear, however, that actual case numbers in Japan are vastly underreported. The ramifications of the underreporting point to a continuing risk of a much larger outbreak. At this point we believe it is clear that any relaxation of social distancing measures in Japan should be delayed as long as possible. We also think greatly expanded testing is called for, and support Dr. Shibuya’s target of 100,000 per day, while recognizing that this may arrive too late if it is achievable at all. More importantly, based on what we’ve seen so far we wonder if increased testing in Japan would actually lead to meaningful changes in the government’s overall response or the ability of the health care system to deal with COVID-19 patients. What would they do differently? We definitely think that effective mechanisms to sustain social distancing need to be found, however. Without adequate social and financial support and better targeted guidance, it is far too difficult for many people to stay at home as much as is required. We hope that good testing at some point in the near future will indicate a clear minimization of the spread of the virus over the course of several consecutive weeks, and allow the country to move into the next phase of recovery. But none of us will be able to relax until an effective vaccination program has been developed and completed.

 

NOTE: ABOUT JAPAN’S INFECTIOUS DISEASE SURVEILLANCE SYSTEM:

To repeat some relevant background information we’ve touched on earlier, Japan does not have an epidemic emergency agency like the CDC in the US or similar agencies in South Korea, Taiwan, and many other countries. Instead, Japan’s National Institute for Infectious Diseases (NIID), which is essentially a research organization, is tasked with collating and analyzing epidemic and pandemic data. It uses a system called the National Epidemiological Surveillance of Infectious Diseases (NESID), which was established in 1981 as part of the Infectious Disease Surveillance Center (IDSC). Due to the complexity of this system, and the difficulty of modifying how it operates, it moves cautiously and slowly, and is not very adaptable under the stress of new outbreaks like we are seeing with COVID-19. In practical terms, this means that data sources which have been part of the system for a long time, particularly public health institutions, are prioritized over others, regardless of their actual relevance to emergency response. Reporting criteria are fairly rigid. A lot of the issues we continue to observe regarding COVID-19 response in Japan appear to be the result of the system is working as it was designed to. It is neither agile nor flexible.

Explaining Japan’s State of Emergency

Wed, 04/08/2020 - 11:12

With Prime Minister Abe’s long-awaited emergency declaration for Tokyo, Kanagawa, Saitama, Chiba, Osaka, Hyogo and Fukuoka yesterday, the response to the COVID-19 pandemic in Japan has entered a new phase. As many people have pointed out, these new measures are not a “lockdown” of the sort that has been implemented in many countries around the world, with legally mandated closures and stay-at-home requirements which carry actual penalties for non-compliance. The Japanese legal system currently makes it almost impossible to implement similarly stringent directives (because the entire nation was compelled to extremely senseless self-sacrifice before and during the Second World War). Instead, for the coming month, the government is requesting voluntary compliance with more extensive social distancing measures than requested previously. Services deemed “essential” like supermarkets, convenience stores, clinics and hospitals, hotels, as well as manufacturing operations, are requested to remain open. As previously, people are asked to avoid establishments where large numbers of people gather, such as bars, clubs, live music venues, and karaoke, and if they have to eat out, to avoid doing so in large groups. Oddly, perhaps, public baths are asked to remain open. Many public venues such as movie theaters, museums, libraries, and department stores have already closed temporarily in Tokyo in response to earlier requests for distancing, and may be asked to do so again. But nobody will be forced to do anything and anyone can refuse to comply, and at present the order only applies to seven out of 43 Japanese prefectures. Alarmingly, there are already numerous reports of people fleeing Tokyo for other prefectures in order to evade the emergency restrictions. Partial shutdowns accompanied by ineffective monitoring of travelers made things immeasurably worse in China, Italy, and elsewhere, as infected people seeded new clusters in their home countries and abroad.

The seven prefectures and metropolitan areas included in the new emergency declaration. Source: NHK

Prime Minister Abe is quoted as saying, “If all of us make an effort and try to reduce person-to-person contact by 70 percent or, preferably, 80 percent, the increase in infections will peak in two weeks and shift to a decline.” There is a lot of uncertainty surrounding this, especially voluntary compliance, which so far has been spotty at best in Japan. We wish stronger and more binding measures, as well as more forceful messaging, had been put in place weeks ago.

Agence France Presse editor Richard Carter tweeted:

On the one hand, after the disasters of March 2011 we saw that Japanese people will readily cooperate with inconvenient emergency measures when the need has been made clear to them. In 2011 this primarily took the form of widespread voluntary energy conservation (setsuden) nationwide — shops turning off half of their lights, illuminated advertisements being turned off in train stations and building exteriors, escalators being shut down, as well as households limiting their own power consumption — which led to about a 20% decrease in overall electricity consumption. Voluntary restraint (jishiku) was also requested then to limit celebrations, other large social gatherings, and extravagance in general, and people complied.

This is in some ways a recent precedent for the still moderate sacrifices being requested now. A few days ago TBS released poll findings which showed that about 80% were in favor of an emergency declaration. But will they actually comply? We’ll know in about a week, though we don’t think the necessary ground preparation has been done by the government and communicated to the public. This includes providing additional free child care, subsidizing workers who have to stay home, as well as their employers, and easing bureaucratic regulations that make it hard to submit paperwork online, among others. In most companies, universities, and other institutions, most staff are still required to be physically present in order to be able to stamp physical documents with their hanko seal. In the current health crisis this can only be seen as barbaric. Some relevant support measures have been talked about and promised, but none of it is actually in place today. We contrast the apparent lack of care in Japan with the thorough planning done by the Singapore government, which last Sunday announced very strong binding measures in response to a “second wave” of infection (something also being experience in Hong Kong now). These guidelines have been communicated unambiguously using official outlets as well as the media, and we think they should be considered best practice.

Japan case data as of April 6th. Source: NHK

There has been a clear uptick in COVID-19 cases in Japan as a whole since late March, led by Tokyo. There is wide agreement that this is due to masses of people having gathered closely in parks three weeks ago for cherry blossom viewing parties and infecting each other, despite half-hearted official requests for social distancing. While some important uncertainties remain, and the central government’s communication efforts are still lousy, data availability for Japan has improved overall in recent weeks. The Tokyo Metropolitan Government’s multilingual COVID-19 web site has become a much clearer and informative official source, better than anything the national government has provided. As of today it shows 1196 positive cases in Tokyo, with a sharp upward trend since two weeks ago, exceeding 100 new cases per day over the past weekend, declining somewhat on two subsequent days, and reaching 144 today. The nation as a whole now has over 4480 cumulative cases, with over 300 new cases reported every day since April 3rd, except on April 6th, which saw 241 new cases. The very well-run independent and bilingual Japan COVID-19 Coronavirus Tracker, which has an extremely detailed prefecture-by-prefecture open database, has become our go-to source of vetted case number data for Japan.

Source: Japan COVID-19 Coronavirus Tracker

As we noted in earlier articles, many people have concluded that the lack of extensive testing in Japan has led to a serious underestimate of the actual number of COVID-19 cases and the rate of contagion here. Dr. Kenji Shibuya, director of the Institute for Population Health at King’s College, London, was quoted in the Washington Post yesterday saying, “It’s too late…Tokyo has already entered an explosive phase, and the only way to stop the collapse in health care was to lock down the city as early as possible.” He considers the sudden uptick in cases over the past week to be clear evidence that the country’s limited testing strategy has been a failure, the magnitude of which will become clearer as testing and discovery scale up.

While testing in Japan has increased, it still lags far behind every country that has succeeded in flattening their outbreak curve. The Prime Minister announced a few days ago that testing capacity would be increased from 7,500 to 20,000 per day, but it’s not clear how soon this can be achieved. As of April 7th, a total of 55,311 people have been tested in Japan, on almost all days fewer than half of the current stated capacity of 7500 tests per day. Germany, by contrast tests 500,000 per week.

In Japan as elsewhere, the inability to test everyone who has died of pneumonia-like respiratory failure also leads to a possible undercount of COVID-19 cases. Conversely, the widespread worldwide practice of categorizing every mortality in which COVID-19 is present as having been due to that virus has been criticized by some as leading to a possible overcount of COVID-19 deaths. But it’s been pointed out that people in many countries who die while suffering from normal seasonal flu are recorded as flu deaths regardless of whatever other health problems may have also contributed. It’s not a controversial practice, though the implications for case severity tracking must be kept in mind. All-in-all, we think it’s clear that there is much greater public health risk from underestimating the scale and growth of the pandemic than from overestimating it.

Japan COVID-19 case severity breakdown. Source: NHK

There is a serious concern among Japanese government and healthcare specialists that not enough intensive care unit beds will be available if the number of serious cases continues to grow at its current pace. The proportion of ICU beds per 100,000 people is much lower here than in many other developed countries (5 per 100,000 in Japan as opposed to 12 in Italy and about 30 in Germany, for example). This independent site shows the current status of ICU bed availability in each prefecture. In at least five prefectures, including Tokyo, the number of COVID-19 cases already exceeds the number of ICU beds. While according to NHK, only about 4% of COVID-19 cases seen in the country so far have become severe enough to require ICU treatment, the potential of severe cases outstripping capacity is looming.

In response, the government has reportedly obtained cooperation to provide about 10,000 hotel rooms in Tokyo and 3,000 in Kansai, as well as 800 rooms in the Olympic village in Tokyo, that can be used by patients with mild symptoms. Patients began to be moved to a hotel in Tokyo’s Chuo Ward yesterday. As we noted back on March 24, although many observers credited various Japanese behavioral norms, like mask-wearing and hand-washing, for having kept COVID-19 numbers relatively low until then, we felt that simple luck had also played a role. What happens now? Japan could continue to be lucky. The current spike could prove to be an anomaly, and the new voluntary measures might be met with widespread compliance sufficient to nip the surge in the bud. A recent study, which may have influenced the decision to announce the state of emergency now, posits a harrowing worst-case scenario that shouldn’t be ignored, however. If the voluntary measures fail to curtail more than 60% of people’s trips outside their home, the authors conclude, then the healthcare system will collapse on or around April 26th due to lack of ICU capacity, and 500,000 people will die. The authors seem hopeful that the 60% decrease can be achieved, noting unpublished research which shows that school closures since March 2 decreased contact frequencies among children by 40%, while voluntary event cancellation since February 27 decreased it among adults by 50%.

As with every study, this model makes basic assumptions that may not be fully accurate and is based on Chinese data that has inherent uncertainty. The Prime Minister has asked the nation to reduce social contact by 70 or 80 percent for the next month. But without clear incentives for companies to allow their employees to remain home without incurring financial hardship, we think these targets will be difficult to achieve. It certainly won’t be as effective as it would have been if stronger and more binding measures and more forceful messaging, like those being implemented elsewhere around the world, had been put in place in Japan weeks ago. Now we seem to be counting too much on luck.

COVID-19 testing, putting a face to the numbers

Fri, 03/27/2020 - 10:54

Earlier this week we launched the COVID-19 Testing Map. In only a few days we’ve already received contributions from across Europe, North America and Asia which is already beginning to tell a new piece of the story.

Since 2011 we have tried to create a platform that gives some control back to people, so they can have a say in their own narrative. In Fukushima, for example, residents have have been able to show that the prefecture is not a nuclear wasteland, as clickbait headlines might have people believe, but rather a vibrant and active population deeply invested in their future. By taking their own environmental readings and publishing their own stories, they’ve had some control in how they are represented rather than relying on someone outside to tell their story for them. We’ve seen similar experiences in other communities around the world as well.

In 2020, when the new Coronavirus began spreading around the world we immediately saw similarities and tried to offer some advice from our experience to make what was inevitably coming next go a little smoother. We knew we had to do more, but at the same time we didn’t want to just rush in and replicate things many others were doing well already. There was an ever-growing collection of dashboards and reported case numbers and visualized graphs, representing confirmed cases, tests and deaths. Through these we began to realize something was missing, a human element. Getting lost in the daily reports of which numbers had increased by what percent were the stories of the people who were suffering but not included in official accounting. It was already becoming clear that testing was not available to everyone, which was yet another point of pain.

Almost a decade ago we saw firsthand that a lack of information causes more stress, and more conflict. In 2011 there was a mandatory evacuation zone around the Fukushima Daiichi Nuclear Power Plant. People who lived in that area moved away immediately. But there was also a voluntary evacuation zone where people were given the opportunity to evacuate if they felt the need. Unfortunately, those people did not have access to an accurate and reliable source of information about what radiation levels they may or may not be exposed to if they stayed, which caused many to assume the worst and created significant social stress. People found themselves stigmatized and resented whether they moved away or decided to stay. Safecast was able to give these people a way to measure their own environments, to get accurate information from which they could then make educated decisions. This in turn put pressure on official sources to release more data as well.

Today the situation is not entirely dissimilar – if someone feels sick and thinks they might have been exposed to COVID-19 a test would allow them to know if they should quarantine themselves so as not to risk infecting others, and would allow them to know if they should be prepared to seek additional medical assistance. Do they go to work or should they stay home? Visit friends and family or isolate themselves? What if an older family member asks for assistance? Without access to testing, people are left wondering, and left to assume the worst – often alone. While we didn’t have a way to immediately get more tests to people, we did have a way to help those people tell their stories – with the hope that enough stories would create a compelling argument that would motivate politicians and governments to increase the availability of testing, to put people’s minds at ease and help people make better educated decisions.

So we put up our map and asked people to tell their stories. And in only a few days, the stories are pouring in. Not unexpectedly, the stories of people who have been turned away from testing are harrowing, and heartfelt. Here are a few examples:

Though not every story is heartbreaking, equally insightful are the stories from people who were able to get tests, and a stark contrast in some cases to read just how easy it was for that to happen. As these examples show:

The obvious point is that any of the people who received negative test results were set at ease. They could relax a bit and go back to their lives, as much as possible, without this stress hanging over their heads. Had they not been able to be tested, they may have spent weeks anxious and wondering, which could lead to other problems. Access to testing was more than just answering a question.

Sadly, not all test results have had a happy ending.

This is only a small sampling of the stories people are telling us. You can read them yourself at this page. Looking at the map view, zoomed out as well as closer in, patterns begin to emerge. As more people see this map, more stories will be contributed and it’s our hope that a larger picture will become clear and the need for comprehensive widespread testing will become obvious. People deserve to know what they’ve been exposed to and what they might be exposing others to. As a global community if we are going to take the appropriate steps to stop this pandemic, we need to, and deserve to have access to information about our health and our environments.

Making sense of COVID-19 numbers in Japan

Tue, 03/24/2020 - 07:32
Safecast has launched a crowdsourced COVID-19 testing information map. Please check it out and share it!

Last week we wrote an article about COVID-19 testing in Japan. We’ve also been publishing an (almost) daily newsletter, which we hope you’ll subscribe to here. For several weeks we’ve been pointing out that it’s difficult to find clear information about important aspects of the COVID-19 crisis. In the case of Japan, there has been continuing confusion about who qualifies for tests. We continue to hear many reports about people in Japan being denied testing or being persuaded by medical staff not to get tests, despite feeling they truly qualified based on their symptoms. This is leading to increased frustration and suspicion. As we pointed out last week, Japan has been an outlier so far among countries which appear to have “flattened the curve,” such as Korea, Taiwan, and Singapore. In every other country that has done so, intensive testing has been essential. Japan has not been doing that, and continues to have one of the lowest COVID-19 testing percentages among developed nations. This, as we noted, is by policy. Where is it leading us?

The narrative that Japan has beaten the virus thanks to mask-wearing, good hygiene, no-handshaking, and cooperation with social distancing programs seems to be gaining currency in many corners lately. We agree that masks and regular hand washing, as well as the relative lack of skin-to-skin contact, may be helping to keep the contagion rate here low so far. But social distancing has been very lax, despite the closure of schools, cancellation of large events, and many people working from home. Parks are full every day with crowds enjoying cherry blossom viewing parties, and trains are pretty full too, as are bars and restaurants. We think that Japan has been lucky so far, while many can’t shake the suspicion that a much higher infection count is being obscured by the lack of testing and the miscategorization of COVID-19 deaths simply as pneumonia.

Prefectures and municipalities in Japan have a fair amount of autonomy when planning emergency response. A recent news report described a town in Wakayama Prefecture that implemented a thorough COVID-19 testing program with results good enough that it is now considered a model. A few days ago, the Governor of Osaka, Hiro Yoshimura, publicized task force findings (in Japanese) which indicated that by the first week of April, Osaka and Hyogo prefectures could have a combined COVID-19 case count of over 3300 people. The Tokyo Municipal Government is securing 4000 hotel rooms to use for additional hospital beds. I suspect we will hear of similar preparations in other Japanese locales in coming days. Though we can’t prove it, the Ministry of Health, Labor, and Welfare (MHLW) seems to have preferred that these deliberations not be made public until a coordinated policy could be announced. Governor Yoshimura deserves credit for setting a precedent for transparency by going public when he did. He was followed by Kanako Otsuji, a Representative from Osaka Prefecture, who provided helpful detail on Twitter (Japanese).

COVID-19 test data for Japan remains maddeningly ambiguous. As we noted previously, the government regularly presents two sets of numbers, one generally almost double of the other. The most recent numbers, as of March 23, are 20,340 (obtained from this chart) and 38,954 (this chart). We discussed with journalists and other knowledgeable people exactly what these numbers indicate, and many had concluded that the higher number refers to the actual number of tests, the lower number, to “official” tests. Osaka Representative Otsuji thankfully clarified in a March 18 tweet that although the larger number is listed as “cases,” in fact it refers to “samples.” Consequently, 20,340 is the number of individuals who have been tested in Japan as of March 23, many of whom were tested more than once. It was unacceptably difficult to resolve this ambiguity. If we had a hard time figuring it out, the general public would not be able to either. Back in 2013, when discussing the obscurity of Fukushima radiation monitoring data, we termed it “ADAP” — As Difficult As Possible to find and use. We think that remains the case here as well.

There is also a difficulty in obtaining data about the death rate from pneumonia in Japan. Because of the concern that the lack of testing means some deaths recorded simply as pneumonia might actually be due to COVID-19, there have been calls for MHLW to clarify the recent pneumonia case and death rates. Unlike influenza data, which is published weekly, similar pneumonia data seems to be unavailable. Writer Jake Adelstein recently tweeted that he contacted the ministry directly and was told that the pneumonia reporting period was every three years, and they had no intention of making an exception now. Again, this kind of inflexibility and lack of transparency only increases mistrust and suspicion. We don’t know why the Japanese government doesn’t realize that.

Ultimately, as Safecaster Joe Moross said the other day, though so far it looks like Japan has bent the curve, we’re still in round one of what will likely be a ten-round fight against the coronavirus. It’s way too early to ease off and declare victory.

Announcing The COVID-19 Testing Map

Mon, 03/23/2020 - 06:45

Today we are launching a crowdsourced map to help people document their experiences when seeking COVID-19 testing — were they able to get a test when they sought one, or not. One of Safecast’s founding beliefs is that people should have access to reliable and accurate information in order to make decisions about their own safety and that of their friends and families. We began to publish crowdsourced radiation and air quality data in order to provide an independent and credible source of information about these risks. COVID-19 is already having devastating impacts on communities around the world. People need to prepare for what’s coming and need good information to do that. We also believe they should have easy access to testing options to give reassurances about their own health and safety, and to help them make better decisions during this global emergency.

Currently, however, in many places around the world, official COVID-19 testing information is ambiguous and incomplete, and people are dependent on single sources of official information which may be neither relevant nor trustworthy. Due to the failure of test kits to arrive where needed, delivery of incomplete test kits, overly complicated approval processes, or favoritism and discrimination, it has become apparent that there is a gap between the availability of testing claimed by some governments and what is actually available. This is disturbingly reminiscent of what we saw after 3/11, which we’ve written about in more detail here. With the help and input of people around the world, this map will hopefully begin to provide a more accurate picture of the relative difficulty of obtaining testing in various locales. It’s our hope that by providing an alternative source of credible crowdsourced information, this map will become a useful tool with which to better target resources and hold governments and officials accountable.

The map can be found at covid19map.safecast.org

How to use this map:

  1. In the menu/navigation you will see options for “Refused Testing” “Testing Unavailable” and “Successfully Tested” which correspond to colored markers on the map. You can turn any of these markers on or off to get a clearer view.
  2. You can zoom in or out by clicking the map, or use the search to find specific locations.
  3. Selecting an individual point on the map will show you the specific details of that situation.
  4. To protect the privacy of contributors, locations shown on this map are obfuscated to within 1 km.
  5. To contribute your experience, please select the yellow + icon and then choose the option that best reflects your situation. A short survey will guide you through the details needed.
  6. All contributions are put into the public domain.
  7. For this map to most useful, we need as many people as possible to contribute their experiences – if you know someone else who has also been tested or has made attempts to get tested, please send them this map and ask them to consider contributing.

Caveats:

  • As all contributions to this map are crowd sourced, it would be impossible for us to guarantee the validity of any information and make no assurances as such. This map is provided as supplemental information only.
  • The survey options might not apply to every person, this is by design. We are not trying to create a map of people who aren’t feeling well or think they might be sick as there are a number of symptom maps being run by medical professionals who are much better equipped to process that kind of information. The purpose of this map is to highlight the disparity between the number of people who are getting tested, the number of people who are unable to get tested despite attempts, and how these numbers compare against official “tested” numbers being published by governments.

As this situation continues to evolve, we anticipate updating and adjusting this map as well as the data we collect and display. For resources and other information about Safecast’s efforts surrounding COVID-19, please see this page.

* A special thank you to our friends at Ushahidi for providing the open source software platform we are using this map. If you find a bug or would like to help improve the software for everyone who uses it please see Ushahidi’s contribution guidelines, if you find an error or want to fix something on our installation of it please use this github repository.

COVID-19 Testing in Japan: The situation and ramifications

Wed, 03/18/2020 - 02:47

 

Source: VOX

Basic COVID-19 testing numbers for Japan as of March 16, 2020:

  • Tested: 13,026
  • Detected: 1,496 (both symptomatic and asymptomatic cases)
  • Deaths: 24

Sources: Toyokeizai, MHLW, Japan Times, Vox

Compared to countries which have rolled out intensive COVID-19 screening and testing programs, like South Korea, Japan has not done much surveillance testing to date. According to Japan’s health ministry, as of March 6, 13,026 people in total have been tested, compared to over 200,000 in Korea. In fact, in terms of percentage of the population tested, while above the US, at the moment Japan ranks lower than the UK, Netherlands, Israel, Taiwan, Italy, Guangdong, China, and South Korea. Therefore people’s concern that the lack of testing here obscures a much wider incidence of coronavirus which is not being detected is understandable. Recent information suggests that asymptomatic carriers of the virus — those contract the virus but experience no physical symptoms of illness, like coughing or fever — account for 86% of the spread to other people. The testing situation in Japan in terms of percentages and timing seems fairly similar to that in the United States, which appears headed for severe healthcare system overload soon.

Source: Financial Times

It’s been difficult to get a solid understanding of what accounts for the very different outcomes we’ve seen, for instance, between South Korea, which appeared touch and go for a while but seems to have gotten past the worst, and Italy, where we see an ongoing and traumatic health system collapse. Many factors can account for the widely varied outcomes, and the scale, timing, and effectiveness of testing seems to have definitely been playing a large role. Countries that promptly established thorough testing regimes, like Singapore, Korea, and Taiwan, have fared much better so far in “flattening the curve” than those which haven’t. A lot of data is available which visualizes this, including the comparative graph above that has been frequently updated by John-Burn Murdoch of the Financial Times (paywalled). Unlike the steep exponential growth seen in most countries, the plot line curve for Japan is very similar in its reassuring shallow gradient to Singapore, Korea, and Taiwan, which suggests that COVID-19 is largely under control here as it is in those countries. But since, unlike those countries, Japan has not been doing thorough testing, why does the outcome appear similar so far?

The graph notes “isolation of elders” in Japan, positing it as a positive factor for limiting the disease spread. While some elderly care facilities have been closed in a handful of cities, this has not yet been widespread. It may well be that many elderly here have gotten the message and are self-isolating. While some in our network here in Japan have observed this, others have not. There has been other notable social distancing, through the closure of schools and the encouragement of working from home. There is significant evidence that despite the school closures and widespread cancellation of large events, social isolation is not being adhered to strongly in many places. Even now, bars, clubs, and restaurants are fairly full in Tokyo in the evening.

Japan, Singapore, Korea, and Taiwan all have good personal hygiene norms, such as frequent hand washing. Except for Singapore, people in these countries also commonly bow instead of shaking hands. It is easy to imagine that behavioral norms like these might contribute to the apparent similarity of outcomes. Some have suggested that maybe face masks, which are commonly worn in all of these countries, especially now, might be similarly beneficial in limiting the disease spread. These questions require good evidence to either prove or disprove, and unfortunately, we have to admit that for the most part nobody knows for sure.

Until now, testing for the virus in Japan has been limited by policy. There is no official body like the US CDC tasked with handling emergency public health issues. Instead, the National Institute of Infectious Diseases (NIID), under the Ministry of Health, Labor, and Welfare (MHLW) has taken the lead. All requests for COVID-19 testing, we are told, must be approved by this body, which is currently overloaded. As many people have noted, including several we’ve heard from who have enough of the symptoms to strongly suspect they have coronavirus but have been unable to obtain a test in Japan, the NIID has set a high hurdle of conditions which must be met before tests will be approved. In order to qualify for the first medical consultation, the person must have been in close contact with a known infected person, defined as contact over a long period of time or living together, examining or caring for a patient without taking protective measures, or contact with bodily fluids, and currently have fever of 37.5’ Celsius or respiratory symptoms; and/or had visited an endemic area in Hubei or Zhejiang Provinces, and currently have fever of 37.5’ Celsius or respiratory symptoms. Those who call Japan’s Novel Coronavirus Patient Consultation Call Center (03-5320-4592/03-5285-8181) and are recommended for in-person outpatient consultation must then appear at the designated center and be examined. If the doctor suspects COVID-19, he can recommend a PCR (polymerase chain reaction) test, and seek approval from the NIID for it. In practice, we are told, the NIID is so inundated with requests it is often difficult for doctors to get through by phone. This system presents a strong bottleneck to testing.

Source

As is unfortunately often the case, it is difficult for average citizens to understand or navigate this system and its requirements, and many are becoming quite frustrated and alarmed. If they’re feeling ill with similar symptoms, they want to know how serious their prognosis is. A recent article in the Nikkei Asian Weekly attempts to explain the policy. The capacity is there, the writer notes, and the number of tests has been limited because the Ministry of Health, Labor and Welfare wanted the data to support an epidemiological investigation, not as medical care. In particular, the policy focuses on identifying clusters of the disease, to help in the allocation of medical resources. This is also emphasized in official policy documents from February 25th of this year, available at the MHLW website:

“Establish the surveillance system to grasp the epidemic situation in Japan, while switching to use of PCR test for the confirmation of diagnosis necessary to treat pneumonia patients who require hospitalization, in communities where the number of patients continues to increase.”

“The local government shall use active epidemiology surveys to identify a cluster based on individual patient outbreaks in cooperation with the Ministry of Health, Labour and Welfare and experts, and request the necessary measures including closure of the related facilities and voluntary restraint of events if there is a possibility that such a cluster exists.”

and

“Shift the focus of PCR test to the confirmation of diagnosis for pneumonia patients who require hospitalization, while strengthening the surveillance system to grasp the epidemic situation in Japan.”

Ministry staff felt that surveillance testing should be adequate for understanding the scale and geographical distribution of the outbreak, but that too much testing, particularly of “worried well,” would overwhelm the system. Notably, the government decided against allowing rapid test kits developed by the pharmaceutical company Roche, which have been used with success in Wuhan and elsewhere, to be used in Japan, fearing that the variability of test results would hamper nationwide epidemiological analysis. After criticism, the government agreed to allow the Roche tests to be used and eligible to be covered by Japanese public health insurance from March 6. Beginning March 16, laboratories and medical institutions tasked with testing for COVID-19 have also been able to purchase kits from Kurabo Industries Ltd. that can detect the virus in 15 minutes, as opposed to up to six hours required for PCR tests. Other companies hope to have similarly rapid testing materials available in Japan within a few weeks. We hope that these developments mean that testing in Japan will increase quickly. A few days ago Prime Minister Abe promised that by the end of March Japan’s nationwide COVID-19 sample testing capacity will increase to 8000 per day from the current 6000. Even so, some prefectures only have the capacity to test a little more than 100 samples per day.

Dr. Kiyoshi Kurokawa, a celebrated public health specialist who has served as a science adviser to the Cabinet and chaired the Fukushima Nuclear Accident Independent Investigation Commission (NAIIC), is also a Safecast advisor. In a recent Japan Times article he is quoted as saying, “Any patient who comes to the doctor, if they have a reasonable suspicion (of having coronavirus), and they want this testing, just do it…And what is the price? That comes later anyway.” The epidemiological study is necessary, but it is equally necessary to transparently alleviate people’s legitimate concerns. He notes the reluctance of officials to approve the outsourcing of COVID-19 testing because it’s not clearly “written into law,” a situation which often leads to government paralysis in Japan. Officials may agree in private that it should be done, but no-one wants to take responsibility for breaking the rules even during an emergency. Kurokawa strongly recommends streamlining the outsourcing of testing to university labs and the private sector.

It’s possible, then, that there has been (barely) enough testing in Japan to allow public health specialists to anticipate the eventual spread of the virus and to prepare the necessary hospital beds. But Kurokawa wryly notes, “Nobody knows.” Is it possible that there is a much larger rate of contagion in Japan which is not being detected? Yes, but the corresponding hospitalizations and fatalities have not been evident. If the numbers were growing exponentially like in most countries, it would seem hard to hide that fact. Is it possible that many Japanese, particularly elderly, are dying of pneumonia or other respiratory diseases which are not being diagnosed as COVID-19? It seems possible. Hospitals are not required to share such data, though, and autopsies are normally performed on fewer than 2% of all deaths. Recent funeral rite guidance has indicated, however, that because the deceased are generally not being tested for coronavirus, all who have died of pneumonia should be handled with the same precautions as if they had the virus.

That said, if there was a very large number of highly contagious cases serous enough for hospitalization, we might expect a corresponding increase in respiratory illness among medical workers, which so far has not been evident. Again, however, hospitals are not required to report this. At present, the lack of widespread surveillance testing cannot be reassuring regardless of the comparatively small number of COVID-19 cases reported here so far. We cannot exclude the possibility that Japan might yet experience an exponential growth in cases, and feel that under the circumstances it’s prudent to be prepared for the case numbers to explode in coming weeks. What’s the likelihood of that happening? Without reliable data, nobody knows.

COVID-19 Action Update

Mon, 03/16/2020 - 12:00

It’s been almost 2 weeks since we published our initial response, best practices and initial assessment to the global Coronavirus outbreak and we wanted to give you an update on our ongoing efforts and actions. Since then the situation has continued to develop and last week we expanded on some of the ideas in our initial post in an article for the Bulletin of the Atomic Scientists entitled “What the Fukushima meltdowns taught us about how to respond to coronavirus” which we hope will help pass on some of what we’ve learned from the experience of the last 9 years. But we do not intend to be exclusively reflective in this situation which we expect will continue to impact us all in various levels of severity.

As a proactive measure we were able to assist our friends at The GovLab and The Federation of American Scientists to build this chatbot to help people quickly access information and answer some of their questions. This is the first step of many.

Here at Safecast we’ve put up a new section which will serve as a directory to efforts and resources – including a new daily newsletter for COVID-19 related info. In the coming days we hope to have more work to share, and will post it on safecast.org/covid19/ as soon as we do.