Living with COVID-19: The Japanese Approach

Emma Ross

Good morning, and thank you for joining us on the Living with COVID-19 webinar series with Chatham House Distinguished Fellow, Professor David Heymann. Today, we’re exploring how Japan has approached the pandemic. It’s widely considered, among international experts, to have been fairly successful, with quite a low number of deaths, that’s 2,139 when I checked yesterday, despite having one of the world’s oldest populations and densely packed cities, and while not locking down hard and taking a rather unorthodox approach to two of the key pillars of epidemic control: testing, and contact tracing.

With us today to discuss this is one of the architects of Japan’s coronavirus strategy, Hitoshi Oshitani. Hitoshi is a Professor of Virology at Tohoku University in Japan, and he sits on several of the expert advisory groups guiding the Japanese response. He’s credited with massive contributions to the knowledge of how the virus is transmitted, and for pushing the urgency early on and constantly pestering the Government to do more, and he’s become a global ambassador for the so-called Japan model, so it’s very exciting to have him with us here today.

But, before we start, I just want to remind you that you can ask questions using the ‘Q&A’ function. Upvoted questions are more likely to be selected, so if you like one of those, do upvote it. Briefing’s on the record, and the recording should be available shortly after on this – on the Pandemic Briefing Playlist on Chatham House’s YouTube channel. So, Hitoshi, welcome, and thank you for joining us today.

Dr Hitoshi Oshitani

Emma, thank you very much for inviting me for this webinar, and it’s my great pleasure to be at this seminar to share our experience in Japan.

Emma Ross

Right, well, I’m sure we have a lot to learn. There’s so much you’ve done in a very innovative way. I was hoping you could start by giving us a brief overview of Japan’s experience to date with the pandemic, and what the Japan model is, how restricted has everyday life been for the Japanese, and what you’ve learned from your experience with the virus, and the strategy you’ve taken to tackle it.

Dr Hitoshi Oshitani

Okay, so, I will briefly explain what we’ve been doing in Japan. But first, let me briefly summarise what has been happening in Japan for the COVID-19. The very first case was identified on the January 15th, the – in the traveller from China and then, in early February, we had the Diamond Princess, the issue in Japan at Yokohama Bay. And then from February 13th, we suddenly saw the locally acquired cases, and the Minister of Health, the Labour, and the Welfare, they set up a cluster task force on 25th of February. Professor Hiroshi Nishiura who is now the Professor at the Kyoto University, and I joined this team. And there, Hiroshi and the team had the preliminary data, which suggested that the majority of infected individual actually did not pass the virus to anybody else, and the small proportion of infected person there infected many others, and that was our early finding from the epidemiological investigation of locally acquired cases. And then we realised that for COVID-19, the transmission cannot be sustained, without forming the large clusters or super-spreading event in which the one person infect many others, and that’s why we’ve been focusing on the cluster, so that our cluster – our strategy is basically the cluster-based approach.

And – but – and then from mid-March, we saw the increasing number of cases, due to imported cases from many different countries, including European countries, the US, South East Asian countries, and others and then, the Government decided to declare a state of emergency on 4th of – 7th of April. But even during the state of emergency, we did not implement lockdown type of measure. We just asked people to stay at home as much as possible, and we also asked people to not travel between the prefectures, and we also asked some restaurants and shops to be closed, but that all these measures are on voluntary basis. And our legal system does not allow us to implement any measure with the enforcement power, so, even during the state of emergency, we did not implement any measure with the enforcement power.

And – but, in general, the people, they follow the government and the expert advice, and the number of cases decreased by mid-May. And we continued to do our cluster-based approach, and to find the cluster, and over – then, at the end of the June or the mid-June, we started again increasing of number of cases, and this, the phase was mainly due to the many clusters in the large nightlife entertainment areas in Tokyo and some other big cities. But we still tried to have a dialogue with the people working there and also customers in the nightlife entertainment areas, and then we managed to suppress the transmission level, and, by mid-August, our daily number went down to the few hundred per day. And then now, we are seeing some increasing strength, due to several reasons, and we are seeing the clusters in different settings, not only in nightlife entertainment areas, but also, in small restaurants and bars and the sports event and so on. And the current phase is much more complicated.

And, as in many other Northern Hemisphere countries, we are going into the winter, and, particularly, we are seeing the increasing trend in the northern part of Japan, particularly in Hokkaido, and also in some other places like Osaka and Tokyo. So, we are now facing the new challenge, but especially under such a situation, it’s getting more difficult to do the profile contact tracing. We are doing the – we are also doing quite a unique approach for contact tracing and, in addition to the usual prospective contact tracing, to the – we are also – we’ve been doing the retrospective or backward the contact tracing to identify the source of infection, because they find they have epidemiologically unlinked cases. There must be the source of the infection, which is likely to be a cluster. So we’ve been trying to find the clusters from the epidemiologically unlinked cases by identify the common source of the infection, and that’s what we’ve been doing. And, as I mentioned, we are facing the new challenge at the moment. But we’ve been discussing how to respond to the current situation, and so that’s the brief overview of what we’ve been doing in Japan.

Emma Ross

Thank you, Hitoshi. I wanted to dig down a bit deeper into this cluster-based approach, more about how you go about this. We’ve heard others talk about you have an army of cluster-busters, and so how do you go about – what is the system for identifying first what the cluster is, and then what do you do once you’ve identified it? Whose involved in this? Have you hired contractors? Do you use an already existing workforce for this? And why did you focus on this particularly? This seems to be a big cornerstone of why you’ve put so much energy, and how much do you attribute your response success to this cluster-based approach?

Dr Hitoshi Oshitani

So, first of all, we’ve been focusing on cluster because, as I mentioned, without forming cluster, the COVID-19 transmission cannot be sustained, and the particularly dangerous situation is where the cluster-to-cluster transmission there occur. So, we have to interrupt the such cluster-to-cluster transmission and, to do so, we need to identify the cluster as many as possible. And so when we have some cases there that we try to identify the source of infection, and this has been done by the Public Health Nurses in Japan. Then we have over 400 public health centres, and over 8,000 Public Health Nurses are working in these public health centres and they’re the ones who are doing the contact tracing, both retrospective and prospective contact tracing. And they are trained there for public health, in addition to the usual nursing curriculum and, most of all, they have been doing the contact tracing, even before COVID-19, for measles, the tuberculosis, and the other infectious diseases. And they’re well-experienced on the contact tracing. And even before we proposed the cluster-based approach, the Public Health Nurses actually already did the retrospective contact tracing to identify the source of the infection and the prospective contact tracing, and particularly for COVID-19, is they’re not so effective. The positive rate is quite low among close contact. But if you find that the common source and if that is a cluster, you can find many positive cases there among the cluster – among the people there who are in the cluster.

So, our approach, they – we were – we’ve been focusing more on the retrospective, the contact tracing to identify the source of the infection. But this is – this has been done based on mutual trust between the Public Health Nurses and the infected people and this is particularly difficult for the cluster in the nightlife entertainment settings. The people – some people do not want to tell the truth to Public Health Nurses. But the Public Health Nurses have been trying to build the trust there with the infected people to get their past activities in the past one or two weeks, and that’s how we’ve been doing our cluster-based approach, including the retrospective contact tracing.

Emma Ross

But are these Public Health Nurses – do they already know the constituents in their – the community members or – and are they – how are they doing it? Are they phoning people? Is there an app? Are they knocking on the door? How are they physically making contact with people in the cluster, and tracking this all down?

Dr Hitoshi Oshitani

So, therefore, particularly for the retrospective ones, we have to interview the confirmed cases. So the most of confirmed cases are either in hospital or a designated – the isolation facilities. And the Public Health Nurses sometimes visit these places, or they phone these individuals to get the details about their past activities, especially the activities related to the risky environment.

Emma Ross

Okay. David, I wanted to ask you on this, and what are your thoughts on the role of retrospective contact tracing as opposed to a sole focus on the prospective contact tracing, so that is tracing forward who people might have infected, once you’ve identified a case? Can this be replicated in other countries, and should it be? And, I’m wondering, could this be why some countries are finding it difficult to stay on top of this? Hitoshi said, “Prospective contact tracing is very difficult to do.” Or is it that they’re using their network of Public Health Nurses to do it? I’m just wondering how generalisable this might be for others, and is there anything we can learn from this or apply?

Professor David Heymann

Well, clearly, what Hitoshi has talked about is good public health, and good outbreak control, investigation, and decisions on what needs to be done. So, the retrospective identification of sources of infection is extremely important in all outbreaks, and, therefore, by shutting that down somehow, you can prevent further clusters, which is what Hitoshi has said. I think what’s been important in Japan is that Japan actually was the first country to show that this does not transmit in the way that does influenza. It does stop off in clusters before it goes into communities. And if you can find those clusters, which are really the Achilles’ heel of outbreaks, you can stop transmission, as has been done in Japan. Other countries have done it. They’ve done it in different ways. They call it different things. But many countries in Asia, and Hitoshi will agree with me, I’m sure, such as Hong Kong, Taiwan, South Korea, Singapore, have been trying to investigate their outbreaks, and trying to shut down the areas of transmission, some of them by a blunt lockdown of nightclubs for a week.

Right now, I believe Hong Kong has their nightlife shut down for a couple of weeks, while they’re waiting to see if they can decrease transmission that was occurring there. So these have been ways that Asian countries, and Japan in particular, have conserved their economies to the best possible way that they could do during a pandemic, while, at the same time, making sure that the efforts that they’re making are effective, and they’ve used local workers to do that because that’s where trust occurs, as Hitoshi said. You can’t do contact tracing by an app or by something which nobody has face-to-face contact with or trust with. They have to have trust in the investigators, and there, in every country, there are investigators that look at TB, as Hitoshi said. They look at many different infections, HIV, trying to help identify contacts and decrease spread.

So the Japanese have just used incredibly wise ways of dealing with this outbreak by understanding early that it doesn’t just go directly into communities when it enters a country. It stops off in clusters. Germany began that technique in Europe, and has continued that. They have many what they call COVID workers who are medical students and others who are doing the job in Germany and many other countries. The UK started it as well, but the UK felt overwhelmed in their contact tracing, and they stopped it during their blunt lockdowns and, now, they’re starting to do it again in areas where there are discrete clusters because they know that that’s the way you can really shut down transmission.

Emma Ross

But, David, do you think that there needs to be or there is some wisdom feasibility in reorienting contact tracing, you know, across the board, in several other countries, towards a more retrospective way that Hitoshi’s describing? I’m talking about the emphasis of the – what – how much energy you put into forward versus reverse. Do you think there might be some wisdom in reorienting the system, and is it even possible to do that?

Professor David Heymann

Well, absolutely, and what Hitoshi described is outbreak investigation, which all Epidemiologists and all public health people do to find the source of infection, and Japan has done it particularly well. I think, as countries come out of this feeling that they’re overwhelmed with cases and go to areas where transmission is occurring still in clusters, and that’s many parts of the countries, including probably right here in London where there are clusters of outbreaks, if they can find them, and shut down the areas where there’s transmission, they don’t have to do these blunt lockdowns that countries have been doing to try to decrease transmission. They can do it in a surgical, precise way instead of a long way.

And, you know, Emma, after the blunt lockdowns in Europe, and Hitoshi may want to comment on this, but after the blunt lockdowns in Europe, which ended in May and June, countries just opened up from one day to the next, and so nothing was maintained as areas of risk for transmission and continued to be shut down. Everything was wide open again, and transmission began to occur within countries and also as people went on holiday to other countries. And so, this transmission is what resulted in the resurgence, which occurred in the autumn months, amplified by the fact that people are more indoors during the cooler weather, and able to transmit more easily from person-to-person. So maybe Hitoshi would want to comment on that, whether or not he feels that these precise lockdowns are the way to go in the future in all countries.

Dr Hitoshi Oshitani

Yes, sure. As I mentioned now, we did not implement lockdown measure in Japan. Instead, we’ve been focusing on the risky environment where most of the clusters are occurring. Actually, the cluster hub are occurring in different settings, depending on the stage of the outbreak. In February, March, April, we’ve been seeing many clusters associated with the middle-age or elderly people, in a sports gym or some other settings. But then, in the June/July, we saw many clusters in the large nightlife entertainment areas. And in current the phase, we’ve been seeing the clusters in different settings, not only in nightlife entertainment areas, but also, in small restaurants and the foreigners’ communities and so on. So, the setting where the clusters are occurring are changing, so it’s important to know in which settings the clusters are occurring, so that we can put the more emphasis on the situation where the clusters are occurring. And also…

Emma Ross

But are you shutting down those environments?

Dr Hitoshi Oshitani

Yeah, in some cases, but at the moment, there’s some local governments, some prefectures, they ask the bars and restaurant to be closed at 9pm or 10pm, not total shutdown. In some areas, in some very small areas, they ask to close some restaurants and bars at night. But we’ve been trying to minimise the social and economic impact by implementing these measures. And, from the beginning, our objective of the COVID-19 response is to minimise the level of transmission as much as possible while maintaining the social and economic activities. So, we’ve been trying to balance between these two difficult ones, the balancing – the suppression of the virus, and the maintaining the social and economic activity is quite challenging, and we have also been discussing, in the past few days, what we should do in the current situation, okay.

Emma Ross

Okay, thank you for that. I wanted to come back to super-spreading event, maybe, David, what Hitoshi was describing where, you know, three-quarters of the cases they found in these clusters did not go on to infect anybody else, but there was a minority that went on to infect loads of people. Seems to me that there are super-spreaders as opposed to a super-spreading event. There’s always been a lot of discussion to be careful to distinguish between – we’re not talking about super-spreaders; we’re talking about super-spreading events. This seems to me that there are, in fact, super-spreaders. Am I reading that wrong?

Professor David Heymann

What I believe you’re seeing is that there are some people who are – who respond differently to the virus than others, and they have a higher level of virus in their blood, in their nasal passage, and in places where they can transmit it, and so they’re the people that transmit. Whereas people who remain asymptomatic or don’t develop a high virus level don’t transmit. It’s basic understanding that higher virus levels in the body cause greater transmission to others, and that’s through coughing, through sneezing, through speaking, through singing, through various measures. And we know that people just before they develop signs and symptoms are able to transmit, whereas people who don’t develop signs and symptoms throughout their infection are at a lower risk of transmitting to others. This has been shown in many places.

In Singapore, they understand that about 7% of people who develop symptoms can transmit within the two days prior to transmission, but they don’t see that transmission occurring in others. And so, you know, this disease is very unusual because there are so many asymptomatic or non-symptomatic infections, but some of them can be transmitting. And what transmits even more are those people who you’re calling ‘super-spreaders’ who have a higher titre virus because – at which then results in disease in them rather than in signs and symptoms rather than just an infection. So, yes, these are super-spreading events caused by people who have higher virus titres. But then, to call them ‘super-spreaders’ gives the impression that they’re attempting to spread it, and they’re not attempting to spread it. It’s just a fact that they have a higher virus titer, for some reason or other.

Emma Ross

So, really, if we’re being honest, there are super-spreaders, but it doesn’t mean they’re doing it on purpose.

Professor David Heymann

Hitoshi, what do you call people who spread disease easier? You call them ‘super-spreaders’?

Dr Hitoshi Oshitani

Yeah, yeah, it’s, kind of, a…

Emma Ross

Yes.

Dr Hitoshi Oshitani

…‘super-spreader’. But, yeah, actually, the super-spreading event can occur due to different reasons. As David mentioned, there are some people probably they’re shedding a large amount of viruses. But the – that kind of host factor there is probably – they are quite important, but not just host factor, but also, the environment and the social factors are involved in a super-spreading event. And we analysed many clusters, and we found that there’re many of these super-spreaders that are relatively young, in 20s and 30s, and that’s probably because they are more active in their social life. And, also, we found that more than 40% of these super-spreading events are caused by the person in pre-symptomatic phase, and that is probably because they are still very fit. They do not have any symptoms. That’s why they are going to the sports gym, the live music event, and the drinking places, and so on, and that’s how these super-spreading events are occurring.

Emma Ross

Okay.

Professor David Heymann

You know, Emma, I’d like just to add to that. In fact, there was an event in Germany, which was when they really realised that they needed to start contact tracing, which was just what Hitoshi described. It was a woman who had come in with infection, and was meeting in a small enclosed space with two or three, up to five people, and she was pre-symptomatic. She developed symptoms two days later when she got home. But she was transmitting during that period of time to these people who were in this very closed environment. So what Hitoshi says is right, super-spreading events are the environment and the host both.

Emma Ross

Okay, thank you. I’m going to move on from those. I get it now. But one thing, Hitoshi, that you said that is very interesting for us is that Japan does not have any authority or legislation in place to enforce this. It’s all voluntary. You’ve got a lot of people in Japan, densely packed. How were you able to get the community buy-in and compliance? I mean, the numbers – your death rate is low. To what do you attribute the fact that without enforcement or threat of anything, you’ve managed to get the community onboard, if you feel you have?

Dr Hitoshi Oshitani

I believe that the number of factors involved in the Japanese situation, first of all, especially during the state of emergency period, the people followed the government advice, including the stay-at-home, the message, and also, most of the restaurants are closed at night, and even without any enforcement power. And, now, the majority of people are wearing masks in the public places. And if you take subway in Tokyo, probably 90, more than 99% of the people are wearing masks, and this is because we have a very strong peer pressure in Japanese society. If you don’t follow the general rules, you are highly criticised and – but the negative side of – so this is one of the main reason why the people followed the – our advice. But the negative side of this is a discrimination type of thing, and so we’ve been seeing such things in the different places of Japan. So, probably because of the high peer pressure, that if you do not follow some advice, you are highly criticised, and even the infected people are discriminated in some places. So, that’s probably the negative side of the Japanese response.

Emma Ross

Okay, yeah, that is a double-edged sword, I suppose. David, maybe, I wanted to ask you about what Hitoshi was saying that isolation is done in isolation facilities, and do you think this could be a major driver of keeping numbers low? I remember when we had Mike Ryan on, he had said that the quarantining and isolation, if you don’t actually isolate and quarantine, stay away from others, you’re not going to interrupt transmission, and that’s probably the single biggest thing that is not happening optimally. I guess, if, in Japan, they are taking people out of the community, and putting them in isolation facilities or quarantine that that might explain – first of all, Hitoshi, do you think that, in part, explains why you’ve been able to do this quite successfully? And then, David, how generalisable do you think that is to other countries, and do you agree?

Dr Hitoshi Oshitani

So, yeah, we are also implementing the isolation and the quarantine measures, and particularly we are doing the cluster-based approach when we have the clusters. We test the most of people in that setting, and then we can find many confirmed cases, and we also ask the people who were at that venue to be quarantined for a certain period of time. And so the – but, initially, we isolated all confirmed cases in hospital settings, and hospitals are completely overwhelmed, and now we are – some people are isolated in their designated – the facilities such as hotels, and some people are also – some confirmed cases can also be isolated at home when they have the – if they have no family member, especially the no – the elderly at home, the people can choose to be isolated at home if they have the asymptomatic or the very mild symptoms, yes.

Professor David Heymann

Emma, maybe I would ask Hitoshi is that mandatory or is it recommended? Is it voluntary, and are they provided with resources, or do they have to pay for their isolation procedures?

Dr Hitoshi Oshitani

So that for isolation, all costs are paid by the government, and it’s mandatory, so they – if you are confirmed as a COVID-19, you must be isolated.

Professor David Heymann

So, you know, Emma, is that transferable to other countries? Well, certainly, some of the aspects of that are. Many countries wouldn’t be able to require people to isolate. But one of the deterrents of people isolating is the fact that many of them don’t have the resources in which to live during that period of time, or the ability to get what they need. And so, if Government is providing this, it adds an added incentive to be able to self-isolate, and I know some countries are doing that, and that’s more of a way of controlling outbreaks. Whereas most countries do not provide that service at their borders, so if international people come in, they’re required many times to isolate at their own expense. Whereas people who are within countries often are isolated, and the government is providing them with the means they need to continue to function and to live and getting them back to work as soon as possible.

Now that there’s testing available, which adds a new element to that, rapid diagnostic testing, some countries are beginning to test people during their quarantine period to see if, after a period of five to seven days, they do have a contact – or do have evidence of infection based on when their contact occurred. And, if they’re free of infection, then they’re released from quarantine earlier. So there are new ways that we can deal with this. But, clearly, getting people who have been in contact isolated is the key to this. Investigating, operate, shutting down transmission, and getting people into isolation to prevent forward transmission into the communities is just good, basic control of an outbreak or a pandemic, and Japan has applied all of these in a very unusual and very effective manner so far.

Emma Ross

I’m going to move on to questions now, and this is one from Caroline Johns, and it is off topic of this discussion, but very on topic for today, and that is to do with the UK’s regulatory approval of the Pfizer vaccine today, and what your thoughts are on that. And, I guess, how much of a game-changer is this? How should we be thinking about the arrival of vaccine in our lives? Can we just, kind of, relax now? What does this mean for us? I know, David, you and I are going to be doing something further on this in the next week or so, look more deeply. But why don’t I start with Hitoshi? What’s – what are we to make of the news that the vaccines are starting to be rolled out? It feels really real now. What do we do with this?

Dr Hitoshi Oshitani

So, we’ve been hearing some good news regarding the effectiveness of a vaccine. But we are quite cautious in implementing a vaccine – vaccination programme in Japan. The Japanese people are quite sensitive to any adverse event that are associated with vaccines, and that’s why that we are not – we cannot implement the human papilloma vaccination programme in Japan, due to the concern about an adverse event. And so, we have to be very careful, and we need also need more data, in terms of effectiveness and safety. And we are not sure that how this vaccine is effective in – especially the long-term effectiveness there is not the proven. So, and, also, we are not sure that how these newly developed vaccine are safe, and so we have to be very careful in implementing this, in starting any vaccination programme for COVID-19.

Emma Ross

Okay, thank you. I’m going to do two questions at once now, just so we can fit more in. One, okay, well, here’s two from Bill Emmett. “What measures have been brought in to protect care homes and other elderly facilities, and what role has been played and when by restrictions on international travel?” That’s for you, Hitoshi. And then, there was another one here. Why don’t we start? Oh, yes, John Mason, “Will the prospect of the Olympics in Japan later in 2021 change the approach to COVID from what it might have been otherwise?” Sorry, David, there’s not one for you there. I’ll try harder next time.

Professor David Heymann

That’s fine.

Dr Hitoshi Oshitani

Okay, so, maybe I can make a start. The nursing home, it is the one with the most important aspect of COVID-19 response. We saw many outbreaks in the nursing home and the hospitals in the – particularly in the March, April, May. And – but now, especially in the August/September, or even in July, June/July, we had a large number of cases in June/July, but the majority of cases at that time were among young people. But we also saw some clusters in the nursing home and hospitals, but the size of outbreak, it was relatively small, probably because they implemented more proactive measures, including the proactive testing there for any suspected cases. But in current phase, particularly this month, we are also seeing some increasing trend of the clusters in nursing homes, and we are – that we need to implement more the measures that prevent the transmission to such setting. As in European countries, we are also seeing the many deaths associated with a cluster in a nursing home and hospital. And, also, in the hospitals, as you know, we are – we have a highly aged population, and many hospitalised cases are elderly people with some underlying medical conditions. So, it’s very critical to prevent the transmission in these settings, and we are implementing more aggressive measures to prevent transmission into these settings.

And international travel, the government is, of course, trying to increase the international travel, due to the economic and other reasons. And – but, again, we have to balance between the suppression of the transmission and maintaining the social and economic activities, and which is quite a different challenge. And we are doing testing at the airport, and we are seeing the many case – positive cases there every day at the airport among passenger from other countries. So, some of them, they may be negative at the airport, but they might be infected. So there is a certain risk of the spread of the virus from the imported cases. So, we have to be, again, very careful in opening our borders and for the Olympic they, again, again, towards the Olympic, the government is trying to increase the international the travel between Japan and other countries. And so – but, again, we have to be careful in opening our border and – but even without Olympic, we need to increase the international travel, for the many reasons, and so we have to – we are now also discussing how we can open our borders. Over to you.

Emma Ross

Okay, thank you for that. I’ve found a couple of questions, David, you could probably field. Here’s two, one for – from Nahida Portocarrero, “Thank you for the interesting presentation. You mentioned the nightlife as a focus point. Is there something specific to nightlife rather than, for example, daytime working that facilitates the spread, for example, kissing?” David, I’m sure you could answer that one. And then, for Hitoshi, this is from Pratik Shariatsharia. Sorry if I’ve mangled that. “Do you carry out retrospective contact tracing for each case identified? If not, how do you decide or prioritise the case for retrospective contact tracing?” David, do you want to answer yours first?

Professor David Heymann

Yeah, well…

Emma Ross

And then also for Hitoshi, sorry, Martin Bobrow, just a quick one, “Have schools and universities remained open, and have they played any major role in cluster generation?” So, David, on the anything specific to nightlife rather than daytime?

Professor David Heymann

Well, you know, virus transmits wherever there’s people in close proximity, and infected people who are able to transfer the virus to others. So, in workplaces, very importantly, they’ve taken measures to make sure that people stay physically distanced, and people in most workplaces now are given the opportunity to remain physically distanced, either by staying home or going into offices where there is – or other areas of work where there is space between people, except in certain industries, which have had problems, such as food processing factories. So, there are no secrets about why nightlife transmits because people are in close proximity. Many times, they’re not physically distanced, and they’re not wearing masks and, by not doing that, they’re infecting others. And, you know, in certain areas, where there’s alcohol consumption, people sometimes let down their guard and if they were trying to physically distance, they end up not being able to physically distance because their judgment is impaired.

So that’s why government has a role to play in making sure that the guidelines that they provide are followed if they’re opening up these areas where work does occur, and it’s the responsibility of those places, as well, to maintain physical distancing possibilities, so that people don’t get infected, and it’s especially important over Christmas. What’s important now is that people who are intending to go visit parents or grandparents, if they’ve been in one of these close situations, during the five to seven days before they’re going to spend time with their families, they should realise that they could create a risk, and could infect family members. And nobody wants to really do that, so it takes responsibility and responsible thinking by us all, as we prepare for getting together with families. But Hitoshi will be able to give a lot more information on that and on other issues as well.

Emma Ross

Hitoshi, do you remember the questions, or do you need me to repeat those others?

Dr Hitoshi Oshitani

Yeah, before starting the other questions, let me add to what David mentioned about the nightlife setting. We analysed many clusters, and we identified the common characteristics for the clusters, and these common characteristics, in which the most of clusters have been occurring that include the closed environment, as David mentioned, the closed environment is quite important. Most of clusters have been occurring in indoor setting, in a closed environment with poor ventilation and, also, crowded condition. To have the cluster with many people, there must be many people at that venue. So the crowded condition is quite important and, also, the closed contact settings, by talking, especially talking without the mask and with loud voice. So, in nightlife settings, most of nightlife settings, there’re these – there’s three conditions. We call it as the ‘Three Cs’, or ‘Sanmitsu’ in Japanese and, so, that’s probably why we are seeing the many clusters in the nightlife settings. And, actually, we are using this Three Cs concept to disseminate our public health message to the general public, and that even small kids in Japan know this concept. And, yesterday, the buzzword of the year was announced, and they identified this ‘Sanmitsu’ or ‘Three Cs’ as the buzzword of the year, so it’s very popular, the word, now in Japan and so it’s quite an important public health message to avoid such settings.

And regarding the privatisation of retrospective contact tracing, and it’s quite important issue, and the retrospective contact tracing is quite time-consuming and labour-intensive, and the Public Health Nurses are spending sometimes more than hour to interview one infected person. And we’ve been trying to interview all cases, but in places where the large number of cases are occurring, at the moment, we are seeing the many cases in Tokyo, Osaka, and Sapporo in the northern part of Japan. And in these places, it’s quite – it’s not feasible to do the detailed interview for each one of a case. And in such situation, we have to prioritise, and particularly, that we are asking the – we are doing more intensive interview to the infected person who were possibly associated with large clusters, like nightlife settings or – and also, possibly associated with the nursing homes or the hospitals. And we are there – we need to prioritise in such setting, and we also need to suppress the transmission by implementing more physical contact measures in the situation where we are seeing the large number of cases, so that we can start the – restart our cluster-based approach in these settings. Over to you.

Emma Ross

Okay, thank you. I’m going to go with the most upvoted question at the moment; well, actually, the two most upvoted questions. So, one is definitely for Hitoshi, but, David, you’re free to speak to it if you want, and I think it’s directed at Hitoshi from Gareth Watson, and it is, “What is your take on the UK’s COVID-19 strategy and rollout? Greatly appreciate your time.” That’s one, and the second question is from Adam Matajovic, and this again is a little bit more on the cluster-busting, saying, “It occurs to me that cluster-busting method is efficient up to a certain number of infections. What might be the critical limit of this approach, e.g., a certain percentage of epidemiologically unlinked cases, or the exhausted number of personnel of contact tracing?” I guess, the question is, does there come a point where there is a limit to this approach and, if it’s not feasible any longer, what would the plan B be?” So those seem to be, at least the first one, Hitoshi, do you want to start?

Dr Hitoshi Oshitani

So I’m not so familiar with the UK approach. But I understand in UK, you have a large number of cases every day and so, the – and, also, the long-term type of measures have many negative impact, and we’ve been trying to avoid such measure to be implemented. And so, the early intervention or early response to the increasing number of cases is quite important to avoid the lockdown and, so far, we’ve managed to avoid such a situation. And we are now, as I mentioned, we are now seeing the increasing trend of the cases. But the level of the transmission is probably much less than the level of the transmission in the September or so in UK. And so that we are trying to implement the early intervention, so that we can avoid the lockdown or some more aggressive measures. But now our goal is not to declare a state of emergency under current situation.

And for the retrospective contact tracing, the limit of retrospective contact tracing, as I mentioned, it’s – we are now facing to this kind of situation, and it’s not feasible to interview every cases under current situation. We – it’s still possible, in some the smaller cities and, actually, in most of places in Japan, it’s still possible. But there’s some metropolitan areas, like Tokyo, Osaka, and Sapporo in the northern part of Japan, it’s getting not feasible to do the proper contact tracing, including retrospective ones. In such settings, it’s important to slow down the transmission, and by implementing more the physical distancing measures. We are now asking that some restaurants and bars to be closed earlier, and also, that we are asking people to stay at home, as much as possible, in some places. And so these measures need to be implemented to slow down the transmission before starting our proper contact tracing.

Emma Ross

So, David, I wanted to ask you if maybe as far as vis-à-vis the UK’s COVID-19 strategy and rollout, what aspects of the Japan model do you think the UK could benefit from? And something I haven’t had time to bring up was the wisdom of mass testing approach. Hitoshi, you in Japan have not gone for trying to test everybody, test, test, test. You’ve been very strategic with your testing. I’ve, kind of, held onto that because that’s the subject of our next webinar next week on strategic use of tests. But, David, maybe you could talk about what aspects of the Japan Model that the UK strategy and rollout could borrow from? It’s a slightly different question, but I just want to move it on, since that’s our last question. I’ve got two minutes left.

Professor David Heymann

Yeah, well, you know, Emma, I’d like to thank Hitoshi because what he’s presented to us is best practice in public health. Japan has done most things right, as far as the public health situation is concerned. They’ve done an epidemiological approach to outbreak containment. What’s happened in the UK is that they began with identifying and working with clusters, and doing contact tracing. But then they felt overwhelmed when hospitals were threatened, and there were the blunt lockdowns. That doesn’t mean that there still aren’t clusters occurring in the UK that could be addressed the way that Japan addresses them. In fact, there are many, especially in rural areas. The urban areas, some of them have had, just like in Japan, will have to close down certain areas, and maintain those closed down, or at least have great caution occurring in those areas moving forward. Whereas there is an opportunity to prevent areas where clusters are occurring from spreading into communities, and that’s where concentration has to be done, especially for contact tracing.

And I think if – what Hitoshi said earlier was very important, that this is done by the local public health system; not by the national system. So the Public Health Nurses who have been working in these areas for their entire careers have the trust of the people, have the confidence, and are the best contact tracers, both forward and backward. And so, it’s not too late for the United Kingdom to adopt many of these policies, and there will be an advantage now because there are vaccines as well, which will certainly prevent mortality in the elderly and in those persons at greatest risk. So there are whole new opportunities in the United Kingdom now, and in other countries, to really move ahead in a way that we can recapture some of the errors or the mistakes that have been made in the past to really move ahead stopping transmission in communities and in clusters, and trying to emulate the best practice that’s occurred in Japan and in many other countries in the Asian setting.

Emma Ross

Okay, thank you for that.

Professor David Heymann

But Emma…

Emma Ross

Well, that’s a good – yeah, yes, David?

Professor David Heymann

…at the bottom of all this though, has to be a willingness of the population to co-operate and to work in solidarity, as has occurred in Japan.

Emma Ross

Yeah, that certainly seems true. But that is all we have time for today, and hopefully, we got through a few more questions than last time. Of course, we’ll be back next week, and that’ll be to talk about strategic use of diagnostic tests, all these new tests we have at our disposal. Hitoshi, thank you so much for giving us your time and your insight today, and so many things we could all learn from the experience in Japan. It’s been a real pleasure to have you.

Professor David Heymann

Thank you.

Dr Hitoshi Oshitani

Thank you, Emma and David.

Professor David Heymann

Thank you very much.

Emma Ross

And thank you all for tuning in and, as I said at the beginning, if you want it, there’s so many juicy details in here. If you wanted to go back to them, if you go to the Chatham House YouTube channel, there’s a special playlist with the whole archive of all our webinars, and this should be on there later on today, almost immediately. So, anyway, thank you all for tuning in, and thank you, Hitoshi, and thank you, David, as ever. And, David, I’ll see you next week, and, Hitoshi, have a great day. Thanks.

Dr Hitoshi Oshitani

Thank you.

Emma Ross

Bye.

Professor David Heymann

Thank you.

Dr Hitoshi Oshitani

Bye.