COVID lessons from Japan: the right messaging empowers citizens | Nature

Hitoshi Oshitani

Nature – There’s no perfect solution to suppress the pandemic, but careful study and communication are key.

Through six waves of COVID-19 in Japan, the number of cases and deaths per capita has been significantly lower than in other G7 countries. This is despite having the world’s oldest population, and being densely packed. Yes, Japan has high vaccination rates, especially for older people, and masking is common. But neither of these is a full explanation. Deaths were low even before vaccines were available, and masks are common across Asia.

Japan has sought to understand the spread and risks of the disease and apply that to minimizing deaths and hospitalizations while maintaining social and economic activities. Trade-offs among these factors can be uneasy. Strong social pressure probably helped to boost protective measures, such as mask wearing, and minimized risky behaviours. Overall, the government quickly equipped its people with information to take protective action and avoided rigid prescriptions.

In 2003, I was the officer responsible for emerging diseases at the World Health Organization (WHO) Western Pacific regional office when the outbreak of severe acute respiratory syndrome (SARS) occurred: it was contained within eight months, with fewer than 1,000 deaths. When I first learnt of a similar coronavirus identified in China in people with pneumonia — SARS-CoV-2 — I thought perhaps the outbreak would follow a similar path.

I soon realized otherwise. With SARS, most people became severely ill. With COVID-19, many cases are mild or asymptomatic — and, unlike SARS, people can spread the disease without being sick. In other words, COVID-19 is far less ‘visible’ and so is harder to contain.

Japan’s constitution prohibits strict lockdowns, so another strategy was needed to suppress transmission. Heading into the pandemic, Japan had more than 8,000 public-health nurses across 400 public-health centres conducting ‘retrospective’ contact tracing for diseases, such as tuberculosis, to identify how people became infected —and that system was quickly adapted to COVID-19.

By the end of February 2020, scientists had identified many clusters of transmission and realized that most infected people did not infect anyone else, but a few infected many. From my past work, I knew that respiratory viruses are mainly transmitted through aerosols. My colleagues and I looked for common risk factors among superspreading events to come up with a more effective public-health message for the public. It incorporated early indications that SARS-CoV-2 could spread through aerosols.

This led us to warn against the ‘3Cs’ (sanmitsu): closed environments, crowded conditions and close-contact settings. Even as other countries focused on disinfection, Japan promoted this concept extensively, by asking people to avoid high-risk activities such as karaoke bars, nightclubs and indoor dining. People largely complied. A panel of artists, academics and journalists named sanmitsu Japan’s buzzword of the year in 2020.[…]

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