Japanese strategy against Covit-19

This is about what the Japanese primary care doctors are doing to deal with Covit-19

I hear voices of suspicion from all around the world about the novel coronavirus statistics the Japanese government has been putting out. Japan did not see an explosive rise of infected or deaths, and many seem to feel that cannot be true. It looks like there are people who do not want to admit the inaccuracy of the virus detection test. The cumbersome PCR test used to detect the infected is only 70% accurate at best. It’s the nature of PCR test. If you rely on the test, those who tested negative by error will go around and spread the virus. That was a painful but valuable lesson the Japanese doctors and officials learned from the Diamond Princess quarantine.

Japan Primary Care Association has been issuing guidelines for the initial intake protocol for the suspected patient (those with flue like symptoms). It takes seriously into account the inaccurate and cumbersome nature of the test. The following is a translated gist of the Japanese guidelines published on 3/11/2020 at

http://www.primary-care.or.jp/imp_news/pdf/20200311.pdf (Japanese only)

Objectives

• Prevent the spread, and minimize the patient health damage
•  Provide proper diagnosis and treatment to those with fever and other symptoms.
•  As healthcare providers, strive to prevent contracting the novel coronavirus ourselves

Symptoms: The symptoms of the novel coronavirus last longer than those of flu

1. The latent period is about 5 days (can be 1 to 14 days)
2. It may present flu-like symptoms (fever, cough, throat congestion, sore throat, runny nose, etc.), lethargy/tiredness (with or without high fever), etc.
3. Some may develop digestive symptoms such as diarrhea and vomiting
4. These symptoms last about 7 days (common cold, flu, digestive tract infections would peak out in 3 to 4 days)
5. 80% can recover on their own
6. 20% will develop lung infection; especially vulnerable are elderly, those with underling heath issues, and pregnant women. Some may develop lung infection very early.
7. Some lung infections may progress to the stage that requires ICU and/or a ventilator
8. The presenting symptoms of novel coronavirus lung infections are varied.

o   Strong wet cough

o   Feeling suffocating, difficulty breathing

o   Light dry cough

o   No respiratory symptoms (lung infection cannot be ruled out from this)

Timeline	Day 1	Day 7	Day 10
symptoms	Looks like regular cold or flu up to 7 days	Breathing problem (80% starts to get better by this point)	Hospitalization	Some goes to ICU
Contagious	Strong	Strong	Strong	Strong

Death Rate by underlying conditions (among those tested positive for Covid-19)

Elderly (older than 80) 14.8%

Circulatory diseases 10.5%

Diabetes 7.3%

Chronic Respiratory diseases 6.3%

Hight Blood Pressure 6.0%

Cancer 5.6%

Healthy adults 0.9%          

Severe symptoms are rare with children

It is important to make sure that everybody knows:

• The people with cold or flu like symptoms should not show up at hospitals and clinics. They need to call first to get the instruction.
• They need to self-isolate at home, also from other members of the family; before coming out, put on a mask, disinfect hands, disinfect and wipe everything the sick person touched, and do not try to reuse the material used to wipe and clean. Otherwise, they can infect their family members as well as the healthcare workers and people in the waiting rooms at the healthcare facilities.
• It is not easy to tell if a person is sick with the novel coronavirus or not at early stages. Even with the PCR test, 30% or more will be missed (false negative). In other words, even when you tested negative, you cannot be sure. On top of that, some people are carrying around the virus without symptoms, and can infect other people. Everybody needs to protect themselves from each other.
• Hospitals and clinics need to have separate traffic lines and spaces (and/or visiting hours) for the people with flu like symptoms so that they do not come into the space that other patients use.

It is important for the primary healthcare workers to know their role as gatekeeper:

• Promote self-quarantine and observation during the light symptom phase, but be prepared to detect the early sign of worsening to move the patient to the next level of care. The objective is to minimize the risk of spreading the virus on one hand and to minimize the death rate on the other, all the while protecting the patient’s rights and avoiding rumors.

• Understand the limitation of PCR test, and properly diagnose the patients with symptoms potentially caused by the novel coronavirus. (negative PCR does not rule out coronavirus infection)

• Healthcare workers must take all the precautions to avoid contracting the virus themselves. Practice proper prevention procedures; make clever use of the limited PPE supplies.

Steps you may go through when you suspect you might have the virus:

Step1	If you have cold or flu like symptoms (fever above 37.5C, cough, and such) stay at home, self-quarantine, record body temperature twice daily. Call and stay in touch with your healthcare provider if you need advice.
	Regular cold and flu start to get better by day 4. If not getting better…	Elderly, Chronic disease patient, Pregnant Women	Those with: Strong tiredness and lethargy Breathing struggle Difficulty with fluid intake and reduced urination
Step2	4 days later	2 days later	Immediately
	Call Novel Coronavirus Triage Center (Those returned from abroad or had close contact with the infected must report on day1)
Step3	High probability case:		Low probability case:
	Sent to designated clinic/hospital	When visiting, wear a mask, wash hands,	Sent to Regular healthcare provider

What healthcare workers should know.

1. Primary care providers are expected to identify patients who may develop severe symptoms, and at the right time, send them to the designated facilities equipped to handle contagious diseases. It is not the role of primary care providers to differentiate those with the novel coronavirus from those without.
2. For those presenting intermediate symptoms, it is important to explore causes other than the novel coronavirus (especially at level 2 emergency facilities). For a patient requiring hospitalization, simple chest CT scan showing “ground glass” images is a strong indication for the PCR test, however, atypical pneumonia such as mycoplasma pneumonia should be ruled out first. Novel coronavirus infection should be considered as one of the possible causes, and the novel coronavirus triage center should be consulted in this context.
3. The simple chest X-ray cannot detect coronavirus lung infection very well. Only about 50% of the cases can be detected. For a clear case of lobar pneumonia, the treatment for bacterial pneumonia can be started.
4. The facilities with limited staff and medical resources can easily be overwhelmed if they try to take cases suspected of novel coronavirus infection. Taking their X-ray will require large additional resources for separating their traffic lines, disinfecting everything used and ventilating the room afterward each time. In those cases, consult the triage center, and refer the suspected to the designated facilities. Please consult and coordinate with the triage center in advance.

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The Japanese custom of respecting each other’s personal space and greeting without handshakes or hugs gives the Japanese society special advantage when controlling contagious diseases. Social distancing is part of the culture. Another advantage is the culture of cleanliness which is deeply rooted in the Japanese religion. The more recent habit of using masks by those suffering from seasonal allergies made it easy for the entire nation to embrace everyday use of masks. In addition, the strategy they devised, as summarized here, not to overwhelm the healthcare service capacity should not be ignored. The careful allocation of resources helps guarantee that all patients get what they need.
Another interesting emerging theory is the effect of BCG (Tuberculosis vaccine), especially, the strain used in Japan and a few other countries. The scientists are serious enough to run a clinical trials. See BCG Vaccination to Protect Healthcare Workers Against COVID-19 (BRACE)    

Below is an interesting graph showing suppressed influenza cases for this winter (2019 to 2010). It started out relatively high in December, before the Chinese outbreak became known, but it never took off all through the winter. One reason may be that people were told to wait and see at home for 4 days before seeking medical help, and many started feel better in 4 days, hence never went to see a doctor. Another reason may be that the protective measures the Japanese took collectively may have worked against the novel coronavirus as well as against flu viruses.

Reported number of influenza patients per healthcare institution
based on the stats by Ministry of Health, Labour and Welfare, Japan

(from https://www.nishinippon.co.jp/image/173703/)

I should also mention the importance of inclusion and solidarity. The warning may not reach those on the fringes and their careless behavior may endanger the whole society.  In Japan, foreigners make up a large portion of the Covid-19 cases. While they make up only 2% of the population, the reported statistics indicate that among the Corvit-19 cases, those identified as Japanese are only around 60%.

I seriously hope you have already known the information presented here from other sources. Japanese speaking reporters and diplomats stationed in Japan might have been informing their home countries. However, hearing governments around the world calling for more tests in unison tells me otherwise. I’d like to remind the world that Japan is one of a few densely populated countries that is keeping this pandemic under control so far.