Chapter 4. Japan’s preparedness for public health emergencies
As an extremely disaster-prone country and a global economic hub, Japan must prepare for public health emergencies of all kinds, from natural hazards to pandemic and disease outbreaks, industrial accidents as well as security threats such as terrorism. This chapter looks at how Japan sets-up and implements public health emergency policies and at how it builds the resilience of its health system, in accordance with the OECD Recommendation on the Governance of Critical Risks and other international guidelines. This chapter suggests that there is scope to strengthen oversight of preparedness measures implemented at the local level, strengthen co-operation between Ministries, and increase the number of disaster preparedness exercises and drills.
The statistical data for Israel are supplied by and under the responsibility of the relevant Israeli authorities. The use of such data by the OECD is without prejudice to the status of the Golan Heights, East Jerusalem and Israeli settlements in the West Bank under the terms of international law.
4.1. Introduction
Given the fundamental responsibilities of governments to provide security and safety, citizens and businesses expect them to be prepared for a wide range of possible crises and global shocks, and to handle them effectively should they arise. The first demand on government is to protect citizens’ physical integrity when shock events disrupt the normal functioning of a society. Public health systems play an essential role in reducing human casualties and other negative health impacts of emergencies through well planned and resourced emergency preparedness, and by building their resilience to such shock events.
Japan has a long history of emergency preparedness given its significant exposure to disaster risks caused by natural hazards of all kinds. However, even the best prepared countries can see their emergency capabilities overcome by unforeseen high impact events, as dramatically shown in Japan in 2011 by the Great East Japan Earthquake (GEJE). Indeed, a broad vision is needed when it comes to public health emergencies and developing public health emergency preparedness and response capacities or building resilience. Critical risks may arise from natural phenomena, pandemics, major industrial or technological accidents and malicious actions that result in adverse impacts of national significance, notably on public health.
An all-hazards and threats approach to risk management is what the OECD calls for, with its Recommendation on the Governance of Critical Risks, adopted under the Chairmanship of Japan Prime Minister Abe at its Ministerial Council Meeting on 2014. This approach requires working across sectors, though a whole-of-government strategic approach to manage critical risks, which should encompass the different stages of the risk management cycle, from risk assessment, to risk prevention, emergency preparedness and response, and recovery and reconstruction. Engaging the whole society in developing its own resilience is also a critical aspect of modern risk management policies, from local governments to civil society and the private sector.
These principles are well aligned with the Sendai Framework for Disaster Risk Reduction adopted in 2015 by the United Nations, which includes preparedness for public health emergencies and health systems resilience amongst its priorities. They are also consistent with the International Health Regulations of the World Health Organisation regarding preparedness for public health emergencies, and their three-pronged approach: prevent-detect-respond.
With a focus on risk governance, this chapter will assess Japan’s policies and their implementation to prepare for public health emergencies, including but not limited to earthquakes, tsunamis, floods and other natural hazards, epidemic and infectious disease outbreaks as well as security risks. In particular this chapter will look at how public health emergency stakeholders work jointly across silos to assess, prepare, detect, respond, recover and learn from public health emergencies. The chapter will also analyse how Japan is building the resilience of its health systems to the diversity of shock events that can occur in our increasingly complex and interconnected societies.
4.2. Japan’s risk profile and potential public health consequences
Prior to diving into policies, this section aims at scanning the risk profile of Japan, to evaluate Japan’s risk level with respect to public health emergencies, and gain insights on why this should be placed at the top of the public health policy agenda in the country. With a classic risk assessment approach, this section includes information on past emergencies, exposure to hazards and factors of present and future vulnerabilities in Japan.
Overall, Japan’s risk profile require that preparedness to public health emergencies be at the top of the public policy agenda. As a particularly hazard-prone country, disasters in Japan can lead to serious public health consequences, injured people, and heightened mental distress, as observed after the Great East Japan Earthquake.
As a global economic hub, the risk of pandemic and infectious diseases outbreaks in Japan is similar to other OECD countries, although lower anti-microbial resistance and widespread hygienic precautionary measures across the population can contribute to reducing the spread of pathogens. However, the organisation of the Olympic and Paralympic Games in Tokyo in 2020 requires an increased level of vigilance for the public health emergency preparedness and response system, be it for infectious diseases, major disasters as for (bio)-terrorism or other risks.
4.2.1. Japan is a natural hazard-prone country with growing vulnerabilities
Japan is characterised by its multi-hazard exposure (Table 4.1). Earthquakes, tsunamis and volcanic eruptions occur frequently, as do hydro-meteorological hazards, such as floods, typhoons, extreme temperatures, avalanches or landslides, causing significant socio-economic damages (Table 4.2).
The islands of Japan extend along the Pacific Ring of Fire, a region in the world that is exposed to major earthquakes and active volcanoes. Between 2004 and 2013, 18.5% of worldwide earthquakes with a magnitude of 6.0 or above occurred in Japan. Japan’s location at the meeting point of four tectonic plates also explains why the country faces significant seismic risk and frequently experiences major earthquakes and related tsunamis (Ministry of Land, Infrastructure, 2007[3]). Earthquakes have been the leading cause of both reported disaster related fatalities and injured, displaced or affected people, in addition to their economic damages in Japan. The Great East Japan Earthquake and its subsequent tsunami wave in 2011 caused nearly 20 000 deaths, close to 370 000 affected, displaced or injured people and an estimated USD 210 billion in damages. The Kobe Earthquake in 1995 caused over 5 000 fatalities and affected more than 500 000 citizens (Cabinet Office, 2016[1]).
There is a high probability – estimated between 70% and 80% – that a major earthquake will occur in the next three decades affecting major urbanised areas of the country, including Tokyo metropolitan area and a large part of Western Japan along the Nankai Trough. These disaster scenarios project that the maximum death toll could reach 23 000 with a further 72 000 people in need of rescue for the Tokyo Inland earthquake scenario, and up to 323 000 deaths for the Nankai Trough’s earthquake (Cabinet Office, 2015[4]). These projections give an idea of the potential scale of such emergencies and their potential health impacts that Japan has to prepare for.
111 active volcanos in 2014 are also spread throughout Japan’s islands, which represent 7.1% of the active volcanoes in the world. Volcanos can lead to a variety of natural dangerous phenomena when they erupt, from lava flows, to cinder dissemination, as it happened during the last important eruption in Japan on Mount Ontake in 2014, which killed 58 persons (Cabinet Office, 2015[4]).
Hydro-meteorological risks are also widespread across Japan. As many of the rivers in Japan are relatively short, but descend with a steep declivity, water levels can rise rapidly, making many of Japan’s rivers prone to flooding, and particularly flash floods which can have significant human consequences (Ministry of Land, Infrastructure, 2007[3]). In 2014, torrential rainfall in Hiroshima Prefecture triggered a series of landslides that killed 82 people and injured many others. In addition, typhoons frequently hit Japan (Ministry of Land, Infrastructure, 2007[3]). In 2000, typhoon Saomai caused a storm surge and heavy rainfall that triggered several landslides across Chūbu and Kansai. Similarly, the 1991 typhoon Mireille caused a storm surge, as well as several landslides and flash floods inland that led to 66 fatalities. The increasing frequency of heavy downpours observed throughout the country in the last decades indicates an upward trend for floods in the country despite the significant flood control projects in which Japan has invested over the years (Cabinet Office, 2016[1]).
Similarly to earthquakes, the Japanese government has modelled scenarios of large-scale floods in key areas of the countries. For instance a flood affecting Tokyo Metropolitan area, that could lead to a maximum death toll reaching 2 600 people, and another 1.1 million people stranded and in need of emergency support (Cabinet Office, 2015[4]).
Japan is also exposed to other hydro-meteorological hazards, including avalanches in its large mountainous area, windstorms and heatwaves. The recent summers for instance were all marked by heatwaves throughout the country, causing excess mortality and significant rises in hospitalisations.
4.2.2. Public health consequences of disasters can be both direct and indirect
This overview of disaster risks affecting Japan shows the multiplicity of potential threats and their significant human consequences. Compared to other OECD countries, Japan suffers on average 4 times more human casualties per inhabitants from disaster risks. Figure 4.1 also highlights the significant variability of this indicator over the years, which indicates how much preparedness for large-scale hazardous events is important for the country.
Source: Cabinet Office (2016[1]), “White Paper Disaster Management in Japan 2016”, http://www.bousai.go.jp/kyoiku/panf/pdf/WP2016_DM_Full_Version.pdf; OECD (2018[5]), Assessing Global Progress in the Governance of Critical Risks, https://dx.doi.org/10.1787/9789264309272-en.
Indeed, disaster risks can have significant consequences for public health in Japan. Reducing the death toll caused by disaster is a fundamental policy objective. Both direct and indirect public health consequences of disasters have to be considered: disaster risks, especially large-scale ones, can lead to a significant number of injured people, for whom specific emergency interventions often on-site have to be planned for traumas or burns directly caused by the disaster.
From a public health perspective, it is equally important to consider indirect health effects, occurring after the disaster, which can be caused by affected health care provision, post-trauma stress and related psychological impact, or population evacuation and displacement. Large-scale disasters consistently show how damaging these indirect health effects can be. The example of the Great East Japan Earthquakes illustrates the range of consequences (Box 4.1).
With 21 839 deaths and missing people, tens of thousands of injured people, hundreds of thousands displaced persons, and many affected psychologically, the Great East Japan Earthquake was an unprecedentedly complex disaster, and demonstrated that more could be done to strengthen the resilience of the country and reduce public health consequences of disaster risks.
Disasters can affect the health system of a country, by damaging hospitals and health care facilities, affecting health care workers, and disrupting essential supplies for the continuity of health care, such as energy, water, or medical treatments. For instance, 80% of hospitals and a third of medical/dental clinics in the three affected Prefectures were damaged to different extents by the Great East Japan Earthquake, with some completely swallowed by the tsunami (Saito and Kunimitsu, 2011[6]). Strengthening the resilience of the overall health system to disaster risk should also be a priority of public health emergency preparedness in Japan.
In the case of large evacuations when temporary sheltering and relocation of an important number of people is organised, health care providers have a key role to play to ensure continuous health care, maintain provision of medical treatments, and take special care of elderly and other vulnerable groups to minimize secondary effects of disasters. A study on mortality rate after the GEJE conducted in the affected areas did show a significant excess mortality rate in the first month after the disaster, demonstrating these indirect effects (Morita et al., 2017[7]). These indirect effects were more severe and persistent for elderly people, and the four leading causes of death were pneumonia, coronary heart disease, stroke and cancer. These impacts show how a loss of access to medical care, environmental changes and physical and psychological stresses can aggravate health consequences of disasters, as well as the need to provide dedicated public health support post disaster to vulnerable groups such as the elderly.
Among the secondary effects, mental health and psychological impacts can also be significant; post-traumatic stress disorder, depression and anxiety symptoms can particularly affect vulnerable groups, from the disaster workers, to children, internally displaced people, and patients with psychiatric disorders. A comprehensive literature review found that following the GEJE a considerable proportion of the population from the affected areas was affected psychologically to a substantial degree, ranging from one tenth to nearly half of the sample respondents, highlighting that psychological assistance is a key aspect of post-disaster public health recovery and requires specific attention in the immediate aftermath of disasters.
Source: Saito and Kunimitsu (2011[6]), “Public health response to the combined Great East Japan Earthquake, tsunami and nuclear power plant accident: perspective from the Ministry of Health, Labour and Welfare of Japan”, http://ojs.wpro.who.int/ojs/index.php/wpsar/article/view/129/70; Morita et al. (2017[7]) “Excess mortality due to indirect health effects of the 2011 triple disaster in Fukushima, Japan: a retrospective observational study”, https://dx.doi.org/10.1136/jech-2016-208652 ; Harada et al. (2015[8]), “Mental health and psychological impacts from the 2011 Great East Japan Earthquake Disaster: a systematic literature review”, https://dx.doi.org/10.1186/s40696-015-0008-x.
4.2.3. Japan has other specific vulnerabilities to disaster risks, some of which are growing
Japan shows some specific vulnerabilities to disasters that call for further close attention to public health emergency preparedness. The high density of Japan’s population in risk prone areas is a potential factor for important human impact of disasters: half of the population is concentrated in the 10% of the country area which is prone to floods (Cabinet Office, 2015[4]). As shown above, major cities and urbanised areas are also prone to the risk of earthquakes. In addition, these areas concentrate most of the economic activities of the country, as well as most of Japan’s health facilities, which by definition are located at the proximity of the population.
The increased interdependencies and interconnectedness between critical infrastructure sectors have to be considered in a vulnerability analysis as well (OECD, 2011[9]). More and more, with technological development, the health sector depends upon a continuous functioning of electricity, telecommunications, transportation, as do emergency services. A major disaster can significantly disrupt these services, with implications going far beyond the affected area. Ensuring the resilience of the health system should therefore consider its dependencies on critical supplies and essential lifelines and infrastructure, as well as their continuity.
The increased share of the elderly in the Japanese population is of serious concern when it comes to individual resilience to disaster risks. Demographic projections indicate that the share of the elderly (65+) will rise from around 26% today, already the highest in the OECD area, to almost 40% at mid-century (OECD, 2016[10]). As shown by the epidemiologic study quoted above, disasters can affect elderly persons disproportionally, notably given their greater likelihood of impaired physical mobility, diminished sensors awareness, poor chronic health conditions and social and economic limitations (Aldrich and Benson, 2008[11]).
Climate change might also be an aggravating factor to take into consideration for preparedness to public health emergencies. While it remains unclear how climate change will affect the frequency and severity of cyclones or flooding events, the increased risk of heatwaves will most certainly led to more severe impacts on human health in Japan (Nakano, Matsueda and Sugi, 2013[12]; Ministry of the Environment, 2014[13]).
4.2.4. Japan is at risk of infectious disease outbreaks
Regarding infectious diseases outbreaks and the risk of pandemics, Japan, as a global economic hub is exposed to virus or pathogens in a similar manner to most OECD countries. The recent most noticeable examples of outbreaks, such as the Ebola virus outbreak in 2014, the H1N1 pandemic influenza in 2009 or SARS in 2003 are all revealing of how similar forms of public health emergencies can affect Japan. Japan is also subject to the resurgence of more classic infectious diseases, such as tuberculosis, dengue, rubella, or measles, which all sporadically continue to affect citizens and cause deaths.
Like most OECD countries, Japan was affected by the H1N1 pandemic influenza in 2009. From its emergence in March 2009 in Mexico, the first case in Japan was confirmed mid-May in western Japan, where the number of cases increased then decreased quickly. A second outbreak that started in early June 2009 quickly spread to all parts of Japan. Overall around 20 million people are estimated to have contracted the H1N1 influenza in the country, 18 000 people were hospitalised (Okumura et al., 2011[14]) and 198 deaths were confirmed at the end of the pandemic (Cabinet Secretariat, 2013[15]). Japan had a significantly lower mortality rate of 0.2 deaths per million individuals compared to other countries such as the United Kingdom (2.2), Canada (2.8), Mexico (2.89), United States (3.3), New Zealand (4.4), Chile (8.1), or Australia (8.6) (Takahashi et al., 2017[16]). Explanatory factors include on one side the scope of the government measures, including large school suspension at the early stage of the outbreak and large distribution of antiviral drugs, and on the other side important societal awareness and good personal hygiene amongst the Japanese population (Omi, 2010[17]).
Other infectious disease outbreaks with global or regional impacts, such as SARS in 2003 which affected many neighbouring Asian countries, or Ebola hemorrhagic fever in 2014, did not affect Japan. These two outbreaks nevertheless led to a large mobilisation of the public health services and caused fear among the population and health workers (Imai et al., 2005[18]).
The prevalence or resurgence of other infectious diseases should also be considered. In Japan, if the number of reported cases of tuberculosis and the prevalence rate has continuously declined over the last 15 years (Figure 4.2). However, compared to OECD peers, the 2017 rate of 15 cases per 100 000 inhabitants remains quite high; for instance, the rate is 3.1 in the United States, 5.5 in Canada, 6.8 in Australia, 8 in France or 8.9 in the United Kingdom (World Health Organization, 2018[19]). In South Korea, Japan’s OECD Asian neighbour, the prevalence rate of TB in 2016 was a very high 70 incidents per 100 000 population.
Almost 70% of new cases of TB affect people over 65 years old and may be subject to the reactivation of previous TB infections. For the younger age population, a significant part of the new cases affect foreign-born people, reaching for instance around 50% of the new cases for the age group between 0 and 24. This illustrates the two groups of population vulnerable to tuberculosis in Japan: the elderly and young migrants. Prevalence is also higher in the dense urban areas of Tokyo and Osaka and in the tropical south (Tuberculosis Surveillance Center, 2016[20]).
Source: Tuberculosis Surveillance Center (2016[20]), Tuberculosis in Japan Annual Report – 2016, http://www.jata.or.jp/english/dl/pdf/TB_in_Japan_FINAL_1114.pdf..
During the rubella outbreak of 2012-2013, about 15 000 cases of rubella and 43 cases of congenial rubella syndrome were reported to the National Epidemiological Surveillance of Infectious Diseases. This resurgence mostly affected middle-age adult men who did not receive routine rubella vaccine in their childhood, and mostly affected the densest part of country, with 80% of cases reported in Tokyo, Osaka and neighbouring prefectures (Ujiie, Nabae and Shobayashi, 2014[21]). Sporadic measles outbreaks have also affected Japan in recent years, mostly due to imported cases.
Regarding vector-borne diseases, a dengue fever outbreak unexpectedly occurred in the summer of 2014, which was the first autochthonous transmission in Japan in the last 70 years. Imported cases of Chikungunya, malaria and Zika have also been reported (Nakamura et al., 2018[22]).
4.2.5. Japan’s high population density and international exchanges contribute to increasing the risk of infectious disease outbreaks but vaccination and hygienic measures lower the risks
Japan’s risk profile related to the risk of infectious diseases outbreaks and spread depends upon a series of factors, such as population density, international exchanges and travels, hygienic precautionary measures taken by the population, population health conditions, vaccination coverage rate (Chapter 1), and levels of anti-microbial resistance. Japan presents a contrasted situation when we look at the different indicators related to such vulnerabilities.
Japan’s high population density, and the large and increasing numbers of inbound and outbound travellers to and from the country are factors that can favour the spread of infectious diseases. Across the 300 metropolitan areas of the OECD metropolitan database, five out of the 20 densest ones are located in Japan (Figure 4.3). Such a high population density increases the risk of contaminations from person to person.
Source: OECD (2019[23]), “Metropolitan areas”, OECD Regional Statistics (database), https://dx.doi.org/10.1787/data-00531-en.
In addition, according to the Japan National Tourism Organisation, the number of annual visitors to Japan has seen a 4-fold increase from 6.2 million in 2011 to 24 million in 2016. The government has set a target of 40 million international visitors in 2020, when the Tokyo Olympic and Paralympic Games will be held (Nakamura et al., 2018[22]). Similarly, according to border control statistics, Japanese travelling overseas were between 16 and 18 million per year in the last decade (around 13% of the Japanese population). The data shows a significant anomaly in 2003, when Japanese travellers abroad dropped to 13 million, which might have been caused by fear of the SARS syndrome which was affecting neighbouring Asian countries that year. This is another example of the application of the precautionary principle by the Japanese population.
As explained in Chapter 1, Japan’s vaccination programmes follow WHO recommendations; vaccinations are highly recommended for 13 selected diseases as routine vaccination. Overall the vaccination rate in Japan slightly exceeds the OECD average contributing to a good level of immunisation for many infectious diseases.
The growing challenge of anti-microbial resistance (AMR) around the world is also a concern for Japan’s preparedness for public health emergencies. According to the National Action Plan on AMR, total use of antibiotics in humans in Japan ranks at a relatively low level (15.8 per day per thousand inhabitants in 2013) compared to EU countries. But, AMR is higher in several reference bacteria (see Chapter 1). Regarding animal AMR, Japan appears to rank at a comparable level to those of OECD countries (Government of Japan, 2016[24]). Beyond nosocomial infections, this raises concerns on the risk of outbreaks of anti-microbial resistant infections at community levels, for which Japan started to collaborate horizontally with the National Action Plan, notably on raising the awareness among the public and health professionals.
Finally, while difficult to measure, the significant use of precautionary and hygienic measures within the Japanese population is largely recognised as a factor that limits the risk of infectious diseases propagation in the country (Takahashi et al., 2017[16]). These measures include regular handwashing and the widespread use of face masks, which has significantly increased amongst the population in recent years, especially following the H1N1 outbreak.
4.2.6. Other risks of public health emergencies in Japan should be part of an all-hazard preparedness approach
In this rapid scan of public health emergency risks in Japan it is also important to mention other risks, beyond natural hazards and diseases outbreaks, can necessitate the development of dedicated emergency preparedness measures. From large-scale food poisoning, or transport accidents, to chemical leaks, nuclear disasters, and terrorist attacks of all sorts, there are many other risks that can have a significant impact on public health. While the analysis of this chapter mostly concentrates on disaster risks and infectious diseases, it also aims to apply an all-hazards and threats approach to the analysis of public health emergencies preparedness policies in Japan.
In the context of the Tokyo Olympic and Paralympic Games (Box 4.2), it appears particularly important to strengthen focus on security threats. The Sarin Gas attack of the Tokyo subway in 1995 remains among the few examples of chemical terrorism among OECD countries. The synchronised attacks led to 13 deaths and more than 5 800 injured people (Public Security Intelligence Agency, 2018[25]).
Japan will host the Tokyo Olympic and Paralympic Games in 2020 which will involve a large population influx from various countries to Tokyo. The Tokyo Metropolitan Government has primary responsibilities for preparing the event and ensuring public safety and security during the Games. Tokyo Metropolitan Government has consequently strengthened its emergency preparedness in order to be ready to host the event in the best conditions. The potential risks for visitors to Tokyo 2020 Olympics are communicable disease risks for vaccine-preventable illnesses such as measles and rubella as well as food and waterborne diseases. The risk of acquiring vector-borne diseases is considered low in Japan. Heat-related illness also represent a potential risk, as Tokyo 2020 is scheduled during the hottest season in Japan, with temperatures generally expected to exceed 30°C. Prior vaccination and appropriate hygiene measures for food and waterborne diseases as well as heat-related illness are highly recommended for visitors. It may also be useful to increase the number of multilingual triage clinicians to provide first contact services and coordination of emergency care in the Tokyo area during the Olympics and Paralympics.
Source: Nakamura et al. (2018[22]), “Health risks and precautions for visitors to the Tokyo 2020 Olympic and Paralympic Games”, https://doi.org/10.1016/j.tmaid.2018.01.005.
4.3. Japan makes of preparedness for public health emergencies a priority, as reflected in its public policies
The snapshot of risks in Japan and their potential public health consequences demonstrate how preparedness can be critically important for Japan. The high number of potentially affected people by disaster risks and the important risk factors for the spread of diseases outbreak within the country demonstrate how preparing for emergencies should be a national priority in the country. In light of these major risks for public health, Japan makes of preparedness for public health emergencies a key policy priority. This is first reflected in its domestic legal and institutional framework related to the important risks of pandemic outbreaks and disasters, but also in its international cooperation activities.
4.3.1. Japan has a sophisticated legal framework for public health emergencies
Japan has a sophisticated legal framework to deal with national emergencies and their public health consequences. Both for pandemic and disaster risk preparedness, parliamentary acts clearly define the roles and responsibilities of ministries, prefectures and municipalities: all actors have to prepare countermeasure plans for their jurisdictions from national to local levels, following the principle of subsidiarity.
The 1961 Disaster Countermeasures Basic Act, with its subsequent revisions, formulates a comprehensive and strategic disaster management system for Japan. This system covers the entire risk management cycle, from prevention, to emergency preparedness and response, as well as recovery and reconstruction. It instructs all levels of governments to establish both a Disaster Prevention Council for policy planning and implementation, and a Headquarters for Disaster Control for operational response, as well as to develop disaster prevention plans at each level. While it establishes the primary responsibility for emergency response at the local level, it also allows higher levels of governments to intervene locally in case local capacities are overwhelmed, by applying the principle of mutual co-operation. The Act promotes a series of disaster risk reduction measures, specifies displaced person support activities, clarifies financial support from the national level and allows the Cabinet to make declaration of a state of emergency disaster. The Cabinet Office bears responsibility for overseeing policy implementation and ensuring multi-stakeholder coordination, and the Prime Minister chairs the Central Disaster Prevention Council.
In a similar mode, the Special Measures Act for Pandemic Flu and New Infectious Diseases Preparedness and Response specifies the responsibilities as well as the countermeasures to be taken by national and local governments, designated public institutions and business operators, to deal with pandemic influenza and infectious diseases. While the 1998 Infectious Disease Control Act classifies diseases it covers into categories depending on their infectiousness and the severity of the symptoms, defines the surveillance systems, and infectious disease control measures, the 2012 Special Measures Act instructs all levels of governments to develop action plans and emergency headquarters, clarifies the stockpiling policy and define a series of emergency measures to be undertaken. The Act also establishes the Response Headquarters led by the Prime Minister.
This legal framework evolves regularly taking into consideration the evolution of risk factors. For instance, the Special Act was a response to the 2009 H1N1 pandemic influenza. It elevated the level of preparedness for infectious disease, which proved particularly useful during the 2014-2015 Ebola outbreak. Similarly, the Basic Act on Disaster Management has been continuously reviewed and revised since its adoption in 1961 following lessons learned from large-scale disasters.
4.3.2. Japan’s institutional setting for public health emergency preparedness and response involves the whole-of-government
In accordance with the OECD Recommendation on the Governance of Critical Risks, Japan’s legal framework allows for whole-of-government engagement in public health emergency preparedness and response, both horizontally across sectors, and vertically across levels of government. However, similar to its legal framework, Japan does not have a unified all-hazards and threats approach to emergency preparedness and response but different ones for different risks. Furthermore, as discussed below, co-ordination remains a major area for improvement.
For all public health emergencies, Japan builds on its three-tiered decentralised governance system, with its 1719 Municipalities, its 47 Prefectures and its National Government, which all have preparedness responsibilities within their jurisdictions, and action plans to prepare following national guidelines (Figure 4.4). The Basic Disaster Management Plan and the National Action Plan for Pandemic Influenza and New Infectious Diseases govern the national government efforts, and are replicated locally in each Prefecture and Municipality of the country.
Source: Cabinet Office (2015[4]), “Disaster Management in Japan”, http://www.bousai.go.jp/kaigirep/hakusho/pdf/WP2015_DM_Full_Version.pdf.
For disaster risks, a bottom-up approach with scaling-up procedures from municipalities, to prefectures and the national level predominates, for pandemics, the prefectural and national levels concentrates more responsibilities. This differentiated approach corresponds well to the different nature of the response to these emergencies and the local capacities that exist: when disasters strike, reducing their public health consequences requires active measures to take care of the affected people locally, to which higher levels of governments can contribute when local capabilities are overwhelmed. For the case of pandemics on the contrary, surveillance, control, and containment policies need a more comprehensive approach at a larger scale.
For both risks, the national level can in any case step in for particularly severe emergencies by establishing a Management Headquarters at Cabinet level and/or through an ad-hoc activation of the government wide crisis response system, as it did in 2014 (Cabinet Secretariat, 2015[26]) immediately after the first detection of fever symptoms in a traveller returned from Liberia to Japan during the Ebola outbreak (Box 4.3).
The largest outbreak of Ebola virus disease (EVD) in West Africa in 2014 resulted in unprecedented transmission worldwide and the World Health Organization (WHO) declared a Public Health Emergency of International Concern (PHEIC) on 8 August 2014. Although the number of travellers from EVD endemic countries was limited and no direct flight was operated to and from these countries, the Japanese Government promptly started to reinforce the border controls and domestic response capacity. First, the government raised awareness among travellers entering Japan through posters at quarantine stations and in-flight announcements. Travelers were asked to declare their travel history to endemic countries. In October 2014, the MHLW revised the entry screening policy for those who had travelled from Guinea, Liberia, or Sierra Leone. The Quarantine Act required these travellers to be isolated if they had symptoms at quarantine, or to be put under active health monitoring. The government activated the government-wide crisis response system in October 2014, immediately after the first traveller returning from Liberia to Japan developed fever at quarantine. In Japan, nine individuals were screened in 2015 and all were negative.
Source: Saito (2015[27]), “Public health challenges and legacies of Japan’s response to the Ebola virus disease outbreak in West Africa 2014 to 2015”, https://doi.org/10.2807/1560-7917.ES.2015.20.44.30056.
4.3.3. Horizontal coordination is better established for disaster risks compared to other public health emergencies
Regarding horizontal coordination, all relevant ministries are involved in public health emergency preparedness and response. Overall coordination is ensured by the Japanese Center of Government; the Cabinet Office has a dedicated State Minister for Disaster Prevention and the Cabinet Secretariat an Office for Pandemic Influenza and New Disease Preparedness and Response for infectious disease outbreaks. The engagement of national leadership in policy formulation, approval of national plans, multi-stakeholder coordination, strategic crisis management and regular drills enshrined in acts aligns well with the OECD Recommendation on the Governance of Critical Risks. This also reflects the fact that public health emergency preparedness is a priority for the country.
Japan’s public health system, in particular the Ministry of Health, Labour and Welfare (MHLW) – with its Office of Public Health Emergency and Disaster Preparedness and Response – and the network of the 500 Public Health Centres throughout the country, is the first in charge for response to public health incidents (Figure 4.5). For disaster risk preparedness and response, the public health system is more a contributing entity to the larger disaster management system, which involves a large number of stakeholders, including the Fire and Disaster Risk Management Agency and the Self-Defence Forces. The main role of the public health system in case of major disasters is to organise the national support to local public health authorities and health care institutions, and deploy health supplies and public health and health care workforce to affected area.
Source: Presentation to the OECD at the National Public Health Institute, 2018.
Overall, the disaster risk management system appears to have established more robust co-ordination mechanisms over the years. This is understandable given the regular occurrence of large-scale disasters in Japan. Coordination of the public health sector with other government agencies for diseases outbreaks is in its early stage – as shown during the Ebola outbreak, during which several non-existing inter-agency coordination mechanisms were established (Saito, 2015[27]) – and would benefit from learning from the better established disaster risk management process.
4.3.4. Beyond government, the private sector and civil society also play a role
Beyond government, preparedness also requires the involvement of the private sector and civil society organisations, which can play a critical role in supporting emergency response with surge capacities, or can also be mobilised for specific capacities required for the response, such as the production of vaccines or therapeutics.
Japan benefits from a large engagement of volunteer and civil society organisations during disaster events. This is favoured by legislation, which encourages citizens’ self-preparedness and volunteerism. The Red Cross Society of Japan is for instance a member of the Central Disaster Management Council and 900 000 volunteers contributed to the emergency response of the Great East Japan Earthquake in the three provinces of Tohoku (Ranghieri and Ishiwatari, 2014[28]).
The specific status of “designated public corporations” also asks critical infrastructure operators in key sectors to prepare emergency plans, both for disasters and disease outbreaks. There is, though, a difference in the list of these public and private companies, as vaccine and pharmaceuticals companies are included for the latter, given the key role they can play for these emergencies (see the subsequent section on stockpiling).
4.3.5. Internationally, Japan is a key supporter of the Global Health Security Agenda
As a major promotor of the Global Health Security Agenda (GHSA), Japan takes a leading role on these issues internationally. Under Japan’s G7 Presidency in 2016 global health was at the top of the agenda, leading to the adoption of the G7 Ise-Shima Vision for Global Health. This is similar for disaster preparedness, as demonstrated by the hosting of the UN World Conference on Disaster Risk Reduction in 2015. The Sendai Framework on Disaster Risk Deduction adopted thereof recognises in particular the need to enhance the resilience of the health system.
As noted in the 2014 OECD Development Co-Operation Review of Japan, these international policy priorities are also reflected in Japan’s development policy, which makes human security one of its priorities (OECD, 2014[29]). This has translated into the mainstreaming of disaster risk reduction into Japan’s development co-operation projects. Japan is also a significant contributor to the budget of the WHO; in 2016 for instance Japan’s contribution to WHO’s core budget represented 38% of the total contribution of the OECD Development Assistance Committee donors.
4.4. Identifying and assessing public health emergencies risk in Japan
Preparing for public health emergencies requires, first, a good knowledge of the critical risks and their public health consequences. Japan assesses its main risks and their public health consequences with a scenario-based approach, which is a good way to plan its capabilities to deal with emergencies.
By combining the use of elaborated modelling and solid databases, the association of its world-class scientific research and the application of international guidelines – such as the International Health Regulations – Japan has identified a series of major risks and estimated their impacts. This is undertaken for most categories of National Emergencies in Japan, which range from earthquakes, to flood, volcanic eruptions, nuclear and industrial accidents, terrorism or pandemic influenza and other infectious diseases. Unlike many OECD countries, however, Japan does not conduct a National Risk Assessment (OECD, 2018[30]), which would allow the comparison of all major risks in terms of likelihood and potential impacts, and to prioritise resources accordingly. This is consistent with the lack of a unified all-hazard and threat approach to emergency management in Japan.
4.4.1. Japan conducts a comprehensive risk assessment for infectious diseases
Under the Infectious Diseases Control Act Japan has established a list of notifiable infectious diseases and defined eight categories of classification according to their infectiousness and the severity of their symptoms, from the most severe – category 1- to the most easily controllable – category 5 – (Table 4.3). This classification is dynamic, and the MHLW or the Cabinet can add or delete diseases to the list depending on the category.
Beyond risk identification, Japan has developed scenarios of pandemic diseases outbreaks for several of them, based on the most advanced scientific knowledge and conservative assumptions. For instance, for H5N1 pandemic influenza, the National Action Plan estimates that 25% of the population could be infected, with 13 to 25 million patients visiting medical institutions. A medium-level influenza pandemic could lead to 530 000 hospitalisation and 170 000 fatalities, at a 0.53% case fatality rate. A severe influenza with a 2% fatality rate would lead to 2 million hospitalisation and 640 000 fatalities. This assessment also estimates the maximum number of hospitalisation per day between 100 000 and 400 000 and a rate of absenteeism reaching 40% for all employees during the peak period (Cabinet Secretariat, 2013[15]). This assessment is also replicated at the local level to inform preparedness at the municipal and prefectural levels. For instance, the Yokohama City Action Plan is based on the most severe of these two scenarios (City of Yokohama, 2014[32]).
This risk assessment approach is similar to the concept of the reasonable worst case scenario developed by the United Kingdom for its National Risk Assessment (OECD, 2018[30]), which is a good way to plan capabilities that would be required to prepare and respond to such public health emergency (Box 4.4).
The UK National Risk Assessment (NRA) is a yearly process aimed at identifying characterising and comparing all the major hazards and threats of national significance that may cause significant impacts in the UK on a five-year horizon. Led by the Civil Contingencies Secretariat of the Cabinet Office, it involves a large multi-agency process that allows ranking risks based on the likelihood –or plausibility- and impact of the “reasonable worst-case scenario” on a series of criteria (human, economic, service disruption and psychological). According to the Civil Contingencies Act, the NRA constitutes the fundamental basis for capabilities-based planning to support emergency preparedness and response from national to local level. Endorsed by the Cabinet Office, the NRA allows risk ownership by assigning the responsibility to manage each identified risk to one government department. While remaining in part confidential, a public version of the NRA is made publicly available and serves as fundamental reference document for risk information and awareness across the country.
Source: OECD (2018[33]), “OECD Toolkit on Risk Governance”, https://www.oecd.org/governance/toolkit-on-risk-governance/home/.
4.4.2. Japan significantly improved its disaster risk assessment following the Great East Japan Earthquake
A similar assessment exercise is undertaken for disaster risks, which helps determine the potential public health consequences for the various hazards that can affect the Japan and to prepare accordingly. Under the coordination of the Cabinet Office, Japan benefits from the combined use of advanced research institutes and government agencies to conduct such assessments, through the development of hazard maps, vulnerability and risk analysis, based on data collection of past disasters impacts and risk modelling.
All the major risks of earthquakes, tsunamis, floods, volcanoes have consequently been assessed in Japan, and scenarios have been developed for the most significant risks. Every year the revision of the Basic Disaster Management Plan provides an opportunity to improve some of these assessments by integrating most recently available knowledge. As discussed earlier in this chapter, this includes for instance the Nankai Trough Earthquake and Tsunami, the Tokyo Inland Earthquake or the Tokyo Metropolitan Flood, for which the number of maximum probable deaths, affected or evacuees are assessed (Cabinet Office, 2015[4]).
The Japanese government had conducted a risk assessment for earthquake and tsunami risks prior to the Great East Japan Earthquake. The anticipated scenario was based on 8.6 magnitude earthquake with a tsunami that would flood an area of 270 square kilometres (Ochi and Suzuoki, 2012[34]). Instead, the GEJE was of a 9.0 magnitude and the flooded area the double that of the scenario estimate, leading to far more human and economic damages than expected, in addition to the unforeseen nuclear disaster. In this sense, the disaster reality far exceeded the anticipated scenario. Post GEJE, risk assessments for major disasters have been reviewed throughout the country, notably regarding their potential damages, leading to significant re-evaluation of preparedness and response countermeasures, and a practical approach to learning lessons from crises. This also led to reviewing the hazard maps in the different municipalities at risk of the country, for the main hazard types. Even if not completed everywhere, this work shows significant progress according to the 2016 White Paper on Disaster Management in Japan (Figure 4.6).
Source: Cabinet Office (2016[1]), “White Paper Disaster Management in Japan 2016”, http://www.bousai.go.jp/kyoiku/panf/pdf/WP2016_DM_Full_Version.pdf.
4.4.3. Assessing other public health risks caused by rare events such as terrorism and nuclear disasters should be continuously improved
The “Terrorist Attack Preparedness Action Plan” established since 2004 includes a joint threat and risk assessment developed in partnership between the public health and the security sector. During interviews with the OECD to inform this review, some stakeholders suggested that coordination between these sectors could be improved to more precisely analyse the likelihood of different forms of terrorist attacks and their potential consequences to better prepare the public health response. Regarding nuclear facility accidents, the Great East Japan Earthquake led Japan to revise its policy and integrate the risk of complex disasters in its Basic Plan for Disaster Management and similarly for local governments located within a 30-km radius from a nuclear power plant should integrate this risk in their local disaster management plan (Cabinet Office, 2016[1]).
4.4.4. Risk communication and awareness programs is a major priority in the country
Well-developed risk knowledge is largely used to communicate about risks, strengthen the risk awareness and risk preparedness culture of the population, and promote societal resilience and self-protection. Japan is among the most advanced countries of the OECD when it comes to disaster education. School curricula from kindergarten to university integrates risk management (Box 4.5), regular exercises and drills are organised at all levels in the Japan, publicly available risk maps are mandatory and indicate evacuation routes to be taken and anticipated safe meeting points (OECD, 2016[10]). Similarly, regarding diseases outbreaks, local government plans, information at public health centres and school programmes all contribute to raising citizens’ awareness on potential health risks and precautionary measures to be taken in case of an outbreak.
The importance of risk education to reduce the impact of disasters has been proven on many occasions, with perhaps the example of the Kamaishi schools during the 2011 tsunami the most well-known. Despite the significant impact of the tsunami, and 1000 casualties in this coastal city, all 3000 school children evacuated to higher ground and none lost its life, taking the appropriate actions making quick and flexible judgment while helping the more vulnerable. In Kamaishi-city, students reacted according to the concept of “tsunami tendenko,” which calls for a quick evacuation. The concept developed in the eastern coast of Japan as a grassroots response to large-scale disasters. The word tendenko has been handed down in the Tohoku region as an important code of action to be observed in local communities at risk of tsunami. Professor Toshitaka Katada of Gumma University also contributed to children’s preparedness. He told the students to make their best efforts in any situation, and to take the initiative of evacuation in the community. In Unosumai, students of Kamaishi East Junior High School immediately ran out of the school to higher ground after the earthquake occurred. Their very quick and resolute response prompted local residents and even the students and teachers in a neighbouring elementary school to follow and consequently saved a lot of lives. The response of Kamaishi East Junior High School students was based on the principles of evacuation taught by Professor Katada.
Source :OECD (2018[33]), “OECD Toolkit on Risk Governance”, https://www.oecd.org/governance/toolkit-on-risk-governance/home/.
4.5. Capabilities for public health preparedness and response in Japan
Based on its risk analysis, Japan has invested resources for the development of a robust infrastructure and dedicated capabilities to prepare for public health emergencies, from their detection and surveillance to the response and medical care. While progress can continuously undertaken in this domain, these capacities appear to be tailored in good accordance with the level of risk, national policies and international standards.
Overall, in terms of capabilities, preparedness for disaster risks appear very advanced in Japan, based on risk analysis, with constant improvements, a large mobilisation of resources throughout the country. Capabilities’ planning for infectious diseases is also risk-based and at a good level, even though concerns about maintaining this level of preparedness, ensuring human resources have the right skills and ensuring that local government can properly fulfil their requirements are widespread across health professionals.
4.5.1. Surveillance, monitoring and information systems make good use of innovation, but more could be done to foster early detection and inter-agency cooperation
Japan’s advanced technical and scientific capacities are constantly mobilised to improve its systems for surveillance and monitoring of the potential risks of public health emergencies. From disease outbreak surveillance to natural hazard detection, early warning systems and information sharing platforms, innovative tools are used by the Japanese authorities to detect emergencies in a timely way, rapidly evaluate their probable public health consequences and disseminate this information across the large network of emergency stakeholders. The potential of big data, social networks and artificial intelligence could further increase timeliness and accuracy of emergency information, as is proposed in several on-going public sector innovation projects.
Regarding disaster risks, dense monitoring networks for hydro-meteorological and earthquake risks allow the detection of natural hazards that can lead to an emergency. Well-established state-of-the-art early warning systems ensure that warnings are provided in a timely manner to disaster management authorities and the public at large, which leads to establishing the Emergency Response Headquarter at the level corresponding to the emergency. For large-scale disasters the Cabinet Information Collection Centre gathers all the disaster-related information from all sectors and disseminates it to the different sectors and the public. In such circumstances, the MHLW provides information regarding health, welfare and labour situations. In addition, the MHLW online Emergency Medical Information System (EMIS) is used to share information among the Ministry and with medical institutions in affected areas. EMIS makes it possible to dispatch Disaster Medical Assistance Teams where the greatest needs are.
However, these information-sharing systems proved to be insufficient for properly assessing the public health emergency priorities during the Great East Japan Earthquake. Significant improvements are currently being elaborated to allow better real-time cross-ministerial information-sharing with the creation of the Disaster Health care Assistance System (Box 4.6), which would allow better tailoring the response to the emergency needs through an innovative data-sharing platform (Kanatani, 2017[35]).
Discrepancies in information-sharing and delayed health care assistance were highlighted during the Great East Japan Earthquake. As part of its cross-ministerial Strategic Innovation Promotion Program, the Japanese government is developing a new information-sharing platform to improve activities of medical assistance teams. The aim of the platform is to automatically integrate disaster information to estimate in real time the number of affected population, their characteristics and their location to support the distribution of medical assistance teams in the first 8 hours that follows a disaster. Damage modelling also assess the status of disaster base hospitals and automatically integrates disaster reports from the different national agencies to refine the analysis and adjust the emergency response accordingly.
Source: Kanatani (2017[35]), “Perspectives on satellite and simulation technologies for disaster response”.
For infectious diseases surveillance and detection, the National Epidemiological Surveillance of Infectious Diseases (NESID), set up in mid-90’s by the Infectious Diseases Control Law, is a robust country-wide system, jointly operated by medical institutions, prefectures and the national government (Zaraket and Saito, 2016[36]). NESID builds on a solid network of 5000 sentinel hospitals, 500 Public Health Centres, 81 Public Health Laboratories, 40 quarantine stations in airports and harbours and the National Institute for Infectious Diseases, with its BSL-4 lab which was made operational in 2014 (Box 4.7).
Social acceptance is necessary for establishing infectious diseases labs handling the most-hazardous pathogens. Introducing the first BSL-4 lab into Japan is one example. Japan’s National Institute of Infectious Diseases (NIID) built the biosafety-level-4 (BSL-4) lab in the city of Musashi-Murayama in 1981, but it has been limited to operating as a BSL-3 lab because of community safety concerns. Over the years, the NIID made various attempts to gain public support for BSL-4 operations at the site, but some citizens and politicians were concerned that the risks outweighed the benefits. Fears that Ebola might reach Japan during the 2014 outbreak in West Africa partly motivated the policy change. An agreement reached in August 2015 between Japan’s Minister of Health, Labour and Welfare and the Mayor of Musashi-Murayama City clears the way for the facility to begin limited work with pathogens such as the Lassa and Ebola viruses.
Source: Shen (2015[37]), “Ebola spurs creation of Japan's first maximum-security biolab”, https://doi.org/10.1038/nature.2015.18179; Dickmann et al. (2009[38]), “Report of the International Conference on Risk Communication Strategies for BSL-4 Laboratories, Tokyo, October 3-5, 2007”, https://doi.org/10.1089/bsp.2009.0023.
Reports collected, pathogen surveillance, school absenteeism and excess mortality are all monitored to inform NESID’s weekly infectious disease report, as well as the bi-monthly meeting of MHLW Health Risk and Crisis Management Coordination. Mobile detection capabilities for biological threats detection also exist among security authorities (Saito, 2017[39]). According to the stakeholders interviewed, the NWSID surveillance system functions well, as shown during the Ebola outbreak. NESID could nevertheless be further strengthened, notably by integrating social-media screening in event-based surveillance (Box 4.8) and better training local health institutions. That could have helped detect the Kansai area H1N1 outbreak earlier (Shobayashi, 2011[40]).
Progress in event-based surveillance benefits from big data analysis and social media screening for the early detection of the emergence of infectious diseases. Canada’s Public Health Agency has been a pioneer in the development of such a tool with the development of the Global Public Health Intelligence Network (GPHIN) in 1997, which has constantly been evolving to integrate new analytical methods. The GPHIN relies on an automated web-based system that scans newspapers and other communications worldwide for potential indicators of outbreaks (or “signals”) that are analysed and rapidly assessed by a multilingual, multidisciplinary team at the Agency. Every day the GPHIN analyses more than 20 000 online news reports (over 30 000 sources) in nine languages worldwide. A web-based program aggregates data based on an algorithm that provides potential signals of emerging public health events. When a risk is identified analysts disseminate relevant information and alerts to senior officials and stakeholders for decision-making. The GPHIN identified the early SARS outbreak in China, was credited with the first detection of MERS-CoV and has played a significant role in the monitoring of the Ebola outbreak in West Africa.
Source: O'Shea (2017[41]) “Digital disease detection: A systematic review of event-based internet biosurveillance systems”, https://doi.org/10.1016/J.IJMEDINF.2017.01.019; Dion, AbdelMalik and Mawudeku (2015[42]), “Big Data and the Global Public Health Intelligence Network (GPHIN).” https://doi.org/10.14745/ccdr.v41i09a02; Parmar, Arii and Kayden (2013[43]), “Learning From Japan: Strengthening US Emergency Care And Disaster Response”, https://doi.org/10.1377/hlthaff.2013.0704.
4.5.2. Japan has made large investments in health infrastructures dedicated to emergencies
Since the mid-90’s, Japan has invested significantly in its health infrastructure to strengthen its preparedness level for emergencies. MHLW established programmes for disaster base hospitals and for Class 1 and 2 infectious diseases designated hospitals based on lessons learned from disasters or following legislation requirements. Japan also has a dense network of Designated Evacuation Centres, which are used when evacuation orders are emitted in case of disasters.
Following the 1995 Great Hanshin-Awaji Earthquake, MHLW decided that at least one disaster base hospitals (DBH) should be set up in every secondary medical zone in Japan. These hospitals should accept the injured patients from the affected area, have surge medical capacities and are required to have a quake-resistant construction and firm lifelines, such as autonomous energy, heliport, satellite telecommunications, and substantial water storage (Homma, 2015[44]). According to the 2017 White Paper, Japan has 706 designated hospitals – with 82 in Tokyo Prefecture. DBH become the centres for the acceptance of patients or the dispatch of required personnel when a disaster occurs. These infrastructure constitute a fundamental element for the resilience of the Japanese health system. The on-going survey on DBH conducted by MHLW is an important step to assess the status of implementation of this policy.
Disaster-affected populations can receive health services to limit secondary health effects of disasters in Designated Shelters, which can host up to 36 million people throughout the country (Cabinet Office, 2016[1]). After the GEJE, the Cabinet Office announced “Evacuation Centre Management Guidelines" to encourage municipalities and others to take necessary measures to manage the living environment of the affected people who stay in evacuation centres.
According to the 1997 Infectious Diseases Act, in addition to the four designated hospitals for novel infectious diseases, every prefecture needs to have a Class 1 designated hospital for deadly and highly transmissible diseases, and for Class 2 diseases there should be one hospital for each secondary care area. However in 2014, as revealed when WHO declared the Ebola outbreak a Public Health Emergency of International Concern (PHEIC), 9 prefectures out of 47 had not yet set-up their Class 1 hospital, (Table 4.4). Similarly to disaster base hospitals, there is a lack of formal control measures in these facilities, in particular on infection control in biosafety wards (Saito, 2015[27]).
4.5.3. Japan stocks large amounts of medical countermeasures and emergency supplies for emergency response
Emergency capabilities also include stockpiling of medical countermeasures (MCM) for diseases outbreaks, as well as of emergency relief supplies for disasters. Japan has a dynamic policy for MCM stockpiling. This policy covers 45 million people to be able to cope with a severe pandemic influenza, which would possibly affect 25% of the population. National and local governments have emergency antiviral stockpiles, mostly of Tamiflu and Inavir. New drugs are included in Japan’s antiviral portfolio to address also the risk of resistance to these widely used treatments. An increased share of the market storage and production is envisioned as well, which would lead to a more dynamic stockpiling policy, which also addresses the risk of drugs expiration when managed by local governments. In the adoption of this dynamic stockpiling policy, Japan is making a good use of its pharmaceutical sector. This is less the case though for new infectious diseases, as Japan does not have an official access programme for the use of unlicensed drugs outside clinical trials (Saito, Tanabe and Tamura, 2016[45]).
Regarding vaccines, four strains of pre-pandemic H5N1 vaccines have been stockpiled in bulk for 10 million people each (Saito, Tanabe and Tamura, 2016[45]). The aim is to supply health care providers as a priority, as well as the people essential to ensure the continuity of the key sectors and lifelines of the country. A prototype cell-cultured vaccine has also been licensed and three pharmaceutical companies are developing capacities to provide such vaccine for all citizens in 6 months. Japan also has a national stockpile of a small pox vaccine.
For disaster emergencies, the disaster risk management system secures rescue equipment and relief supplies for affected population throughout the country across the three government levels. The exceptional Great East Japan Earthquakes demonstrated how quickly these supplies can be used in large-scale disasters, notably for drugs and medical treatments (Parmar, Arii and Kayden, 2013[43]).
4.5.4. Emergency health care providers can be mobilised rapidly when disasters hit, but skills shortage in infectious disease control and treatment is a concern
The mobilisation of adequate health care workers is an essential feature of the response to public health emergencies. Ensuring that the right skills are developed and can be rapidly mobilised and dispatched to the affected areas requires dedicated programmes and resources.
Following the 1995 Kobe earthquake, the MHLW has developed a dedicated programme for disaster medical care with the creation of Disaster Medical Assistance Teams (DMAT). DMAT are specialised teams – typically composed of a doctor, two nurses and one coordinator – which can be immediately deployed in disaster-affected areas to provide emergency medical care in the acute phase, typically the first 72 hours after a disaster. The 1 426 DMAT teams throughout Japan are composed of 9 328 members, and automatically go in standby when major disasters occur, while the DMAT Secretariat ensures their transportation to the affected area through military airplanes to provide surge capacities in disaster-base hospitals and in the affected areas (Hakuno, 2016[46]). While DMAT expertise is not limited to post-earthquake assistance, DMAT’s special skills in trauma care can be particularly useful when major earthquakes occur and complement well the well-trained local and specialised search and rescue teams of Japan’s disaster risk management system. While DMAT is a fundamental asset for public health emergencies, Japan needs to continue improving its medical surge capacities to respond to the diversity of public health consequences that can be caused by disasters.
During the Great East Japan Earthquake (Box 4.9), there were fewer lifesaving interventions to undertake, given the devastating and fatal combination of the earthquake with a tsunami, which led to many deaths by drowning (Saito and Kunimitsu, 2011[6]). The need was more for support to vulnerable populations in need of classic medical care, drugs and treatment or psychological assistance. The DMAT teams deployed could not make the best use of their skills and the medical teams organised by the Japan Medical Association (JMA Teams, JMAT) were of particular importance, and stayed longer to contribute to the restauration of the significantly affected health care system of the disaster-hit region (Ishii, 2016[47]). This illustrate the complementary capacities of these two systems. It also highlights the importance of completing the DMAT system to take into consideration all the public health needs after a disaster. The MHLW is currently supporting the development of a new system of Disaster Health Emergency Assistance Team (DHEAT), to focus more broadly on public health consequences of disasters. Training started in 2016, and DHEAT were first deployed in July 2018 during the devastating floods which affected south-western Japan.
Regarding psychological assistance, the MHLW started a similar approach with the Disaster Psychological Assistance Teams (DPAT) a few years ago. These teams are composed of psychiatric workers and deployed in disaster-affected areas, and particularly in psychiatric institutions. By meeting an important demand, this programme has been evaluated as successful, but it faces constraints as long-term action is often required for psychological assistance and requires corresponding engagement of DPAT members. The surge capacity provided by the DPAT system could be better linked with the local mental health institutions and practitioners so that a longer-term follow-up system is set up.
In the case of infectious diseases, there are more concerns over human resources. According to the National Institute of Public Health, 33% of Class 1 hospitals are lacking clinical infectious diseases experts, for instance. The Field Epidemiologist Training Programme of NIID also does not train sufficient staff. In a context where infectious diseases outbreaks are not as frequent as disasters, and with a decreasing budget and population, maintaining capacity, expertise and awareness within the public health system to deal with the risk of pandemic diseases outbreaks is a challenge.
During the Great East Japan Earthquake, approximately 6000 teams of over 23 000 people were involved in assisting the affected prefectures and municipalities, which includes the 383 Disaster Medical Assistance Team (DMAT) consisting of 1 852 members dispatched on the day of the disaster. Once Miyagi Prefecture requested aid on March 14, many health care teams (physicians, nurses, and pharmacists) from across the nation gathered and then dispersed to the disaster shelters. While these professionals made full use of their ingenuity and creativity to provide care for evacuees and disaster victims in local areas, this disaster highlighted several shortcomings in public health preparedness for complex disasters in Japan.
During the GEJE, health relief activities encountered included (1) delay in the resource delivery and evacuation (2) delay in reaching evacuees (3) the lack of leadership and coordination system (4) the lack of logistic supports of non-clinical public health issues (5) inefficient disaster control centres (6) disparity in levels of living condition among shelters. Public health nurses and town employees initially had to reach the shelters on foot because of lack of transportation; this forced them to take much more time in assessing the situations and needs of the affected people.
The GEJE revealed weak points in Japan’s health preparedness including disaster response plans in general. The relevant legal framework had expected damage of a much more limited scale. Thus, prefectures were not prepared to replace the leadership for disaster response when the local municipalities were destroyed and ceased to function. As well as physical structures, well-prepared management systems are necessary to strengthen resilience.
Source: Uehara (2013[48]), “Be Prepared! ∗ Lessons learned from the Great East Japan Earthquake and tsunami disaster, http://www1.med.or.jp/english/journal/pdf/2013_02/118_126.pdf”.
4.6. Emergency countermeasures and their implementation during crisis
Japan has developed a set of emergency plans to mobilise its capabilities and implement countermeasures when public health crises occur. While this large set of preparedness plans from national to local levels – as well as in designated services – makes clear the different countermeasures to be applied to reduce public health consequences of all kinds of emergencies, the lack of centralised oversight and quality control is a lost opportunity for cross-constituencies learning and overall continuous improvement of the national preparedness level. Improvements to inter-agency coordination across sectors and more regular practical exercises with the health sector would multiply the benefits from Japan’s sophisticated system of preparedness planning.
4.6.1. Public health emergency plans are developed at all levels but there is a lack of oversight and control of these plans
In application of legislation related to disaster risks and diseases outbreaks, emergency response stakeholders, public authorities at all levels and key private sector partners all have to prepare action plans at their levels composed of a series of countermeasures to limit public health consequences of emergencies. From the overarching Basic Disaster Management Plan and National Action Plan for Pandemic Influenza and New Infectious Diseases, which govern the national whole-of-government emergency response for disasters and diseases outbreaks, national guidelines instruct all ministries and local authorities to prepare their own emergency plans.
As such, the MHLW has developed a series of response plans for public health emergencies in Japan, which address potential public health emergencies. The MHLW’s Disaster Management Operational Plan sets out both the preparedness measures for the organisation of the public health response to disaster events and for maintaining the continuity of the activities of the Ministry. The public health response follows standard operating procedures set out in the plan to ensure the rapid deployment of DMAT, DPAT and emergency supplies in the affected areas, as well as support to Disaster Base Hospitals. Regarding heath crises, the National Action Plan proposes a comprehensive set of actions on 6 areas: surveillance and information collection, information provision and sharing, prevention of occurrence and spread, medical services and maintenance of stability of civil life and economy. These two plans have complemented the pre-existing MHLW Basic Guidelines for Health Risk and Crisis Management adopted in 1999, which were an initial effort to make the different sectoral division of the Ministry work on a joint crisis management framework for health crises related to drinking water, food poisoning, pharmaceuticals and infectious diseases. This series of emergency plans at the Ministry level allows for all-hazard and threat preparedness for public health emergencies.
At the local level, all the Prefectures and government-designated cities also have to develop a pandemic influenza and new infectious disease preparedness plan. These plans should follow the 10 national guidelines for countermeasures established by the Ministry which cover areas such as surveillance, risk communication, quarantine measures, prevention of spread, immunisation, medical care, antivirals, measures in office, measures in communities, burial and cremation. Box 4.10 presents the set of countermeasures implemented by Japan during the H1N1 influenza pandemic. These plans can also be used as a risk communication and awareness tools for citizens, as done for instance by the City of Yokohama (City of Yokohama, 2014[32]). While all Prefectures published their action plan by the end of 2014, one year after the new Act, there is no system in place set up by the Ministry or the association of the Prefectural governments to assess their quality, control their compliance or identify areas for improvement in these plans. In addition, not all major cities have developed a disease outbreak preparedness plan.
Similarly for disasters, all prefectures and municipalities have to develop their own disaster management plans, which should include emergency preparedness measures. While the White Paper on Disaster Risk Management prepared by the Cabinet Office and presented every year to the Parliament includes a series of statistics on emergency planning at the local level, these plans also are not subject to a quality control process. This can leave to some potential gaps as demonstrated during the Great East Japan Earthquake, when insufficient medical supplies or poor health and hygiene conditions in shelters showed that local governments’ capacities and preparedness planning were not at the level expected. Following this tragic disaster Japan undertook a review of its planning assumptions and revised its national plans for large-scale disasters such as for the Nankai Trough earthquake, the Tokyo Inland earthquake or the Tokyo large flood. These revised national plans for local large-scale disasters have all increased the number of potential affected or injured persons, or deaths, that public health emergency preparedness measures should prevent. In addition, these renewed plans establish a timeline of actions for life-saving for the initial 72-hour period post disaster (Ogata, 2016[49]).
Following the outbreak of pandemic influenza (A/H1N1) in April 2009, the Japanese government took various measures to ensure early detection of patients and prevent the spread of infection. First, important announcements were made by the Japanese government regularly at fixed times following the outbreak of pandemic influenza. The mass media offered informative feature programs, which helped many people understand the pandemic influenza and this presumably prompted people to take concrete actions. Second, surveillance was conducted in various. Third, the government issued the Guideline for Securement of Medical Services, Quarantine and Requests for Temporary Closure of Schools, Day-care Facilities. After the WHO declared phase 6 on June 12, the Guideline was revised in a week. The government also requested the temporary closure of schools in a certain area in response to the emergence of first patients in Japan. Fourth, the government requested prefectures and other authorities to set up fever counselling centres according to the action plan and guidelines. Fifth, vaccination was conducted in a budget-based programme with the cooperation of prefectures, municipalities, and medical institutions. The mortality rate in Japan remained low thanks to the efforts of individual citizens and the professional efforts of health care workers at hospitals, clinics, and pharmacies.
Source: Shobayashi (2011[40]), “Japan's Actions to Combat Pandemic Influenza (A/H1N1)”, https://www.med.or.jp/english/journal/pdf/2011_05/284_289.pdf.
As a complement, designated public institutions in critical sectors, disaster base hospitals, and public health centres all are required to develop business continuity plans for disasters and other public health emergencies, but there is no detailed guidelines for such plans nor a review process in place.
4.6.2. Inter-agency coordination mechanisms for emergency response are too complex and MHLW lacks resources to contribute effectively
While all these preparedness measures and plans ensure that every relevant institution prepares for public health emergencies, recent crises revealed shortcomings in inter-agency coordination, as well as between the different levels of governments. While improvements have been made, notably after the GEJE or the H1N1 pandemic, there is still a need to better prepare joined-up emergency response across sectors.
The engagement and leadership of the Cabinet Crisis Management Centre and of its various offices for pandemic and disaster preparedness aim to ensure that government-wide approaches are set-up. The Crisis Management Centre operates on a 24/7 basis and in case of an emergency, it allows the national government to take a whole-of-government response by convening the emergency response team for rapid information-sharing and to discuss countermeasures. This team is composed of the Director Generals from all the relevant sectoral ministries. Depending on the type of emergency, a Disaster Countermeasure Headquarter can be set up or an ad-hoc Countermeasure Headquarter for infectious diseases convened.
In parallel, the relevant ministries and local governments establish their crisis management structures. For disease outbreaks, the prefectures and designated cities are fully in charge for many of the countermeasures, while for disasters, municipalities, prefectures and the national government all establish their Disaster Countermeasures Headquarters. The multiplicity of stakeholders, structures and coordination bodies can lead to redundancies and question the roles of the different structures, which can affect the effectiveness of the response (Shobayashi, 2011[40]).
In this framework, the public health response is coordinated by MHLW, with its Office of Public Health Emergency and Disaster Preparedness and Response, which establishes the Ministry’s medical and health response headquarter. Representatives of the Ministry participate in the national headquarters at the Cabinet and in the field. For infectious diseases outbreaks, the Ministry emergency response team coordinates closely with the Prefecture Health Bureau and the crisis management structures set up by the Governors.
The absence of a permanent dedicated and well-equipped Emergency Operations Centre at the MHLW makes it challenging for the Ministry to ensure a rapid reaction and a smooth coordination of all the different stakeholders. Similarly, with only 7 fully dedicated members in its emergency office, the MHLW could face severe human resource shortage in case of a major crisis to coordinate effectively the public health response.
Furthermore, even though this overall engagement of diverse stakeholders in the response and the set-up of inter-agency mechanisms makes sense to improve cooperation, the lack of working-level relationships and routine coordination between ministries and levels of government remains largely prominent. At times this can compromise the required level of agility and flexible partnerships that are needed to deal with complex emergencies. During the GEJE for instance, the fact that DMAT and Search and Rescue teams were separated in action led to difficulties for health care providers to access the persons in need (Uehara, 2013[48]), Collaboration arrangements between the different institutions in charge are often made during the crises rather than in advance (Saito, Tanabe and Tamura, 2016[45]). There is scope for practical improvement in inter-agency coordination across sectors to increase preparedness and response to public health emergencies in Japan, beyond the written guidelines or plans.
4.6.3. Improving crisis communication requires better training of public officials and an increased use of social media
Crisis communication is an essential part of emergency response. It is fundamental to convey critical messages for the safety and security of the population as well as to reduce citizens’ uncertainty during crises (OECD, 2015[50]). Good or poor crisis communication can significantly change the course of a crisis, both in terms of public health consequences (e.g.if citizens are not well informed of the countermeasures taken or that they should follow) and/or in terms of trust in government and public institutions (e.g. if the perception that the crisis is not well managed prevails).
There is widespread recognition that the Japanese Government’s communication during the Great East Japan Earthquake and the Fukushima Daichi nuclear crisis was could have been more effective (OECD, 2015[50]). The lack of clear information led to significant confusion both nationally and internationally, which led many to question how transparent the Government was. Similarly, the Review Meeting held after the H1N1 pandemic outbreak by the MHLW identified major weaknesses in crisis communications, such as overly frequent government notifications and difficult-to-understand official jargon, which all together did not ensure that messages were conveyed effectively to the population (Shobayashi, 2011[40]).
These examples have shown the importance of developing a doctrine for crisis communication and better training public officials for this difficult task. In addition, the widespread use of social media platforms also requires that government crisis managers make best use of these tools, to communicate with the public as well as to counter rumours and avoid panic (OECD, 2015[50]). While the Japanese Government has been a pioneer in the use of social media for crisis communication by setting up dedicated twitter and Facebook accounts during the Great East Japan Earthquake (OECD, 2015[50]), it appears that not all public health emergency stakeholders use these tools effectively. The MHLW for instance does not have a response policy to counter rumours or false information during a crisis. Several methodologies for the effective use of social media in crisis communication have been developed in other OECD countries, such as those of the US Center for Digital Government (Box 4.11).
Over the last few years, social media has become one of the preferred means of communication in modern societies, including in crisis situations. In 2012, over 20 million tweets related to Hurricane Sandy were posted on Twitter. Although social media represents a rapid way to communicate, it is also sometimes imprecise, and authorities need to be present and effective on social media during a crisis to counter this. In the United States, the Center for Digital Government has developed seven “best practices” for crisis managers using social media during crisis situations:
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1. Identify a consistent hashtag: it is important to give the disaster a name, helping social media users easily find and follow information;
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2. Be the voice of authority: it is essential to have a clear and authoritative voice;
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3. Establish a rumour control website: since social media facilitates the spread of rumours in a very short time frame, a website for tracking, verifying and correcting rumours is useful;
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4. Use several people to manage the flow of requests: because major disasters require continual coverage of social media, it is important to divide the work;
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5. Avoid social media scams: there are many social media scammers, and it is important to identify, avoid and blow the whistle on them;
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6. Implement a social media archiving solution: this is particularly useful following a crisis, especially for evaluating the actions of the authorities;
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7. Choose a precise communications strategy in advance: targets and types of social media must be defined, tasks and responsibilities for communications in the crisis structure must be defined, and accounts listing the organisation’s role must be opened;
Source: Center for Digital Government (2014[51]), “Issue Brief. Social Media: Emergency Communications’ Best Ally”, http://snoco.wa.gov.archivesocial.com.
4.6.4. Multi-stakeholders emergency simulation exercises based on complex scenarios could be done regularly
In Japan, simple exercises are undertaken regularly to test emergency plans and procedures as well as the different inter-agency coordination committees, but simulation exercises based on more complex scenario including multiple stakeholders are necessary to improve its preparedness. Every year there is a disaster exercise conducted at the Cabinet level, as well as one on pandemic influenza, to which the Prime Minister regularly takes part. For instance in 2017, all the relevant ministries, prefectures, municipalities and designated public institutions participated in a communication exercise, which included the establishment of the National Countermeasures Headquarters with the Prime Minister.
The MHLW also conducts four exercises per year, one to set up a countermeasures headquarters within the ministry, one for pandemic influenza and new infectious diseases, one for ensuring gathering of emergency personnel to the ministry and a drill for safety confirmation of the personnel. This is similar at the local level where Prefectures must undertake exercises linked to their disaster plan and infectious disease plan, every year.
Despite the usefulness of this series of exercises to test understanding and knowledge of emergency plans, this approach is may not be sufficient to prepare for complex emergencies. Indeed, these exercises are too-often conducted as table-top exercises and lack elements of surprise and complexity which would force crisis managers and officials to go out of their comfort zone as real emergencies require, and to detect areas of improvement. Beyond the yearly whole-of-society exercises on the Disaster Prevention Day, such complex exercises should involve the entire network of emergency responders from the different sectoral ministries as well as the levels of government, the private sector and civil society. As more and more OECD countries are now utilising exercises to go beyond the testing of emergency procedures to learn lessons, identify deficiencies and improve policies and procedures, Japan could learn from these advanced approaches, such as the LUKEX exercises in Germany which focused in 2013 on an exceptional biological threat (Box 4.12).
Germany established the National Strategic Crisis Management Exercise (LUKEX), which takes place every two years and aims to raise awareness among top government officials. The LUKEX provides training for cross-ministerial management and crisis response staff and includes the participation of political authorities, relief organisations, scientific institutions, critical infrastructure operators and key service providers. The entire cycle of the strategic exercise lasts 16-18 months. The exercise is intended to be as complete as possible and comprises table-top activities to introduce the scenario to the operational staff in their normal working environment and real-situation simulations.
In 2013, the LUKEX exercise was conducted over two days with a scenario of an exceptional biological threat. It included the deliberate addition of the toxin Ricin to the food chain and a simultaneous intentional contamination with Tularaemia pathogens at a major public event. A total of about 2 000 individuals were involved in the exercise conduction either as active participants in crisis staffs or as members of the exercise control organisation. These included participants from six federal departments, 19 federal authorities, nine federal states, 24 businesses and associations, 3 Poison Control Centres, 4 relief organisations, one diplomatic mission and the European commission,
This exercise identified a series of areas of improvement for public health crisis management, including in the field of resource management (e.g. laboratory capacities) and the allocation of tasks to Federal and federal state committees, as well as in the fields of internal and external communication. Legal and technical issues were also identified in connection with the reception and (deliberate) disposal of contaminated food require examination. The clarification of the obligation to report toxic poisoning, the improved surveillance and the drafting of recommendations and guidelines for the management of exceptional biological threats were identified as a key areas for improvement.
Source: Federal Office of Civil Protection and Disaster Assistance (2013[52]), “LÜKEX 13 Exceptional Biological Threats Comprehensive Exercise Report” https://www.bbk.bund.de/EN/Topics/Crisis_management/LUEKEX/LUEKEX_History/LUEKEX_his_node.html#doc10174870bodyText2.
4.7. Conclusion
In line with the important risks the country faces, from large-scale disasters to widespread outbreak of infectious diseases, Japan has invested significantly in public health emergency preparedness. By learning lessons from past events – particularly in the aftermath of the 1995 Great Hanshin-Awaji Earthquake and the Great East Japan Earthquake – and applying international guidelines, over the years Japan has developed a sophisticated system for preparedness, supported by a comprehensive legal framework. The major risks in Japan are well known and comprehensively assessed, capacities to detect emergencies and capabilities to respond have been properly set-up across the different sectors and levels of governments, as well as with the private sector and civil society. Emergency countermeasure plans are prepared, coordination mechanism established and exercises are held. Japan makes of public health emergency preparedness a priority of its public health policies.
Despite this well thought-out system, Japan nonetheless faces some challenges in order to make sure it can effectively respond to complex emergencies. Disasters such as the Great East Japan Earthquake, and the response to the H1N1 pandemic influenza, did show how important it can be to be ready for complex and unforeseen emergencies. The lack of oversight and control over the preparedness measures implementation at the local level, the limited co-operation between the sectoral ministries and levels of governments beyond formal requirements and the insufficient number of real-condition exercises and drills limit Japan’s ability to guarantee that the preparedness level reaches its full potential. There are missed opportunities to fully make sure that Japan is as safe and prepared as it intends to be.
Overall, Japan appears to be over-reliant on planning at all the levels of its administration, which is important but not sufficient to be ready for more complex and unforeseen emergencies. Strengthening capacities for a more agile response based on information sharing, multi-stakeholder partnerships and flexible arrangements should be the guiding objectives for Japan to for further progress in emergency preparedness. Finally, in order for Japan to adapt its public health preparedness system to the future, it is important to maintain and develop the relevant skills and workforce, as well as to make a best use of innovative approaches and technologies.
References
[11] Aldrich, N. and W. Benson (2008), “Disaster preparedness and the chronic disease needs of vulnerable older adults”, Preventing Chronic Disease, Vol. 5/1, http://www.cdc.gov/pcd/issues/2008/jan/07_0135.htm.
[1] Cabinet Office (2016), White Paper Disaster Management in Japan 2016, Cabinet Office Japan, Tokyo, http://www.bousai.go.jp/kyoiku/panf/pdf/WP2016_DM_Full_Version.pdf.
[4] Cabinet Office (2015), Disaster Management in Japan, Government of Japan, Tokyo, http://www.bousai.go.jp/kaigirep/hakusho/pdf/WP2015_DM_Full_Version.pdf.
[26] Cabinet Secretariat (2015), Japan’s Response to Ebola Virus Disease, Cabinet Secretariat , Tokyo, https://www.kantei.go.jp/jp/singi/ebola/ebola_eng.pdf.
[15] Cabinet Secretariat (2013), National Action Plan for Pandemic Influenza and New Infectious Diseases, Cabinet Secretariat, Tokyo, https://www.cas.go.jp/jp/seisaku/ful/keikaku/pdf/national%20action%20plan.pdf.
[51] Center for Digital Government (2014), “Issue Brief. Social Media: Emergency Communications’ Best Ally”, http://snoco.wa.gov.archivesocial.com (accessed on 17 January 2019).
[32] City of Yokohama (2014), Measures for Pandemic Influenza, City of Yokohama, Yokohama, http://www.city.yokohama.lg.jp/kenko/hokenjo/genre/kansensyo/pdf/reaf.pdf.
[38] Dickmann, P. et al. (2009), “Report of the International Conference on Risk Communication Strategies for BSL-4 Laboratories, Tokyo, October 3-5, 2007”, Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science, Vol. 7/2, pp. 227-233, https://doi.org/10.1089/bsp.2009.0023.
[42] Dion, M., P. AbdelMalik and A. Mawudeku (2015), “Big Data and the Global Public Health Intelligence Network (GPHIN)”, Canada Communicable Disease Report, Vol. 41/9, pp. 209-214, https://doi.org/10.14745/ccdr.v41i09a02.
[2] EM-DAT (2017), The Emergency Events Database, http://www.emdat.be/ (accessed on 18 July 2018).
[52] Federal Office of Civil Protection and Disaster Assistance (2013), LÜKEX 13 Exceptional Biological Threats Comprehensive Exercise Report, Federal Office of Civil Protection and Disaster Assistance , Berlin, https://www.bbk.bund.de/SharedDocs/Downloads/BBK/DE/Publikationen/Broschueren_Flyer/Fremdsprach_Publikationen/LUEKEX-13_Bericht_en.pdf?__blob=publicationFile (accessed on 17 January 2019).
[24] Government of Japan (2016), National Action Plan on Antimicrobial Resistance 2016-2020, Government of Japan, Tokyo, http://www.mhlw.go.jp/file/06-Seisakujouhou-10900000-Kenkoukyoku/0000138942.pdf.
[46] Hakuno, H. (2016), ““Designated Remarks” In Ogata, T. (2016) “Disaster Management in Japan””, Japan Medical Association Journal, Vol. 59(1)/30, https://www.med.or.jp/english/journal/pdf/jmaj/v59no01.pdf.
[8] Harada, N. et al. (2015), “Mental health and psychological impacts from the 2011 Great East Japan Earthquake Disaster: a systematic literature review”, Disaster and Military Medicine, Vol. 1/1, p. 17, https://doi.org/10.1186/s40696-015-0008-x.
[44] Homma, M. (2015), “Development of the Japanese National Disaster Medical System and Experiences during the Great East Japan Earthquake.”, Yonago Acta Medica, Vol. 58/2, pp. 53-61, http://www.ncbi.nlm.nih.gov/pubmed/26306054 (accessed on 16 January 2019).
[18] Imai, T. et al. (2005), “SARS Risk Perceptions in Healthcare Workers, Japan - Volume 11, Number 3—March 2005 - Emerging Infectious Diseases journal - CDC”, Emerging Infectious Diseases, Vol. 11/3, pp. 404-410, https://doi.org/10.3201/EID1103.040631.
[47] Ishii, M. (2016), “Japan Medical Association's View of Disaster Measures and Practice.”, Japan Medical Association journal : JMAJ, Vol. 59/1, pp. 31-34, http://www.ncbi.nlm.nih.gov/pubmed/27738585 (accessed on 16 January 2019).
[35] Kanatani, Y. (2017), Perspectives on satellite and simulation technologies for disaster response.
[3] Ministry of Land, Infrastructure, T. (2007), Land and Climate of Japan, http://www.oecd.org/fr/publications/the-changing-face-of-strategic-crisis-management-9789264249127-en.htm.
[13] Ministry of the Environment (2014), Comprehensive Study on Impact Assessment and Adaptation for Climate Change 2014 Report, Government of Japan, Tokyo, https://www.nies.go.jp/s8_project/english/index.html.
[7] Morita, T. et al. (2017), “Excess mortality due to indirect health effects of the 2011 triple disaster in Fukushima, Japan: a retrospective observational study.”, Journal of epidemiology and community health, Vol. 71/10, pp. 974-980, https://doi.org/10.1136/jech-2016-208652.
[22] Nakamura, S. et al. (2018), “Health risks and precautions for visitors to the Tokyo 2020 Olympic and Paralympic Games”, Travel Medicine and Infectious Disease, Vol. 22, pp. 3-7, https://doi.org/10.1016/j.tmaid.2018.01.005.
[12] Nakano, M., M. Matsueda and M. Sugi (2013), “Future projections of heat waves around Japan simulated by CMIP3 and high-resolution Meteorological Research Institute atmospheric climate models”, J. Geophys. Res. Atmos, Vol. 118, pp. 3097-3109, https://doi.org/10.1002/jgrd.50260.
[31] National Institute of Infectious Diseases (2018), Infectious Disease Surveillance System in Japan, https://www.niid.go.jp/niid/images/epi/nesid/nesid_en.pdf (accessed on 01 July 2018).
[34] Ochi, S. and M. Suzuoki (2012), The lessons of the Great East Japan Earthquake 2011 and the countermeasures against earthquakes and tsunami in future- Fundamental Concepts behind Future Tsunami Disaster Prevention, https://www.nehrp.gov/pdf/UJNR-4217.pdf.
[23] OECD (2019), “Metropolitan areas”, OECD Regional Statistics (database), https://dx.doi.org/10.1787/data-00531-en. (accessed on 22 January 2019)
[5] OECD (2018), Assessing Global Progress in the Governance of Critical Risks, OECD Reviews of Risk Management Policies, OECD Publishing, Paris, https://dx.doi.org/10.1787/9789264309272-en.
[30] OECD (2018), National Risk Assessments: A Cross Country Perspective, OECD Publishing, Paris, https://dx.doi.org/10.1787/9789264287532-en.
[33] OECD (2018), OECD Toolkit on Risk Governance, https://www.oecd.org/governance/toolkit-on-risk-governance/home/ (accessed on 01 September 2018).
[10] OECD (2016), Japan: Boosting Growth and Well-being in an Ageing Society, Better Policies, OECD Publishing, Paris, https://dx.doi.org/10.1787/9789264256507-en.
[50] OECD (2015), The Changing Face of Strategic Crisis Management, OECD Publishing, Paris, http://www.oecd.org/fr/publications/the-changing-face-of-strategic-crisis-management-9789264249127-en.htm.
[29] OECD (2014), OECD Development Co-operation Peer Reviews: Japan 2014, OECD Development Co-operation Peer Reviews, OECD Publishing, Paris, https://dx.doi.org/10.1787/9789264218161-en.
[9] OECD (2011), OECD Reviews of Risk Management Policies: Future Global Shocks, OECD, Paris, http://www.oecd.org/governance/48329024.pdf (accessed on 16 January 2019).
[49] Ogata, T. (2016), “Disaster Management in Japan”, Japan Medical Association Journal , Vol. 59/1, pp. 27-30, https://www.med.or.jp/english/journal/pdf/jmaj/v59no01.pdf.
[14] Okumura, A. et al. (2011), “Deaths Associated with Pandemic (H1N1) 2009 among Children, Japan, 2009–2010”, Emerging Infectious Diseases, Vol. 17/11, https://doi.org/10.3201/eid1711.110649.
[17] Omi, S. (2010), “Novel influenza H1N1 pandemic: lesson learned”, Nippon rinsho. Japanese journal of clinical medicine, Vol. 68/9, pp. 1602-1604, https://www.scopus.com/record/display.uri?eid=2-s2.0-79952044105&origin=inward (accessed on 16 January 2019).
[41] O'Shea, J. (2017), “Digital disease detection: A systematic review of event-based internet biosurveillance systems”, International Journal of Medical Informatics, Vol. 101, pp. 15-22, https://doi.org/10.1016/J.IJMEDINF.2017.01.019.
[43] Parmar, P., M. Arii and S. Kayden (2013), “Learning From Japan: Strengthening US Emergency Care And Disaster Response”, Health Affairs, Vol. 32/12, pp. 2172-2178, https://doi.org/10.1377/hlthaff.2013.0704.
[25] Public Security Intelligence Agency (2018), 23 years on from the sarin incident on the subway report, http://www.moj.go.jp/psia/aum-23nen.html (accessed on 15 November 2018).
[28] Ranghieri, F. and M. Ishiwatari (eds.) (2014), Learning from Megadisasters: Lessons from the Great East Japan Earthquake, The World Bank, https://doi.org/10.1596/978-1-4648-0153-2.
[39] Saito, T. (2017), Overview of Bioterrorism Preparedness and Response in Japan.
[27] Saito, T. (2015), “Public health challenges and legacies of Japan’s response to the Ebola virus disease outbreak in West Africa 2014 to 2015”, Eurosurveillance, Vol. 20/44, p. 30056, https://doi.org/10.2807/1560-7917.ES.2015.20.44.30056.
[6] Saito, T. and A. Kunimitsu (2011), “Public health response to the combined Great East Japan Earthquake, tsunami and nuclear power plant accident: perspective from the Ministry of Health, Labour and Welfare of Japan”, Western Pacific Surveillance and Response Journal, Vol. 2/4, pp. 7-9, http://ojs.wpro.who.int/ojs/index.php/wpsar/article/view/129/70.
[45] Saito, T., M. Tanabe and D. Tamura (2016), Revisions and Advances in Pandemic Preparedness in Japan after 2009 pandemic, https://isirv.org/site/index.php/component/content/article/9-events/352-options-ix.
[37] Shen, H. (2015), “Ebola spurs creation of Japan's first maximum-security biolab”, Nature, Vol. 524/7565, pp. 274-275, https://doi.org/10.1038/nature.2015.18179.
[40] Shobayashi, T. (2011), “Japan's Actions to Combat Pandemic Influenza (A/H1N1)”, Japanese Medical Association Journal, Vol. 54/5, pp. 1459-1463, https://www.med.or.jp/english/journal/pdf/2011_05/284_289.pdf (accessed on 16 January 2019).
[16] Takahashi, S. et al. (2017), “Public preventive awareness and preventive behaviors during a major influenza epidemic in Fukui, Japan”, Journal of Infection and Public Health, Vol. 10/5, pp. 637-643, https://doi.org/10.1016/J.JIPH.2017.04.002.
[20] Tuberculosis Surveillance Center (2016), “Tuberculosis in Japan Annual Report - 2016”, Department of Epidemiology and Clinical Research, the Research Institute of Tuberculosis, http://www.jata.or.jp/english/dl/pdf/TB_in_Japan_FINAL_1114.pdf.
[48] Uehara, N. (2013), “Be Prepared!— Lessons learned from the Great East Japan Earthquake and tsunami disaster”, Japan Medical Association Journal, Vol. 56/2, pp. 118-126, http://www1.med.or.jp/english/journal/pdf/2013_02/118_126.pdf (accessed on 16 January 2019).
[21] Ujiie, M., K. Nabae and T. Shobayashi (2014), “Rubella outbreak in Japan.”, Lancet (London, England), Vol. 383/9927, pp. 1460-1461, https://doi.org/10.1016/S0140-6736(14)60712-1.
[19] World Health Organization (2018), Tuberculosis country profiles, https://www.who.int/tb/country/data/profiles/en/ (accessed on 17 January 2019).
[36] Zaraket, H. and R. Saito (2016), “Japanese Surveillance Systems and Treatment for Influenza”, Current Treatment Options in Infectious Diseases, Vol. 8/4, pp. 311-328, https://doi.org/10.1007/s40506-016-0085-5.