Japan is becoming a center of concern as the coronavirus spreads globally, with the country’s official infection tally suspected to be the tip of the iceberg of a much wider outbreak.
As of Friday, Japan had about 200 confirmed cases of the pneumonia-causing virus, excluding those that erupted on the Diamond Princess, a cruise ship quarantined for weeks in Yokohama harbor. In neighboring South Korea, however, the number of infections has swelled rapidly, reaching almost 1,800 after the government tested tens of thousands of people to get a clearer picture of the deadly outbreak.
That divergence has experts -- and members of the public -- concerned about Japan’s approach to diagnosis.
“For every one who tests positive there are probably hundreds with mild symptoms,” said Masahiro Kami, chair of the Medical Governance Research Institute in Tokyo, and a practicing doctor. “Those with mild symptoms are not being tested.”
While the government says it has the capacity to conduct 3,800 tests a day, only 5,700 were actually carried out between Feb. 18-23, Japanese Health Minister Katsunobu Kato told parliament Wednesday. That included the tests made on passengers and crew of the Diamond Princess, where Japan’s attempt to quarantine the boat resulted in an explosion in infections to more than 700 cases.
Japan’s low level of confirmed infections has enabled Prime Minister Shinzo Abe to maintain a relatively relaxed stance on the outbreak compared with South Korea and China, where more than 78,000 cases and over 2,700 deaths have been recorded.
Unlike other countries in the region, Japan hasn’t imposed travel bans on citizens from highly infected nations -- including China -- and Abe has encouraged, but not enforced, the cancellation of major public events. Many people in Tokyo continued to commute to work in packed trains. As public criticism mounted, Abe announced Thursday evening that schools will be shut from next week to April.
“In order to grasp the current situation, we should test,” said Kazuhiro Haraguchi, a lawmaker with Japan’s opposition Democratic Party for the People. “Tests are not 100% reliable, but we need to know the facts.”
Minister Kato said that public health centers had refused to test some people for the virus, probably because they were concerned they didn’t have sufficient capacity.
Reflecting growing concerns over the outbreak in Japan as well as globally, the Nikkei 225 dropped as much as 3.5% in Friday morning trade and is down more than 9% so far this week.
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The country has already come under fire for not testing the Diamond Princess passengers more extensively, with at least two Japanese testing positive for the virus after they returned home. Both had used public transport and been out in the general public after disembarking from the ship.
There’s also rising anxiety over the number of Japanese virus patients whose infection routes can’t be traced. For example authorities have not yet been able to identify connections between those who got infected in the northern island of Hokkaido, which has now grown to become the biggest outbreak in Japan with 54 cases.
Unlike some other Asian countries, Japan didn’t see a widespread local outbreak during the SARS and MERS virus epidemics. That lack of experience may have left it ill-equipped for dealing with the novel coronavirus, which is thought to be more infectious than those diseases, though less deadly.
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Unlike South Korea and many other developed countries, Japan doesn’t have a Center for Disease Control, meaning virus prevention and outbreak control is in the hands of bureaucrats from the health ministry, aided by a group of experts.
While there is a national benchmark for how testing for the virus should be undertaken, some cities and regions are applying different standards.
The official guidance is for anyone with mild symptoms to stay at home. Those with serious conditions are told to contact a hotline, where they can be linked to an appropriate medical facility. Doctors can recommend testing at Japan’s local public health centers if they suspect a coronavirus infection.
Some public health centers -- including in Tokyo, the city of Nagoya and the Wakayama prefecture -- say they haven’t had consistent supplies of testing kits to meet requirements. Wakayama, which has confirmed 11 virus infections, is using its own parameters to decide when testing is needed.
Hospitals and clinics could also be concerned that if a case is confirmed on site, they’ll be forced to shut down for disinfection, according to opposition lawmaker Haraguchi, who wants the government to compensate operators in these cases.
Even a member of the government’s expert panel on the virus has criticized their efforts on diagnosis. Hitoshi Oshitani, a professor at Tohoku University Graduate School of Medicine, said last week that Japan’s initial efforts at testing were like using a pen light to hunt for a ping pong ball in the Tokyo Dome baseball stadium.
The handling of the Diamond Princess virus outbreak had already undermined trust in the government’s capacity to handle the crisis. After discovering cases of the virus, Japan locked the ship down for 14 days, a move that some public health experts said probably fueled the spread on board. About a fifth of the ship’s 3,700 passengers and crew have tested positive for the virus.
Health minister Kato told parliament this week the government is working on a system to support the private sector to conducts tests so that more people can be tested for the virus.
With trust in authorities eroded, a broader testing regime is now needed to calm public unease, said Kenji Shibuya, director of the Institute for Population Health at King’s College London, and a former chief of health policy at the World Health Organization.
“Scientifically we should target and prioritize the patients,” he said by email. “But it is now beyond that -- we are dealing with public fear, and to tackle it, we need to give people an opportunity to get tested.”