COVID-19 and the COVID-19 Vaccine in Japan—A Review from a General Physician’s Perspective
Round 1
Reviewer 1 Report
I thoroughly enjoyed and benefitted from reading this first person account in perfect and transparent English. It would be interesting to obtain similar articles from the UK, US, Italy…
I would not change a word, because it is a first person narrative. The author makes many important conclusions.
I think the key is to make a box or table prioritising his conclusion on many topics.
An important question is how different were the situations in different countries. The author assesses the situation in Japan as unusual. The reactions to the early days of COVID-19 varied in different countries and set the pattern of concern for that country. Northern Italy is an interesting case because they had high initial rates of COVID-19 deaths including health personnel and the commentary was that in Cremona dissemination was heightened by important soccer matches at the time and celebrating in bars and pictures of multiple coffins of health care personnel were shown on TV.
A second important issue is the effect of the media and what they chose to report and with whom did they TV conduct interviews. In Canada there were few with infected persons, vaccine accepters or refusers, and those with Long COVID compared to “experts.”
A third is how informed the politicians were as they communicated the information they were provided with or sought, including levels of concern, how they were securing PPE and respirators ... In the US President Trump dominated the news from the President’s office, downplaying the situation and arguing that he was getting out supplies of PPE by the army. He also focused attention on Dr. Anthony Fauci of the CDC.
A fourth is who spoke for the health professions. In Canada the national Chief Public Officer of Health Dr. Tam made balanced presentations of data and recommendations weekly and the Chief Medical Officer of Health for Alberta similarly for Alberta, and the CPHOs similarly for the other provinces.
In Alberta detailed statistics on the evolving situation were presented for physicians (who had to register) and other health professionals in a one hour weekly “COVID Corner”
Less controlled and thus more varied were infectious disease experts who were interviewed on TV nightly for 10 second sound bites. They varied in their level of expertise, information and the solutions they offered. The author comments on the varied focus of the ID experts.
A fifth is what the pandemic disclosed about the countries’ health systems. In the US it was clear that the US did not have a functioning public health system.
In short, whatever the author thinks would increase the impact of his article is fine.
Author Response
Reviewer 1
Thank you for your meaningful and constructive comments.
・I think the key is to make a box or table prioritising his conclusion on many topics.
During the revision process, I reaffirmed that policymaking authorities and the media play an important role; therefore, I have added them to Figures 7A and 7B.
・An important question is how different were the situations in different countries. The author assesses the situation in Japan as unusual. The reactions to the early days of COVID-19 varied in different countries and set the pattern of concern for that country. Northern Italy is an interesting case because they had high initial rates of COVID-19 deaths including health personnel and the commentary was that in Cremona dissemination was heightened by important soccer matches at the time and celebrating in bars and pictures of multiple coffins of health care personnel were shown on TV.
A second important issue is the effect of the media and what they chose to report and with whom did they TV conduct interviews. In Canada there were few with infected persons, vaccine accepters or refusers, and those with Long COVID compared to “experts.”
I think the important point you raise is the relationship between infectious disease specialists in Japan and the media and policymaking authorities.
“5. The position of infectious disease specialists in Japan,” a chapter was included in the report as follows:
“In Japan, there are approximately ten specific infectious disease experts in the media every day to provide their opinions (5). Most of their opinions, at least from 2020 to 2021 were devoted to reiterating the characteristics of COVID-19, which are not com-mon in conventional infectious diseases, such as sequelae or the spread of infection even from asymptomatic people, and to stress the importance of controlling human movement, infection control measures, and vaccination promotion. Most older adults, the majority of the TV audience believed the information as it was presented, and attempted to implement a lifestyle of self-restraint.”
・A third is how informed the politicians were as they communicated the information they were provided with or sought, including levels of concern, how they were securing PPE and respirators ... In the US President Trump dominated the news from the President’s office, downplaying the situation and arguing that he was getting out supplies of PPE by the army. He also focused attention on Dr. Anthony Fauci of the CDC.
We believe that your comment is important. I have added a chapter on "Characteristics of the Japanese healthcare system in the COVID-19 pandemic compared to other countries.” I also included a chapter on "Strong promotion of COVID-19 Vaccination in Japan" because I believe that the debate over the COVID-19 vaccine is unique to Japan.
I also found an excellent review article on the relationship between infectious disease specialists and politicians.
“On February 14, 2020, the Expert Group on Countermeasures to Combat New Coronavirus Infections was established and became a Subcommittee on Countermeasures to Combat New Coronavirus Infections on June 24, 2020. Politicians are primarily informed by this subcommittee.
Dr. Imamura of the University of Tokyo has provided an excellent review of the relationship between experts and politicians as policymakers in developing COVID-19 countermeasures (6). In the discussion of this review article, Dr. Imamura stated the following:
In Japan, a government task force headed by the prime minister was established in the early stages of the pandemic. The decision to issue or extend the "basic response policy," which included a general policy on infection control, and the "emergency declaration," which aimed to prevent the collapse of the medical supply system, was made by this task force. The government issued a "basic response policy" and an "emergency declaration" to prevent the collapse of the medical supply system.
The government has repeatedly stated that it would like to make decisions based on expert opinions. The emergency period was also pronounced in accordance with the analysis and judgment of experts. The presence of experts was also significant in presenting a new lifestyle of self-restraint and avoidance of contact with others, with a focus on infection control, dissemination of information on behavior change, and explanations of the accompanying public policy decisions. This was an unclear relation-ship in which the government task force ostensibly made the final policy decision, but the experts had the actual authority to make policy decisions, and the experts who were involved in providing advice pointed out the unclear nature of this relationship. The experts themselves sometimes determined the line between the roles of professionals and politicians, and there seemed to be some anguish over this line.”
・A fourth is who spoke for the health professions. In Canada the national Chief Public Officer of Health Dr. Tam made balanced presentations of data and recommendations weekly and the Chief Medical Officer of Health for Alberta similarly for Alberta, and the CPHOs similarly for the other provinces.
In Alberta detailed statistics on the evolving situation were presented for physicians (who had to register) and other health professionals in a one hour weekly “COVID Corner” Less controlled and thus more varied were infectious disease experts who were interviewed on TV nightly for 10 second sound bites. They varied in their level of expertise, information and the solutions they offered. The author comments on the varied focus of the ID experts.
In Japan, Dr. Shigeru Omi, head of the Subcommittee on Countermeasures for COVID-19, spoke to health professionals. I described him as follows:
“Dr. Shigeru Omi, the head of the subcommittee on countermeasures to Combat New Coronavirus Infections, made recommendations to the government as a representative of medical experts. He often held press conferences alongside the Prime Minister when a state of emergency was declared (7). In a debate over whether to host the Tokyo Olympics in the summer of 2021, Dr. Omi said, “It is not normal to hold the Olympics during this pandemic. (8)” In addition, when IOC President Bach was invit-ed by the International Paralympic Committee (IPC) to revisit Japan after the Olympics to attend the opening ceremony, Dr. Omi's statement to President Bach that he should not come was criticized as overstepping his authority and caused quite a stir (9). It can be said that throughout
the pandemic period, there were many critics of Dr. Omi, even from the medical community (10, 11).”
・A fifth is what the pandemic disclosed about the countries’ health systems. In the US it was clear that the US did not have a functioning public health system.
We believe that is an important comment. I have added a chapter on "Characteristics of the Japanese healthcare system in the COVID-19 pandemic compared to other countries.” I also included a chapter on "Strong promotion of COVID-19 Vaccination in Japan" because I believe that the debate over the COVID-19 vaccine is unique to Japan.
“9. Characteristics of the Japanese healthcare system in the COVID-19 pandemic com-pared to other countries
In terms of the number of COVID-19 cases and deaths per population, Japan re-mains at a low level compared to Western countries. However, the lack of ICUs and Japan's poor mobility and regional coordination compared with other countries are seen as reasons for frequent medical crises and emergency declarations.
It is well known that among developed countries, Japan has an extremely high number of hospital beds per population. The number of hospital beds per 1,000 people is 13.0, approximately 4 to 5 times higher than the 2.9 in the United States and 2.5 in the United Kingdom, respectively. As for the number of "acute care beds" to treat patients with COVID-19 pneumonia, it is also the highest among the Organization for Economic Cooperation and Development (OECD) countries. At 7.8 per 1,000 population, it is more than double the OECD average of 3.7 (52). The following is an excerpt from an online article comparing Japan's healthcare system to other countries (53).
“Despite having many hospital beds, Japan is prone to serious medical tightness in certain areas as the number of serious cases nationwide approaches 1,000. A medical crunch not only concentrates the burden on a few medical personnel, but also has a tremendous impact on the economy because it can lead to an increased risk of death and force the public to restrict their activities. Various factors can explain why medical care is tight in Japan.
First, there are few intensive care units (ICUs). The number of ICU beds in Japan is only 2% of the total hospital beds, compared to 8% in Germany and 7% in the U.S. (OECD statistics). Although the number of total beds in Japan is 13.0 beds per 1,000 population, which is more than Germany's eight beds and the United States' 2.9 beds, the number of ICU beds is 5.2 beds per 100,000 population and 13.5 beds including high care units for patients of intermediate severity between ICUs and general wards, which is less than half the 29.2 beds in Germany. In addition, the number of intensivists per capita in Japan is only one-seventh of that in Germany.
Secondly, there were problems with the conversion of beds to ICUs, hospital col-laboration within and outside the region, and mobility during the assignment of physicians. The prevalence of infectious diseases differs significantly between regions. The situation in Osaka in early May 2021 during the fourth wave was extremely serious, and there was no room for ventilator-assisted treatment in the ICUs. In contrast, Ger-many has added 10,000 ICU beds since August 2020 to cope with this coronavirus infection and has converted and expanded its hospital beds to 40 beds per 100,000 population. In Sweden, hospitals are flexibly linked across regions, and physicians with dif-ferent specialties are trained and assigned to treat ICU patients. The flexible coordination and response of hospitals may be partly due to the differences in hospital management entities. In Japan, the ratio of private hospitals is 81.6%, and the number of private hospital beds is 71.3%, which differs significantly from the EU's ratio of private hospital beds of 33.9% (2014).
In Sweden, national hospitals were the main players, and the government centrally controlled the use of hospital beds in each hospital from time to time and ordered emergency transport of patients beyond the boundaries of local governments. In Japan, it is necessary to establish a system that enables the flexible conversion of hospital beds in emergencies, cooperation between clinics and hospitals, cooperation be-tween hospitals, and flexible allocation of doctors and other personnel.”
- Strong promotion of COVID-19 Vaccination in Japan
Since 2021, Japan has firmly pushed for the expansion of COVID-19 vaccination. Even after the Infectious Disease Control Law was changed to Category 5, the government continued to push for a sixth vaccination, mainly for the elderly, starting in May 2023.
Although there are still many older adults who honestly go for vaccination when they receive their free vaccination coupons because they feel they must be vaccinated, many question why only Japan is promoting additional vaccinations while other countries have stopped doing so; this issue has been addressed in the Diet (54).
Some researchers have suggested that Pfizer may process an excess COVID-19 vaccine inventory in Japan (55). Some news reports have focused on adverse reactions to the COVID-19 vaccine (56). Another theory suggests that one possible cause of the increase in excess deaths in Japan after 2021 could be an adverse event caused by the COVID-19 vaccine. It is necessary to examine the causes of the increase in excess deaths from various perspectives (57).
However, a shocking incident occurred in May 2023, when this article was written and submitted. NHK, Japan's flagship TV station, ran a news program that featured the bereaved families of people who had died after receiving the COVID-19 vaccine as if they were the bereaved families of people who had died from COVID-19 itself, and the NHK apologized (58-60).
In a controversial manner, it has even been reported that "there is an unspoken agreement in the NHK news bureau not to give out any negative information about vaccines. (61)" Although the circumstances of this incident are unclear, it is difficult to believe that such a thing could have happened because of a simple mistake, and those involved would be required to be accountable for their actions in good faith. A local TV broadcast covered the relationship between the COVID-19 vaccine and excess deaths.
The video was uploaded to YouTube, but it was immediately deleted. This may have occurred because of the idea that negative information about the COVID-19 vac-cine should not be released (62).
The tendency to avoid publicizing negative information about vaccines exists in the media and the medical community. The Japan Neurological Society requires that pa-pers on post-vaccine neurological adverse reactions be submitted to academic journals issued by the Japan Neurological Society with proof of a causal relationship, specifically, sufficient discussion of the time course and pathogenic mechanism based on data such as antibody titers and analysis of changes over time in cytokines and chemokines in the cerebrospinal fluid　(63). This requirement is based on such an idea; for example, the development of Guillain-Barré syndrome after COVID-19 vaccination may occur incidentally, unrelated to vaccination, and its misinterpretation as an adverse reaction to the vaccine may lead to lower vaccination coverage and associated unnecessary morbidity and mortality (64). However, there is an opinion that facts need to be reported and accumulated even when the causal relationship with vaccination is unclear. Debate on COVID-19 vaccination is expected to continue.”
Reviewer 2 Report
Dear author,
Your article seems to outline the situation of COVID-19 in Japan as of May 2023, highlighting the decrease in severe cases due to widespread vaccination and the emergence of the Omicron variant, which is characterized as an attenuated strain.
1. The claim that hybrid immunity from vaccination and natural infection is prevalent is consistent with the current understanding of immunology, as exposure to a virus through infection and/or vaccination can lead to a stronger immune response.
2. The article also mentions the significant impact of COVID-19 measures on the economy and society, which is a reality observed globally during the pandemic. It emphasizes the need for policies that balance infection control with broader socio-economic considerations, which is a common perspective in public health policy.
3. In your article, I would like to see more clarification or supporting evidence. For example, the article claims that overreaction to COVID-19 caused disadvantage for many patients, and that this overreaction was due to statements by infectious disease experts. This could be further substantiated with more specific information on the nature of these statements and their impacts.
4. Similarly, the classification of Omicron as an "attenuated strain" may require additional context or explanation, as the term "attenuated" typically refers to a live virus that has been weakened for use in vaccines, rather than naturally occurring variants.
5. While it's mentioned that a significant portion of the population has high antibody titers, the source of this information isn't provided. This data would be valuable to support the conclusion about the necessity of additional vaccinations only for those who would benefit most.
6. In conclusion, the article appears to provide a broad overview of the COVID-19 situation in Japan, presenting perspectives on the role of experts, vaccination policy, and the importance of holistic approaches to public health policy. Also, some case reports included are interesting. However, a few points could benefit from further clarification or supporting evidence.
Author Response
Reviewer 2
Thank you for your meaningful and constructive comments.
- In your article, I would like to see more clarification or supporting evidence. For example, the article claims that overreaction to COVID-19 caused disadvantage for many patients, and that this overreaction was due to statements by infectious disease experts. This could be further substantiated with more specific information on the nature of these statements and their impacts.
Thank you for this comment. I think your point is valid.
I report that the focus on COVID-19 has delayed the diagnosis and treatment of other diseases. We have added the following sentences:
“Regarding acute appendicitis, it has been reported that the incidence of complicated appendicitis (CA) in children increased after the pandemic in Japan, and the du-ration of preoperative symptoms also increased. This may be due to the fear of contracting COVID-19 when visiting a hospital, which may have led to a reluctance to see a doctor and delayed treatment (1).
One of the reasons for this reluctance to see a doctor and delay in treatment is thought to be that in the early days of the 2020 pandemic, there was a great deal of publicity about reducing contact with others by at least 70% and as much as possible by 80%, following the recommendation of Professor Nishiura of Hokkaido University, who was then a member of the Cluster Response Team of the Ministry of Health, Labor, and Welfare (2).
The adverse effects of delayed diagnosis and treatment have also been observed in patients with cardiovascular diseases requiring emergency treatment. After the COVID-19 pandemic, primary PCI was performed significantly less frequently, and the incidence of mechanical complications resulting from ST-elevation myocardial infarction (STEMI) increased. Not seeking immediate medical attention and waiting at home when heart attack symptoms occur may worsen the outcomes of patients with STEMI (3).
Reperfusion therapy for acute ischemic stroke has also been affected by the COVID-19 pandemic. The number of stroke admissions decreased during the emer-gency declaration, and the time from hospital arrival to imaging and thrombolysis was prolonged compared to before the COVID-19 pandemic (4). Thus, there is a delay in treating more lethal emergency illnesses due to the fear of contracting COVID-19.”
- Similarly, the classification of Omicron as an "attenuated strain" may require additional context or explanation, as the term "attenuated" typically refers to a live virus that has been weakened for use in vaccines, rather than naturally occurring variants.
We believe that it is appropriate to describe the omicron strain as attenuated. The replication and virulence of the omicron variant of SARS-CoV-2 in mice are attenuated compared to those of the wild-type strain and other variants (Nature. 2022 Mar;603(7902):693-699.). It has shown rapid growth, low virulence, and attenuated virulence in humans (Nature. 2022 Mar;603(7902):700-705. Both studies used the term "attenuated.” We have added the following text:
“In mice, the replication and virulence of omicron variants are attenuated compared to wild-type strains and other variants (27). Omicron strains show rapid growth, lower fusogenicity, and attenuated pathogenicity (28-29).”
- While it's mentioned that a significant portion of the population has high antibody titers, the source of this information isn't provided. This data would be valuable to support the conclusion about the necessity of additional vaccinations only for those who would benefit most.
This remains an important issue. There is a significant portion of the population with high antibody titers, and to the best of our knowledge, this has not been reported in a large study.
I have added the following statement.
“Based on an analysis of blood donations, it was reported that, as of February 2023, 42.3% of the population in Japan possessed N antibodies representing the existing COVID-19 infection (49). At the beginning of 2022, when most of the population (over 70%) was vaccinated up to the second dose, the cumulative number of COVID-19-infected persons in Japan was approximately 1.7 million. However, by May 2023, the cumulative number of infected individuals was approximately 34 million. In other words, in the case of Japan, most of the infected people are thought to have been infected after more than a second dose of vaccine and after the Omicron strain re-placed SARS-CoV2. Therefore, most of the Japanese with N antibodies indicating previous infection are thought to have hybrid immunity due to vaccination and natural infection, and the number of such people is around 40% of the total population. Although some people may have been naturally infected for six months to a year and whose antibody titers have declined, many with hybrid immunity are thought to have high antibody titers. Therefore, it is highly desirable to clarify the distribution of SARS-CoV2 anti-body titers in the Japanese population through a nationwide, large-scale study.”
Round 2
Reviewer 2 Report
All comments addressed.
