Covid-19: Japan prepares to extend state of emergency nationwide as “untraceable” cases soar

Dear Editor

On April 7, the Japanese Prime Minister Shinzo Abe declared a state of emergency in 7 prefectures of Japan in response to the spread of coronavirus disease 2019 (COVID-19).[1] This are applied to all 47 prefectures on April 16.[2] The government had already taken pre-emptive measures, such as, a nationwide closure of schools on March 2, but this newest announcement was primarily intended to endorse and reinforce social distancing at the national level. However, the Japanese government is constitutionally forbidden from enforcing a full-scale lockdown.

This news is significant because it refers to the elderly citizen in Japan. In the world, Japan has the highest proportion of 65 years old or older. [2] They were requested to stay home and avoid contact with others just like any other citizen.

Many organisations have voluntarily suspended their activities in response to the government’s social distancing order. One such category is kayoinoba or recreational ‘salons’—which are run independently, primarily by local volunteers—where the senior citizens of a community can congregate, exercise, and socialise. Japan has promoted kayoinoba for many years as a component of community-based elder care policy, recognising the importance of physical and social stimulation for preventing frailty in older adults. While their activities have been suspended to minimise the risk of COVID-19 spread among the community-dwelling elderly, this move has robbed them of their regular setting for exercise and socialisation, and most of them now stay secluded at home to prevent transmission.

Recognising the disruptions caused by the epidemic, Keisuke Kuwahara and colleagues have already noted the challenges posed to older adults, such as ensuring that they can still engage in appropriate levels of community activity, and especially the problem of social isolation.[3] One predictable consequence of suspending activities which have heretofore played a crucial role in frailty prevention is a rise and exacerbation of frailty among the elderly. There is little doubt that this frailty risk will be increased by the continuation of policy measures intended to stem the tide of infections. Today, as the society prepares for an extended battle against the COVID-19 pandemic, I believe that additional measures to support the health and well-being of the elderly are just as crucial, lest we face a secondary epidemic of ‘corona-frailty’.

To craft an effective response for those at risk of corona-frailty, it is imperative to also focus on older adults uninfected by COVID-19. British researcher Peter Lloyd–Sherlock has criticised the lack of specific recommendations for older adults in WHO guidelines.[4] This topic is not widely discussed in recent literature as PubMed searches conducted by the author on April 18 yielded just 100 hits for the query “COVID-19” AND “older”, and 227 for “COVID-19” AND “elderly”. To make matters worse, only a small percentage of these publications that have specifically discussed infection control measures targeting older adults mention the suspected effects on frailty or mental and physical health in the elderly population.

Community activities have long underpinned the health and well-being of Japanese seniors; their social activities have already been reduced for nearly two months. Flattening the curve and treating the infected are unquestionably the highest priorities at present, but this does not change the fact that anti-frailty measures continue to be an urgent issue for millions of community-dwelling elderly and an incipient corona-frailty epidemic is likely already emerging in our midst. However, as the novel coronavirus continues to spread throughout the country, efforts to study the community-dwelling elderly in Japan are hampered by the restrictions imposed by the prioritisation of infection prevention. One Chinese team has reported the effects of the COVID-19 pandemic on citizens’ mental health and quality of life,[5] but their methodology—an online survey—is difficult to apply to groups of community-dwelling elderly, whose access to and familiarity with information technology is typically limited. Researchers must carefully consider how to contact and interact with subjects while still abiding by the social distancing guidelines. Telephonic surveys show promise in this respect, and this method has already been used to investigate respondent awareness and attitudes toward COVID-19 in an American population, which included a wide range of age groups from youth to older adults.[6]

The COVID-19 pandemic has eroded the social functions of communities around the world. Fortunately, in Japan, at least one lifeline is still available for the community-dwelling elderly who are at risk of frailty, i.e., regular ‘patrols’, which consist of regular visits or interview by telephone and check-ups by neighbourhood volunteers. Today, with the help of collaborating local volunteers, we are planning to conduct a survey to investigate the current frailty status and risks among the community-dwelling elderly who have lost all the socialising opportunities provided by kayoinoba. We are also preparing to distribute pamphlets about frailty prevention among residents, and to conduct a different strategy of using postal questionnaires to determine the benefits of enhancing community support measures through frailty screening. We anticipate that the findings and reports resulting from our work will shed light on which anti-frailty measures are the most feasible under COVID-19-related restrictions, and to supress the extent of the corona-frailty phenomenon.

References
[1] Looi MK. Covid-19: Japan declares state of emergency as Tokyo cases soar. BMJ 2020;369:m1447. doi: 10.1136/bmj.m1447
[2] Looi MK. Covid-19: Japan prepares to extend state of emergency nationwide as “untraceable” cases soar
BMJ 2020;369:m1543. doi: https://doi.org/10.1136/bmj.m1543
[3] Kuwahara K, Kuroda A, Fukuda Y. COVID-19: Active measures to support community-dwelling older adults. Travel Med Infect Dis 2020;101638. doi: 10.1016/j.tmaid.2020.101638
[4] Lloyd-Sherlock PG, Kalache A, McKee M, et al. WHO must prioritise the needs of older people in its response to the covid-19 pandemic. BMJ 2020;368:m1164. doi: 10.1136/bmj.m1164
[5] Zhang Y, Ma ZF. Impact of the COVID-19 pandemic on mental health and quality of life among local residents in Liaoning Province, China: A cross-sectional study. Int J Environ Res Public Health 2020;17(7): 2381. doi: 10.3390/ijerph17072381
[6] Wolf MS, Serper M, Opsasnick L, et al. Awareness, attitudes, and actions related to COVID-19 among adults with chronic conditions at the onset of the U.S. outbreak: A cross-sectional survey. Ann Intern Med 2020. doi: 10.7326/m20-1239

Yours sincerely,

Tomoyuki Shinohara, PhD, Kosuke Saida, MS, Shigeya Tanaka, PhD
Takasaki University of Health and Welfare, Japan
Akihiko Murayama, PhD
Gunma University of Health and Welfare, Japan