Japan's National Scheme for Public Health Security

Japan's National Scheme for Public Health Security Tomohiko Makino, MD, MPH, MBA Office of Public Health Emergency Preparedness and Response (IHR National Focal Point of Japan) Health Science Division, Minister s Secretariat Ministry of Health, Labour, and Welfare (MHLW) of Japan makino-tomohiko@mhlw.go.jp

1. Introduction Today s Topic 2. MHLW s response to the combined Great East Japan Earthquake, tsunami and nuclear power plant accident in March 2011 3. Mechanisms for Health risk management and coordination in MHLW 4. IHR core capacity implementation: IHR NFP function in Japan 5. Topics: Tokyo Sarin and Pandemic H1N1 2009 [Disclaimer] This presentation was prepared or accomplished by Tomohiko Makino in his personal capacity. The opinions expressed in this presentation are the author's own and do not reflect the view of the Ministry of Heath, Labour and Welfare, or the Government of Japan. No conflict of interests to disclose.

Landscape of Health Risk of Concern in Japan 1940s ~ 1950s Infectious Diseases 1960s ~ 1970s Environmental Pollution 1980s Medication Scandal (e.g. HIV-tainted blood incident) 1990s ~ Earthquake Emerging Disease Medical Malpractice WMD/Terrorism Climate change

Year Health Crisis Event Mass Gathering Event 1995 Hanshin-Awaji Earthquake Tokyo Subway Sarin Attack 1997 O157 Food Poisoning 1998 Arsenic-laced Curry Incident 1999 Criticality Nuclear Accident 2000 Contamination of Daily Products by S.aureus Volcanic Eruption (Miyakejima) Kyushu-Okinawa G8 Summit 2002 SARS FIFA World Cup 2004 Niigata-Chuetsu Earthquake Acute Encephalopathy caused by Mushroom 2005 Railway Crash 2007 Niigata-Chuetsu Earthquake 2008 Imported Contaminated Dumplings Incident Tohyako G8 Summit 2009 Pandemic Flu Key Public Health Crises in Japan 2010 APEC Japan 2011 Tohoku-East Japan Earthquake, Tsunami & Fukushima NPP Accident Combined Disaster another issue of public health challenge

Ministry of Health, Labour and Welfare Minister s Secretariat Health Sciences Division Office of Public Health Preparedness and Response Health Policy Bureau Health Service Bureau Pharmaceutical and Food Safety Bureau Labour Standards Bureau Employment Security Bureau Human Resources Development Bureau Equal Employment, Children and Family Bureau Social Welfare and War Victim s Relief Bureau Health and Welfare Bureau for the Elderly Health Insurance Bureau Pension Policy Bureau Director-General for Policy Planning and Evaluation

Our role Office of Public Health Emergency Preparedness and Response Intelligence (consolidating information, investigation, analysis and communication) on domestic/international health crisis event IHR National Focal Point (since 2007) Coordinating emergency response to health emergency event by unknown causal (or in the uncertain phase) Secretariat for Health Risk Management Coordination Meeting Preparedness Table Top Exercises (TTX) Medical Countermeasure Preparedness: Smallpox Vaccine etc.

Enhancement of Function of Cabinet Secretary In November 2003 Cabinet reorganized first response scheme of the government, integrating different response schemes for different risks and threats. In case of a major incident, Emergency Assembly Team Assessment of Scale of Incident Is made on following criteria: -Severity -Range of Effect -Availability of Countermeasures -Elucidation Status of Causes (members are responsible persons of relevant agencies) are convened.

First Response Scheme to Major Incidents Incident Press Cabinet Intelligence & Research Office Situation Center (24h/day) Assembling member Public/private sector report Ministries report - Deputy CCS for Crisis Management - Assistant CCS for National Security and Crisis Management - Cabinet Councilor for Crisis Management Report/instruction Crisis Management Center Prime Minister Chief Cabinet Secretary (CCS) Deputy CCS Report/instruction If necessary to collect information & coordinate consultation to emergency incidents Consequence Management Office Dispatch members ministries Emergency Assembly Team Special Advisory Committee for Contingency Planning National Security Council (in case of an emergency response situation ) Consequence Management Headquarter (Prime Minister may establish CMHQ.) Cabinet Meeting Recognize emergency response situation Emergency Response Policies Task Force for Emergency Response Situation

Each phases for Health Security Prevention (Prophylaxis) International cooperation Intelligence CIQ Under the Cabinet Office event Early Detection (Checkups) Response (Treatment) Lifestyle (e.g. No smoking) Surveillance Local response Routine Examination Control of terrorists/agents Disaster Management Intensive Care, Surgery, etc Simultaneously collaborated National response Police Self Defense Force Intelligence, Embassies Coast Guard (MILT) Nuclear Powerplant (MEXT) Medical response (MHLW) Immigration (MOJ) Mitigation (Rehabilitation) Medical and health care Reconstruction Outpatient Follow-up Quarantine (MHLW & MAFF) Custom (MOF)

1. Public health emergency 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.

Damage by the Great East Japan Earthquake at 14:46 on March 11 th, 2011 North American Plate (As of December 25 th, 2012 by Cabinet Office) Human Suffering Death 15,878 Missing 2,713 Wounded 6,126 Eurasian Plate Philippine Plate March 11 th Epicenter Pacific Plate Housing Damage Total Collapse 129,724 Half Collapse 267,663 Partial Collapse 731,673 Sufferers Evacuees 321,433 Rescued victims 27,157 Total Damaged Property (As of June 24 th, 2011 by Cabinet Office) $210 billion

Characteristics of 3/11 Disaster The 4 th largest earthquake in the history (Mw 9.0) Followed by numerous aftershocks (>M7.0, 6 times; >M6.0, 93 times; >M5.0, 560 times) Huge tsunami Wetted surface: 561 km 2 13

http://www.coastal.jp/tsunami2011/ 14

morioka-times 15

http://www.coastal.jp/ 16

10 m-high 2km-long Tsunami Barrier Taroumachi, Miyako City Tsunami Evacuation Area 17

Characteristics of 3/11 Disaster The reality far exceeded the anticipated scenario Great East- Japan 2011 Anticipated Scenario Mw Wetted Surface Area Dead & Missing Destroyed houses 9.0 561 km 2 >17,000 >120,000 8.6 270 km 2 2,700 9,400 18

Characteristics of 3/11 Disaster Many municipal office had a destructive damage; lost their functions. Town Mayor and many executives died by Tsunami during the emergency meeting at Otsuchi Town Municipal Office Building, Iwate Prefecture http://www.city.anjo.aichi.jp/mayor/message/2011/07.html 19

Nuclear Power Stations Nuclear Reactors near Epicenter of the Earthquake 4 Nuclear Power Stations with 14 Units Onagawa Unit 1 524 MW, 1984- Unit 2 825 MW, 1995- Unit 3 825 MW, 2002- Fukushima Dai-ichi Unit 1 460 MW, 1971- Unit 2 784 MW, 1974- Unit 3 784 MW, 1976- Unit 4 784 MW, 1978- Unit 5 784 MW, 1978- Unit 6 1,100 MW, 1979- Fukushima Dai-ni Unit 1 1,100 MW, 1982- Unit 2 1,100 MW, 1984- Unit 3 1,100 MW, 1985- Unit 4 1,100 MW, 1987- Tokai Dai-ni Unit 1 1,100 MW, 1978- automatic shut down Periodical inspection cold shut down

Earthquake and Tsunami hit the Nuclear Power Plant Fukushima Dai-ichi NPP Epicenter Source: www.tepco.co.jp The height of tsunami which attacked Fukushima NPP#1 was higher than 15 m The earthquake and tsunami destroyed the external power supply of the nuclear reactors. The prime minister declared the nuclear emergency at 19:03 on March 11 th. Fukushima Dai-ni NPP Source: www.tepco.co.jp 21

Combined Disaster This is the first time that the world has experienced such a complex emergency involving earthquake, tsunami and nuclear accident. High tide Flood Heavy snowfall Heavy rain Storm Earthquake Disasters Tsunami Volcano eruption Other natural phenomenon Fire or wildfire Explosion Release of Radiation Ship accident Others (train, plane)

What happened in Tokyo? Tokyo 23

Stranded Commuters 24

Do you poo more than usual due to the earthquake? 26

Rolling Blackouts 27

MHLW s Response 14:46, March 11 th M9.0 Earthquake hit in Sanriku offshore 14:50, March 11 th Disaster Response HQ of MHLW was set up 09:00, March 12 th Local Disaster Response HQ of MHLW was set up in 3 prefectures (Miyagi, Iwate, Fukushima)

MHLW s Response Rescue and Relief Dispatched 340 teams (1,500 members) of Disaster Medical Assistant Team (DMAT) from March 11 th to 22 nd DMAT engaged in medical relief operations such as hospital support, transfer of patients within the area, wide-area medical transport and transfer of hospitalized patients. 29

Damage at hospitals and clinics in the affected areas Prefecture Number of hospitals Damage by the Great East Japan Earthquake Completely destroyed Partially destroyed Iwate 94 3 59 Miyagi 147 5 123 Fukushima 139 2 108 Total 380 10 (2.6%) 290 (76%) Number of clinics Damage by the Great East Japan Earthquake Prefecture Medical Dental Completely destroyed Partially destroyed Medical Dental Medical Dental Iwate 927 613 38 46 76 79 Miyagi 1,626 1,065 43 32 581 367 Fukushima 1,483 919 2 5 516 374 Total 4,036 2,597 83 (2%) 83 (3.2%) 1,173 (29%) 820 (32%) (as of 11 July, 2011)

MHLW s Response Coordination of dispatching healthcare professionals such as 2,662 Medical Assistance Teams From Japan Medical Association, etc. 1,394 Nurses 1,915 Pharmacists ~2,900 dentists 11,255 Public Health Practitioners 57 Mental Healthcare Teams Psychiatrists and Nurses A meeting of a medical team

MHLW s Response Securing Pharmaceutical Supply Assisting nation-wide procurement Assisting logistics of drug whole-salers and distributors priority supply of gas and emergency pass for vehicles which carries pharmaceutical supplies were granted Self Defence Forces and US military Helicopters were used for shipping 32

Other MHLW s Roles Nursing care and welfare services Health Insurance System/Pension Employment Provisional Housing Water supply Food and Water Safety

2. Mechanisms for Health risk management and coordination in MHLW 34

Establishment of Health Risk Management Framework in MHLW Triggered by HIV-tainted blood scandal in 1980 s More than 1,800 haemophilia patients contracted HIV via tainted blood products A Review Report by the Project Team for Preventing a Recurrence of Medication-related Health Disaster (July 1 st, 1996) pointed out the importance of sharing health risk information and early alerting and response to prevent such a health risk event. Memorial stone

Establishment of Health Risk Management Framework in MHLW Basic Guideline for Health Risk Management in MHLW (January, 1997) Office of Public Health Emergency Preparedness and Response was established To enhance sharing information on health risk event among relevant departments and coordinate response in MHLW, Health Crisis Management Coordination Meeting was established.

Health Risk Management in MHLW Operations for prevention, mitigation, and medical countermeasures for threats and risks for public health caused by medication, food poisoning, infectious diseases, drinking water and other causes Basic Guideline for Health Risk Management in MHLW (January, 1997) 37

Health Risk Management Coordination Meeting A key platform for information sharing, risk assessment and coordination of managing health risk event Bimonthly (2 nd & 4 th Friday) Regular Meeting for information sharing and consulting Agenda Drug-related incidence, Food Safety, Outbreaks, Nosocomial infections, Natural Disasters, Medical incident report, &etc. (e.g. missile launch by North Korea etc.) May hold a provisional meeting for initial risk assessment and response when a potential health hazard was recognized.

Guidelines and Manuals for Health Risk Management National level Basic Guideline for Health Risk Management Health Risk Management Manuals in each department responsible for Drugs/ Infectious Diseases/ Drinking water/ Food poisoning Public health research institutes (e.g. NIID) MHLW s local branch Local level A guideline for Health Risk Management at the local level

Public Health Risk Management in MHLW Information on Domestic/International Health Risk Local Health Center Hospitals Local Government Regional Bureau Relevant Org overseas National Research Institutes NIID/NIPH/NIHS, etc Scientists Relevant Divisions e.g. Safety Division, Pharmaceutical and Food Safety Bureau (Drug Adverse Events), TB and Infectious Diseases Control Division (Infectious Diseases), Water Supply Division (Drinking Water), etc. Office of Public Health Emergency Preparedness and Response (Information Gathering and Analysis, Early Phase Response, Planning and Implementation of Training) Coordination Regular/Provisional Health Crisis Management Coordination Meeting Sharing Info, Coordinating Response & Intervention HQ Command Report Request for Response Report Coordination Command Report Offices responsible for Health Crisis Implementation of Response & Intervention Minister (& Vice Minister) of MHLW, etc. Information Sharing Information Sharing Cooperation Health Crisis Management Committee Relevant Org. e.g. Cabinet Secretariat Consultation Public./ Local Health Center/ Hospitals/ Local Government/ Regional Bureau/ National Research Institutes/ Relevant Org Overseas, etc.

Health risk information report from research projects funded by MHLW Health Risk Info Grading by investigators A:Critical B:Calling for attention C:Reference Assessment by relevant departments and experts Health Risk Management Coordination Meeting Response Feedback to Investigators

IHR Core Capacity Implementation ~ IHR NFP Function in MHLW ~

Implementation of revised IHR IHR(2005) Is an international agreement which is legally binding on all WHO Member States. Was adopted at the 58 th WHA in 2005. Has come into force on 15 June 2007 replacing the previous IHR(1969).

The purpose of the IHR(2005) prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade. (Article 2) take all measures to prevent international spread of disease.

The major changes in the IHR(2005) 1 Broader scope Public Health Emergency of International Concern (PHEIC) PHEIC is an extraordinary event: i. to constitute a public health risk to other States through the international spread of disease and ii. to potentially require a coordinated international response. Disease means an illness or medical condition, irrespective of origin or source, that presents or could present significant harm to humans.

The broadened scope of the IHR covers existing, new and re-emerging diseases, including emergencies caused by non-infectious disease agents.

The major changes in the IHR(2005) 2 Notification - mandatory notification of any event to WHO that may constitute a PHEIC within 24 hours assessment of public health information i. Use of the decision instrument (Annex 2) ii. Notify within 24hours of assessment of all event that may constitute a PHEIC (Article 6) iii. Continue to communicate with WHO including case definitions, laboratory results, source and type of the risk, number of cases and deaths, conditions affecting the spread of the diseases, health measures employed (Article 6)

Decision Instrument (Annex2) Assess the event whether to notify the WHO based on the following points 1 public health impact serious? 2 unusual or unexpected? 3 risk of international spread? 4 risk of travel/trade restriction? * A case of the following diseases shall be notified: Smallpox, Poliomyelitis due to wildtype poliovirus, Human influenza caused by a new subtype, SARS.

The major changes in the IHR(2005) 3 National IHR Focal Points (Article 4 ) - be accessible at all times 4 Definition of core capacities (Annex 1) - strengthen and maintain the capacity to detect, report and respond rapidly to public health events. 5 Recommended measures (Article 15-18) - make every effort to implement WHOrecommended measures 6 External advice regarding the IHR (Article 48-49)

NFP Functions under IHR (2005) National PHE command & response structure Senior Management Relevant depts/agencies Surveillance & response POE Food safety authority MoA Others NFP (24/7) Functions within the country Consolidating info Disseminating info WHO (24/7) Functions (with WHO): Consultation Notification of a potential PHEIC Information sharing Other reports Verification Determination of a PHEIC Coordinated response to a PHEIC 50

Flow of Information Based on the Revised IHR(2005) A Country B Country C country D country Member Countries WHO Emergency Committee Certifying Public Health Emergency of International Concern. WHO IHR Contact Point IHR Secretariat Provision of information Notice Consultation MHLW Health Risk Management Coordination Meeting Focal Point of Japan (Health Science Division, MHLW ) Tuberculosis and Infectious Disease Control Division Evaluation of the potential event which may fulfill the component of "Public Health Emergency of International Concern. Food Safety Division Surveillance Community Health Division Local information gathering Health Risk Management Committee Quarantine Operations and Management Division Other Health Risk Management Divisions Transmission of the information Domestic relevant organization, ministries and agencies etc. Information gathering

NFP of Japan s activities Notification of PHEIC to WHO A/H1N1(2009)pdm First case at quarantine (May 9 th, 2009) Identification of Tamiflu-resistant strain (July 3 rd, 2009) Nuclear Power Plant accident after March 11 th Earthquake and Tsunami in 2011 Disseminating information to relevant sectors recommendation from WHO DG Information on the Event Information Site Exchanging information with other NFPs Notification of patient/close contacts with patient among travelers (e.g. Measles, TB, Shigellosis) Inquiring WHO for health emergency event in other countries