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Tokyo 2020 Olympic & Paralympic Games: mass gatherings and disease outbreak prevention

Preparations for the 2020 Olympic and Paralympic Games in Tokyo are well underway in Japan. But mass gatherings of this magnitude present significant public health challenges of their own. In this Infectious Thoughts interview, we hear more from Dr. Naoki Yanagisawa (Harvard T.H. Chan School of Public Health and Japan's National Center for Global Health and Medicine) and Dr. Koji Wada (International University of Health and Welfare) about their views on risk assessment of infectious diseases for the Tokyo 2020 Games.

Japan and, in particular, the city of Tokyo is preparing to host in 2020 one of the world's most exciting events, the Tokyo Olympic and Paralympic Games. Outbreaks of emergent or resurgent diseases, including vector-borne diseases such as dengue are rapidly spreading - there have been recent cases reported in Spain and France for example. In your opinion, is there sufficient surveillance of diseases such as dengue fever and is there sufficient awareness at both the public and institutional level of this threat? Is this something being considered actively by the Organizing Committee?

A dengue fever outbreak unexpectedly occurred in the summer of 2014, which was the first time in 70 years that Japan had experienced autochthonous transmission. This has certainly raised awareness at both the public and institutional level about dengue. As we mentioned in our recent article3), we believe that the current controls for dengue detection which include guidelines and services to update both physicians and travelers on infections are robust. However, continuous efforts are needed to maintain awareness of dengue and strengthening the capacity of infectious disease control. Furthermore, increasing the awareness of other vector-borne diseases such as Zika and chikungunya remains a challenge. An outbreak of these diseases has not been recognized in Japan to date; therefore, physicians have limited clinical experience.

What are some of the main variables (such as weather, traveler flow...) which could affect public health in the mass gathering for Tokyo 2020?

We have summarized the potential health risks and precautions for visitors to the Tokyo 2020 Olympic and Paralympic Games in an article published previously this year 1). To highlight some of the key points, we believe that measles and rubella would continue to be a major concern. Even though Japan eliminated measles in 2015, imported cases are still being reported (35 cases in 2015, 159 cases in 2016). Between 2012 and 2014, Japan experienced a nationwide rubella epidemic with approximately 14,000 cases and 45 congenital rubella syndromes being reported during the outbreak. Currently, the number of rubella cases in Japan is sharply increasing, and the Center for Disease Control on Prevention has just issued a travel health notice (Alert level 2) on October 22, 20182). Apart from infectious diseases, heat-related illness represents a potential risk not only for the athletes but also for the event staffs, volunteers and spectators. The Tokyo Olympic and Paralympic Games is scheduled during the hottest season in Japan with temperatures generally expected to exceed 30 °C.

What do you foresee as being some of the main public health challenges, given the large number of guests and nationalities attending?

The following would be some of the main public health challenges in mass gatherings: • Introduction of a new or non-endemic infectious disease • Health systems are stretched and may strain the existing surveillance systems • Risk communication. Political/media interest and rumors may magnify anything negative. • Multisectoral approach is essential to mitigate the risks

The number of annual visitors to Japan is increasing sharply (6.2 million in 2011 to 24.0 million in 2016). Furthermore, the Japanese government currently aims to increase the number of inbound visitors up to 40 million per year by 2020. Therefore, the potential risks are already on the rise in Japan.

From a public health perspective, what recommendations would you make on how the international community can best prepare for this event - whether as an attendee, an organizer, the WHO...?

Maintaining an up-to-date routine vaccination schedule is highly recommended for visitors attending the Tokyo 2020 and appropriate hygiene measures for food and waterborne diseases as well as health promotion for heat-related illness. It may also be useful to increase the number of multilingual triage clinicians whom can be placed within emergency departments during the Tokyo 2020 to provide first contact services and coordination of emergency care among non-Japanese speaking visitors to Tokyo.

Mass gatherings such as the Olympics, religious pilgrimages, cultural events offer an excellent platform to reach individuals from a large cross section of countries and there is a big potential to share information which can also be taken home with participants - what could be done to increase the opportunities for sharing important and international public health messages?

It is important to capture the lessons learned from previous experiences from different countries. These lessons should be applied and tested thoroughly in the context of the country’s existing systems before facing the real mass gathering event.

How can your research, which has focused particularly on the Tokyo 2020 Olympics, improve global understanding of other mass gatherings and what lessons can be applied elsewhere?

Our research used the failure mode and effects analysis (FMEA) to test the vulnerability and resiliency of Japan’s current preparedness plans and design ways to strengthen those plans for dengue. However, we believe that this framework could be expanded and tailored to other diseases or mass gatherings as well.

1) Nakamura S, Wada K, Yanagisawa N, Smith DR. Health risks and precautions for visitors to the Tokyo 2020 Olympic and Paralympic Games. Travel Med Infect Dis. 2018 Mar - Apr;22:3-7.

2) Center for Disease Control and Prevention. Rubella in Japan., Accessed Oct 25, 2018.

3) Yanagisawa N, Wada K, Spengler JD, Sanchez-Pina R. Health preparedness plan for dengue detection during the 2020 summer Olympic and Paralympic games in Tokyo. PLoS Negl Trop Dis. 2018 Sep 20;12(9):e0006755.


About Dr. Naoki Yanagisawa, MD, PhD, MPH

Naoki Yanagisawa is a visiting scientist at the Department of Environmental Health, Harvard T.H. Chan School of Public Health and a medical officer at the Bureau of International Health Cooperation, National Center for Global Health and Medicine in Japan. His research interests are in assessing the role of tourism and climate change on vector-borne diseases and to create preparedness plans for mass gathering events. Naoki received a MPH Degree from the Harvard T.H. Chan School of Public Health. He previously received a PhD degree from Tokyo Women’s Medical University and a MD degree from Chiba University in Japan. Naoki is certified as a Fellow of American College of Physicians (FACP), Infectious Disease Society of America (FIDSA).

About Dr. Koji Wada MD, MSc, PhD

Koji Wada has been working as a professor, Department of Public Health, Faculty of Medicine and Graduate School of Public Health, International University of Health and Welfare(IUHW) since April 2018. He worked for the JICA Project for Improvement of Hospital Management Competency in Cho Ray Hospital in Vietnam as the chief advisor from 2017 to 2018. He had also worked in Myanmar as the advisor for HIV in 2014. Dr. Wada has numerous scientific publications, including authorship of risk assessment of infectious diseases for Tokyo 2020 Olympic and Paralympic Games. He has received several noteworthy awards by the Japan Medical Association, the Japanese Society of Public Health, and the Japan Society of Occupational Health.

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