Why Japan has so “few” Covid-19 cases

Coronavirus Japan. An opinion piece on why Japan has so few Covid cases from a long term resident of Japan. I have been living in Japan for 20 years, permanently since 2006. I was here after the triple disaster of March 11th 2011, which gave insight into how Japan handles crises. However, I have no medical or scientific training or background. This is my two cents on why Japan has relatively few Covid-19 cases. Including seasonal and cultural influences, Government policies and actions, masks and B.C.G.

Coronavirus Japan

On Friday March 20th 2020 Japan’s confirmed number of Coronavirus cases exceeded 1000 people for the first time. A number exceptionally low considering that Japan was one of the first places to record a case outside of China as early as January 16th (January 14th also has been reported).

You would think given that parts of Japan are so densely populated and our proximity to China, plus the numbers of Chinese tourists that visited Japan during Chinese New Year, that Japan would have seen an explosion of Covid-19 cases by now. We haven’t, but we will very shortly, and here is the why to both…

Why Japan has so few Covid-19 cases

Why does Japan have so few Covid-19 cases?

There are multiple layers to why Japan currently seems to have such relatively few Coronavirus cases. They include testing policies, outbreak cluster control, self-quarantine, seasonal influences, mannerisms and Government measures. There is a possibility too that a long term national B.C.G vaccination policy is also contributing.

  • Testing and outbreak clusters
  • Hay fever and flu season
  • Mannerisms and self-quarantine
  • Curtailment measures
  • A national BCG vaccination policy**

    **The BCG theory was added on April 4th further to increasing support of the possibility the B.C.G vaccine is affording some protection.

Testing and outbreak clusters

If you haven’t heard by now: Japan is not testing the way other countries are. Despite having the capacity to test around 6000 people a day, they had only tested 37,726 people in total between February 18th and March 19th 2020. (Source: Kyodo News, March 22nd)

Japan coronavirus testing

At first I was extremely frustrated and annoyed that Japan was not testing. And I would like to see them testing more. However, I can see some of the benefits of Japan’s approach to date, but unfortunately this can no longer be sustained as, I believe, Japan’s figures are about to multiply in the coming days. (See Why Japan is about to have an increase in Covid-19 Cases below).

In order to get tested in Japan you need to have a had a fever for five days or more. You can’t just rock up to any hospital and request a test. First you have to ring the designated coronavirus management center in your area. They will take your history and details. If you have had a fever and other symptoms for five days, and / or have been in close contact with someone who has had the novel coronavirus or who has traveled to regions where there is a high prevalence of Covid-19, they will come for you in a hazmat suit. Otherwise, they will tell you to self isolate and record the progress of your symptoms.

The benefit this has had to date is that regular hospitals and clinics have been protected, for the most part, from infected patients. They also have not been inundated and can go about regular practice. It also succeeds in keeping sick people home long enough to determine without a test if they have something other than Covid-19. Furthermore, it has kept panic at bay.

Other countries are placing a great emphasis on testing. As I said above, I wish that Japan would test more. However, testing alone will not magically curb the spread. Japan has been focusing on identifying outbreak clusters. But of course the fear is that there are other clusters they haven’t identified. Mass testing avoids that, but it also creates fear especially as the figures are often given out of context. On the flip side, under testing has created a risky level of complacency.

Hay fever and flu season

Japan had a warmer than normal winter. I have only suffered from hay fever for four years, but I get it quite bad now. However, this was the first time I was effected by hay fever as early as January. And I wasn’t the only one. Due to the warmer than normal winter many of us started taking antihistamine and/or hay fever medication from late January. (And I have wondered if by any chance antihistamine might unknowingly been giving us some protection from Covid19?)

Also, as it was flu season hand sanitizer was posted at the entrance way to most shops and restaurants as is customary here every winter. Those who weren’t wearing masks for hay fever were wearing them as a precautionary step against catching the flu.

Masks

Coronavirus Japan why does Japan have so few Covid-19 cases

Prior to Covid, I personally had never worn a mask to prevent illnesses, but it is a common preventative measure here. I do wear masks when the pollen levels are high. And I do wear a mask now to prevent covid. Due to the early onset of hay fever this year, and as it was flu season, a large percentage of the Japanese population were wearing masks in January and February.

Coronavirus Japan masks B.C.G
Original graph by J Perla | How to change global policy | Buy a mask (I have no affiliation to these websites)
Taken from “Masks Save Lives” website.

Masks in my humble opinion are useful in helping to curb the spread. As the World Health Organization (WHO) themselves said; many people are asymptomatic. So they are carrying and spread the virus without ever showing signs of having the virus themselves. Similarly, they have told us that most likely people are contagious before they show the symptoms of the virus. So by wearing masks you are less likely to spread the virus if you have it unknowingly.

Mannerisms

As you know in Japan we bow rather than shake hands, hug or kiss. While this in itself is not enough to curtail the spread of the novel coronavirus there is a chance it has helped in slowing and/or reducing the spread.

The cases from the Princess Diamond and people repatriating from China in the early days were asked to self-quarantine. For the most part people were co-operative and adhered to self isolation without policing. There were of course exceptions.

Curtailment measures

Prime Minister Abe came under a lot of criticism for how he initially managed the outbreak. Then on Thursday February 27th he did a 180 and surprised the nation by introducing additional curtailment measures. On the 20th they had started the ball rolling by requesting events that attract more than 500 participants a day be either postponed or cancelled.

A very good analogy regarding herd immunity and controlling an outbreak came out of England. Think of a sink with several taps. If all taps are turned on full blast at once it doesn’t take long for the sink to fill up, overflow even. But if the flow of the taps is controlled, particularly with some turned off, it takes longer for the sink to fill or overflow.

On February 27th Abe gave the word to turn off several taps! By requesting schools finish up for the school year (which ends at the end of March in Japan) by March 2nd, he essentially turned off several taps. By closing down museums, amusement parks, zoos and other tourist attractions he turned off several more. (See places effected by the Covid-19 closures in Saitama Prefecture.) I personally believe that Abe and the Government were trying to buy time to get things in place for the surge in numbers that is yet to come.

Added on April 4th – B.C.G Vaccine

I was reluctant to add the information about the B.C.G when I initially wrote this article on Coronavirus Japan on March 21st. Although several reputable scientific magazines and media outlets had picked up on it, there still wasn’t enough “evidence” to support the theory. Which suggests that countries, such as Japan, that have had a long term nation wide B.C.G vaccination program have fewer per capita COVID cases.

There is mounting support across the global scientific world as we get a better picture of the figures of Covid-19 in dozens of countries, that there may indeed be some protection afforded by the B.C.G vaccine. To the point that both Australia and the Netherlands are currently conducting B.C.G trials with health workers. (Source: University of Melbourne and Sciencemag.org).

CountryNational BCG ProgramDate of
1st COVID case
Cases Per MillionDeaths
Per Million
April 4th
Deaths Per Million May 4th
JapanLong termJanuary 16th230.54
ChinaLong termDecember *Disputed 5723
TaiwanLong termJanuary 21st150.20.3
ItalyNeverJanuary 31st1982243478
BelgiumNeverFebruary 4th1590111677
AmericaNeverJanuary 20th83822207
SpainStopped in 1981January 31st2,668251540
UKStopped in 2005January 29th56253419
AustraliaStopped in 1991January 25th21814
insaitama.com April 4th 2020, Deaths Per million updated May 4th 2020
Compiled from: Worldometer and BCG World Atlas
and media sources (1st case dates)

Further reading on the link between B.C.G and coronavirus provided at the bottom of the article.

Why Japan is about to have an increase in Covid-19 cases

Even if there is protection from the B.C.G vaccine, there is no way that Japan is completely immune from this viral outbreak. Abe and the powers that be know that. In my humble opinion, by slowing down the spread in early March, they bought sometime to get things in order for an upsurge in numbers, which I personally believe will be seen in the next week or two. Because on Friday 20th of March several taps were turned back on simultaneously.

Pick up: Self-quarantine

Japan are now asking tourists from dozens of countries to self quarantine for two weeks after arriving in Japan. They are also asking them not to use public transport. Source: Japan Times.

Back to school

In a press conference late on Thursday March 19th a representative of a panel of experts announced that schools could choose to start back at their own discretion. They asked that events remain cancelled for the meantime, and that people refrain from picnicking under the cherry blossom trees, but other than that they insinuated that life can go back to normal.

Back to normal

On Friday March 20th, the start of a three day weekend in Japan, life sure enough did go back to normal. People who had been cooped up at home for the past two to three weeks, welcomed the opportunity to get out and about again. Images of full shopping streets and lines at restaurants dominate social media. In my own area, on a drive to a remote nature spot, we passed a mall that had queues of cars to get in and out of the parking lots. We witnessed sleepy rural towns bustling with tourists and people sharing food in close proximity to each other.

In effect, since March 20th people are no longer isolating themselves at home, people are not practicing social distancing, and for all intents and purposes life seems to have gone back to normal. So unless there is something preventative in the antihistamine and hay fever medication around 20% of Japan’s population is currently on, it only makes sense that this sudden return to proximity of people will lead to a surge in the Covid-19 cases in Japan within the next week or two.

In summation

I personally believe that the measures Japan took bought us sometime. I think Abe chose to cancel events and close schools in order to do that, but he knows we can’t evade this virus forever. And so now that they’ve done what they can to prepare, they are actually encouraging the spread by letting people go back to normal.

The approach Japan has taken seems similar to the controlling measures of herd immunity. Regardless of the real motivation and reasons behind the approach Japan has taken, the lifting of restrictions on March 19th is no doubt going to have a knock on effect. And I have absolutely no doubt we are going to see a surge in covid-19 numbers in Japan in the next week or two.

April 4th update: the numbers started to rise in Japan from March 24th. They continue to rise daily, however, the increase is nothing like what we have seen in other countries which some scientists attribute to the long term national B.C.G vaccination program in Japan.

Further Reading – B.C.G

Science Mag, March 23rd 2020 – Can a century-old TB vaccine steel the immune system against the new coronavirus?

University of Melbourne, March 27th 2020 – Preventative vaccine trial for COVID-19 health workers.

Murdoch Children’s Research Institute, March 27th 2020 – Murdoch Children’s Research Institute to trial preventative vaccine for COVID-19 healthcare workers.

MedRxiv, March 24th 2020 – Correlation between universal BCG vaccination policy and reduced morbidity and mortality for COVID-19: an epidemiological study.

New York Times, April 3rd 2020 – A tuberculosis vaccine invented a century ago is cheap and safe, and seems to bolster the body’s immune system.

Euractiv, April 1st 2020 – The Brief – Is Eastern Europe more resilient to COVID-19?

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35 comments on “Why Japan has so “few” Covid-19 cases

  1. AndysWorldJourneys

    interesting. the thing about testing is, you cant count as a someone with the virus if it hasnt been confirmed and to confirm it, you need to be tested. So generally worldwide we are not seeing the true numbers of people with the virus. With only 37000 tested in Japan, the number of actual cases is likely to be CONSIDERABLY more. Masks apparently do not stop you from getting it. although they may help if you have it from spreading to others to a certain extent. Japan is a pretty sterile country and i remember hand santiser in so many places when I was there where it isnt normally found in other countries – at many places where social events are held for examples, EVERYWHERE in schools, and students (and teachers) use it because there is such an emphasis. so that probably helps, clean habits are ingrained in the psyche. I wish the same could be said here and elsewhere.
    \take care through this crisis Australia is slowly moving to lockdown – Victoria (State where I live) is going to a much stricter lockdown as of Tuesday because people have not been following the guidelines. its all going to get a lot worse before it gets better

    Reply
    1. L M N

      I totally agree. I think we can never possibly know the true numbers. Even in China I suspect the numbers are higher for the reason you stated: the whole population was not tested. And the same thing is happening in Japan. South Korea are trying their best to test as many as possible. What I would like to know but don’t is what percentage of people who were tested were negative. I can deduce it for Japan, but actually its not accurate because some people have been tested multiple times. There have even been in two cases in Japan were people had it, were released from hospital after 3 weeks after testing negative twice in 24 hours and ten days later tested positive again. One of them has subsequently died. 🙁

      We will just never truly know. But of course testing gives us a better indication and I do truly wish japan would test more.

      As for masks – they tell us they are not effective, but then why do medical staff wear them? That is a can of worms I really don’t want to open, but I agree that they are not completely effective for preventing you from getting it, but I do think they can help limit the spread.

      Thanks a million Andy.

      Reply
  2. Anika

    I agree. I also believe we will see an increase of case in one to two weeks.
    However, specialists advise to let the infections come in waves by restricting life, loosening it, and then restricting it again.
    I think that this is what we will see in Japan.
    Meanwhile I hope that it will be easier in the future to get the antibody-test to see if our common cold already was Covid-19. It would be so nice to know..
    At the moment we don’t know if the cough and sore throat is coming from hay fever or not😅

    Reply
    1. L M N

      Thank you for commenting Anika. That would be great if we could see in the future if we already had Covid-19, it would certainly bring some peace of mind especially if it turns out we had it without being sick from it. I didn’t know about the waves, I really like that idea and somehow find it comforting actually, that maybe Japan is on top of it and executing a plan that will be for the greater good. I really appreciate your thoughts <3

      Reply
  3. Helen

    I hope you and your family will all be fine. Seems that Japan has been taking a somewhat similar approach to Britain. I have no idea if this is a positive thing but it makes a change to read about other perspectives.

    Reply
    1. L M N

      Hi Helen, thank you. Likewise I hope you are all well. I check in on your blog – and garden 😊- from time to time, delighted to see your still blogging too.
      I have noticed the similarities between the UK and Japan too. Our PMs had a good chat about it supposedly. The big difference is transparency in Britain. I think its good that Japan and the Uk are taking a different approach, and Korea a separate one too… we won’t know for sometime yet which is most effective but I think its risque for all countries to do the exact same thing – sorry I’m not very articulate first thing in the morning!!

      Reply
  4. Krysten Quiles

    Very interesting. I think, though, that we’ll never know the real numbers because tests just aren’t available. Here in the US one of my coworkers had all the symptoms of covid. Her doctor gave her the authorization to be tested, but the test was apparently “lost”. If she DID have it, she infected everyone she works with, myself including. And we’re all still working, which means we infected people and so on. It’s a damn mess.

    Reply
    1. Elle Post author

      It really is a mess 🙁 I am sorry to hear that you may have been exposed. We’ve had cases of people here who have all the symptoms, but tested negative. Their Doctors have told them they have it, but they won’t go on the official numbers because they tested negative for it. 🙁 It will be months, maybe even years, before we get a clearer picture of exactly how many people had it. Unfortunately and so so sadly the number of deaths give a clearer picture at this time, but I have my suspicions that some deaths for Japan are currently registered as “pneumonia” rather than Covid but I expect / hope with time that will all be cleared up. Sorry to talk of death as statistics. Its all so sad. I hope you don’t catch it and can stay safe.

      Reply
  5. Tee

    Very interesting read. I’ve pretty much thought that it will be hard for any country to know the true number of cases. And currently over her in the UK the number roust keeps increase and it’s scary. Stay safe with your family x

    Reply
    1. Elle Post author

      I totally agree with you. We may never know, but hopefully in a few months or a year or two they will be better able to estimate truer figures. Thank you Tee and you stay safe with your family too x

      Reply
  6. Anne Marie

    I think it’s wise that countries around the world are not applying a “one size fits all” approach because situations and populations are different. Thanks for sharing your experiences in Japan!

    Reply
    1. Elle Post author

      Absolutely. And we need to have tested a few different methods so we can see what is most effective and where. Thank you Anne Marie.

      Reply
  7. World In Eyes

    Still the situation is not in control around the globe, as per “worldometers” report corona is affecting around the world and number are increasing every day, In the Japan total 42,882 tests has been conducted till date and confirmed cases are 3,139 which is about 25 cases/1Mil Population. The percentage is not showing better situation but Japan is very famous by technology (here in my region and er prefer made in japan brands). Japan can control on it and will reduce cases of COVID-19. Your research based article is showing very much better situation. We pray for your safety and better health. Keep it up good work.

    Reply
    1. Elle Post author

      Thank you very much for your kind words and encouraging support. I don’t know if it is an illusion that Japan has a better situation – we may never know the exact truth – but personally I still do not know of even one suspected case in my “real life” friends and family here in Japan. And in my online world of friends / online networks I still only know of one confirmed case and one suspected one. We all have to remain cautious and vigilant and do our bit to contain curtailment. I truly appreciate your comment and I too pray for your safety and health.

      Reply
  8. Nyxinked

    It’s good to see other countries taking a different approach. The UK certainly hasn’t handled this very well, especially not at the beginning, so it’s a relief to see other countries doing better.

    Reply
    1. Elle Post author

      I think we may be the opposite – they handled it well near the beginning (not the very beginning though) and now they aren’t handling it all. Numbers jumped up today, unfortunately I fear they are going to keep spiking. Meanwhile it seems like the UK has a better grip on it how (please God). I guess it was just so new and unprecedented that nobody really knew what to do and all they could try was what they thought might work. But only time will tell. Its just so so sad. There is a nurses teacher I love and watch from the UK “Doctor John Campbell” on Youtube, he’s been great at keeping me calm. Have you seen any of his stuff? Take care, I hope you and your family can evade it.

      Reply
  9. Hang Around The World

    This is an informative reading! This situation affects everyone, some more and some less. But if we do our best, things will be fine. – Paolo

    Reply
  10. Kelly

    I figured Japan had a better social practices than we do in America just because of how you greet each other, and the common practice of wearing masks. I am curious to see if you are right in your thinking. I hope you are not. But, I do believe, all countries will continue to see cases until we are able to get a vaccine and a antidote. Thank you for your thought provoking article.

    Reply
  11. Cris

    This is all very interesting. I think Japan’s cultural norms – bowing, following instructions without question, etc – have helped, as you stated. In the US, we’re quite the opposite – very touchy-feely and not happy about being told what to do, even if it is in our best interests! So many places now have had to close because people wouldn’t listen to social distancing guidelines.

    We are now also not testing as readily because there simply aren’t enough tests. A friend had was exposed via someone else, started feeling ill a few days later, and couldn’t request to be tested until he had been sick for 4 days. It then took another 2 days for his appointment. By that time, he was feeling better.

    Reply
  12. Marie

    It is so hard to know what is actually effective. And the numbers can be so different than in reality. I do hope that we can all do what we need to in order to allow it to end as quickly as possible.

    Reply
  13. littlemisadvencha

    I always love Japan as a whole. <3 I believe that discipline is indeed the key to control the spread. Japanese people are number one in discipline, I believe. This I can attest.

    Reply
  14. Britt | Shed Happens (@ShedHappenscmty)

    The testing process here in Canada sounds similar to what you have described. You aren’t supposed to visit your local hospital – instead you call it in and it’s determined if you qualify for testing. In the beginning, you had to have been out of the country recently and be showing signs. Now that it has been here long enough, I believe they have dropped the out of country requirement, but you still need to show signs for testing. There have been some exceptions made, but the general rule stands. In our case, it’s simply the fact that there aren’t enough tests to support testing everyone who believes they need to have it done.

    Reply
    1. Elle Post author

      It does sound very similar. And likewise, initially you had to have been out of the country and/or in close (like the same house) contact as someone who had it. They have loosened that a little, but they don’t test the majority of suspected cases until they’ve had symptoms for five days (unless from the get go they seem critical). I hope you and your family can evade it. I pray daily for a cure and vaccine and that we all do our bit to curb the spread and protect the vulnerable. What strange times we live in. “This too shall pass” is my daily mantra!

      Reply
  15. kcarr125

    This is an interesting read. Living in the United States in like to read how other countries are handling the virus. Thanks for this input

    Reply
  16. Lyosha Varezhkina

    very interesting read. I think Japan’s discipline is what works aside good health care. In Russia testing is have hard to get, that’s why the cases are so few

    Reply
  17. jenlooksandcooks

    This is really informative. Thank you for all of your research. Living in the US, I believe making tests available will aid in keeping our numbers down.

    Reply
  18. Scott Gombar

    The truth about COVID-19 is noone truly knows that is going on. I was just reading how 1-5 cases of COVID-19 has heart damage even after recovery. I live only 90 miles from NYC and it’s getting worse hear. It’s a little scary.

    Reply
  19. Susan1375

    Really interesting and well thought out post. I don’t think we will ever know the real number as all countries are manipulating their data and testing is not uniform across the world so results are not really comparable.

    Reply
  20. Peachy A.

    I think all countries should extend their lockdowns until those who are catching the virus decrease as day goes by. Thanks for sharing your experience.

    Reply
  21. ダイクストラヨハネス

    Dear Lynda,

    Thank you for your nice blog. I am a scientist, live in Japan, and speculate that immune changes in the lungs induced by hay fever helps/helped to protect the Japanese population from the spread of COVID-19

    https://www.researchgate.net/post/Could_hay_fever_help_protect_against_COVID-19

    for the principle of inducible immune tissue in the lungs see https://en.wikipedia.org/wiki/Bronchus-associated_lymphoid_tissue or https://www.frontiersin.org/articles/10.3389/fimmu.2016.00258/full

    Hans

    Reply
    1. L M N

      Dear Hans,

      Thank you very much for reading my blog. And a very sincere and warm thank you for these links. This information is invaluable and, as a Mother of children with allergies and asthma, extremely hopeful and reassuring. Said children are vying for my attention right now, so tonight after they go to bed I intend to re-read and digest all the information. I’ve only had the chance for a quick read this afternoon.

      Back in February and March I searched almost daily for information about the possibility of a link between antihistamine / hay fever and covid protection (on a hunch!) without turning anything up. I gave up I guess. I am so grateful you wrote about it and shared the link here.

      All the best,

      Lynda

      Reply

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