国立感染症研究所

19th meeting of the COVID-19 advisory board of Ministry of Health, Labour and Welfare (December 22, 2020).   Document 4

Latest infection status, etc

Infection status

• The number of new infections in Japan continues to increase, reaching a record high level. It maintains an upward trend in the Tokyo metropolitan area (mainly in Tokyo), and no obvious decrease is seen in the Kansai and Chubu areas. The situation in metropolitan areas has extended to other regions where no significant spread of infection had been seen before. The infection is now spreading nationwide due to such persistent spread in each region.
  Effective reproduction number: Above 1, nationwide (as of Dec. 6). The average weekly level exceeds 1 in metropolitan areas such as Tokyo, Aichi, Kyoto, Osaka, and Hyogo. (as of Dec. 6).
• Despite measures taken in and after November, no apparent decrease in the number of new infections has been seen in the Kanto, Chubu and Kansai areas. Accordingly, the numbers of inpatients, severe patients and deaths have continued to increase. Staffs at public health centers and medical facilities are already exhausted from continuous work. The situation has also impacts on usual care service, such as limitations on scheduled surgery procedures and emergency admissions, the transfer of patients to other hospitals to secure beds, and difficulty in adjustment for the hospitalization of those who have dementia or require dialysis. Under circumstances close to the year-end and New Year holidays when the medical care provision system will get relatively weakened, there is concern about rapid responses to the occurrence of disease while it has become difficult to balance the treatment of novel coronavirus disease with usual care in various regions.
• For a new variant which recently became the most common strain in the UK, ECDC and other relevant agencies have no data suggesting that it causes severe condition but point out that it is highly infectious. It arouses concern about burden on medical care. Although this variant has not been found in Japan so far, attention should be paid to the risk of import.

[Trends in regions where the infection has spread]

(1) Hokkaido: The number of new infections is decreasing. Many of new infections occurred in hospitals/facilities. For medical and welfare facilities in Asahikawa City, continued attention should be paid to infection status.　

(2) Tokyo metropolitan area: The number of new infections in Tokyo continues to increase, exceeding 30 per 100,000 persons in the last week. The medical care provision system also continues to be in a very tough situation. It is becoming difficult to accept severe patients. There is a growing need to divert the beds for usual care in order to secure beds for patients with coronavirus disease. Effective efforts are required to suppress infections. While the route of infection is unknown in many cases, the spread of infection via gathering to drink and eat is anticipated. The number of new infections also increases in Saitama, Kanagawa and Chiba throughout the metropolitan area, making the medical care provision system be in a severe situation.

(3) Kansai area: In Osaka, the number of new infections is decreasing but still at a high level. The number of severe patients continues to increase, putting more pressure on the medical care provision system. Hospital- and community-acquired infections continue to occur. The proportion of cases with an unknown route of infection is approximately 60%. In Hyogo, infections also continue to occur. The medical care provision system is in a difficult situation. In Kyoto, the number of new infections continues to increase. In Nara, infections also continue to occur.

(4) Chubu area: Infections continue to occur in and around Nagoya City. In Nagoya City, the number of new infections remains high, and no decreasing trend is observed. The medical care provision system continues to be in a difficult situation. In Gifu, infections also continue to occur.　

* In Okinawa, the number of new infections is decreasing while infections continue to occur. The infection is spreading newly or starting to spread again even in regions where no large-scale infection had occurred, such as Miyagi, Gunma, Okayama, Hiroshima, Kochi, Fukuoka, and Kumamoto. Especially in Hiroshima, the number of new infections has significantly increased mainly in Hiroshima City, and the situation surrounding the medical care provision system is rapidly becoming severe.

Analysis of infection status

• An analysis was conducted for the impact of measures taken in and after November on infection status mainly in Hokkaido, the Tokyo metropolitan area, Aichi and Osaka. In Hokkaido, the flow of people has decreased since November in Sapporo, where a request to restaurants and bars for shortened opening hours was made early, and the effective reproduction number continues to be 1 or less. The number of new infections also continues to decrease in the entire Hokkaido. However, attention should be paid because the effective reproduction number is reaching 1 recently.
• In Tokyo, the effective reproduction number was below 1 temporarily in late November. But it turned to be 1 or more after that, and the same level continues. Despite a request for shortened opening hours, no decrease in the flow of people has been seen. The persistent spread of infection in Tokyo has extended to surrounding regions, and the number of new infections continues to increase throughout the Tokyo metropolitan area including Saitama, Chiba and Kanagawa.
• In Osaka, a decrease in the flow of people has been seen since late November in some areas of Osaka City where a request for shortened opening hours was made, and the effective reproduction number became around 1. In Osaka, the number of new infections also started to decrease slightly in mid-December. For other regions of the Kansai area, it still continues to increase in Kyoto and remains high in Hyogo.
• In Aichi, the degree of decrease in the flow of people is small, and the effective reproduction number continues to be around 1. The number of new infections remains high.
• There is a certain relationship between the increase/decrease in the flow of people and that in the effective reproduction number.
• As described above, no apparent decrease in the number of new infections has been seen except in Hokkaido. It continues to increase in the Kanto area. The continuous infections in Tokyo especially contribute to the spread in its surrounding regions. The spread of infection in metropolitan areas probably affected the recent outbreak in local regions. It will be difficult to control infections in local regions if infections in large cities cannot be suppressed.
• Infected persons are dominated by those in their 20-50s who are active in social activities (e.g., eating and drinking together). The recent spread of infection in various regions including metropolitan areas is attributed mainly to eating and drinking together.

Necessary measures

• In regions where the spread of infection is expanding/continuing, especially in regions which require measures for Stage III and correspond to Scenario 3 or 2 proposed by the subcommittee, reinforcement of measures is needed. Especially in the Tokyo metropolitan area, where the number of new infections continues to increase, measures should be strengthened immediately.
• Infections have been reported even from regions where no large-scale infection had been seen, and infections in medical and welfare facilities have frequently occurred. The rapid spread of infection may swiftly deteriorate the medical care provision system. It is therefore necessary to promptly prepare/secure the medical care provision system including an accommodation facility for the end of year. If infections spread, additional measures such as a request to restaurants and bars for shortened opening hours should be considered.
• Cooperation of citizens is essential to suppress the spread of infection. Appropriate and strong messages should be delivered to ask them to spend quiet year-end and New Year holidays by avoiding a year-end/new-year party and crowded shopping place.
• A plan to strengthen measures for the New Year was shown at the meeting of the Novel Coronavirus Response Headquarters on December 14. The analysis/evaluation of infection status should be conducted while monitoring the effect of such efforts carefully. And if such efforts are found to be insufficient, necessary measures should be considered.
• Even under the severe situation, it is also necessary to prevent the spread of infection due to the import of new variant found in the UK or other foreign countries. For this reason, appropriate actions should be taken promptly regarding the way of people’s coming and going between Japan and related countries as well as the way of testing/monitoring.

Figures (Number of new infections reported etc.) (PDF)

18th meeting of the COVID-19 advisory board of Ministry of Health, Labour and Welfare (December 16, 2020).   Document 4

Latest infection status, etc

Infection status

• The number of new infections in Japan has remained high, and has then started to increase recently; it is still at a record high. There is not a clear decrease in the number of infections in the Tokyo metropolitan, Kansai and Chubu areas. The tendency of new spreading and re-spreading of infections is observed in regions where large-scale infection has not been observed before, and there is concern that the infection may spread all over Japan, including other regions.
  Effective reproduction number: Slightly above 1, nationwide (as of Nov. 29). The average weekly level exceeds 1 in metropolitan areas such as Tokyo, Aichi, Kyoto, and Hyogo, etc. (as of Nov. 30).
• With the recent spreading of the infection, the number of new infections is increasing to a greater extent, and the absolute number of elderly patients is also increasing. The numbers of inpatients and severe patients are increasing, as are the burdens on the medical care provision system and the public health system. The number of deaths is also showing an increasing trend. The rate of new infections among people aged 60 years or older has increased and severe patients may continue to increase for the time being, and there is concern that deaths may further increase. The staff in public health centers and medical institutions who are responding to the disease are already exhausted to a considerable extent, the usual care services have been affected, for example, there are cases of limitations on scheduled surgery procedures and emergency admissions, the transfer of patients to other hospitals to secure beds, and cases of adjustments for the hospitalization of persons with dementia or those who require dialysis, which has become difficult, and there is concern about rapid responses to the occurrence of disease while it has become difficult to balance treatment of the novel coronavirus disease with usual care in various regions.

[Trends in regions where the infection has spread]

(1) Hokkaido There is a decreasing trend in the number of new infections, however infections are continuing to occur mainly in Sapporo City and Asahikawa City. Many cases of infection are related to hospitals/facilities, and schools. Infections in Sapporo City have decreased, and the public health centers are somewhat relieved of impending situations. In Asahikawa City, normal care has been affected, and the situation is still severe.　

(2) Tokyo metropolitan area Many cases of the infection are continuing to occur throughout Tokyo, and medical institutions are experiencing very severe conditions. It is becoming difficult to accept severe patients. There is also a growing need to divert the beds for usual care in order to secure beds for patients with coronavirus disease. In the entire metropolitan area, the medical care provision system is under severe pressure due to spreading of infections in Saitama, Kanagawa, and Chiba too. In addition, new infections decreased once in Tokyo, Chiba and Kanagawa, and then have started to increase again. An clear increasing trend in new infections is continuing in Saitama.

(3) Kansai area In Osaka, the number of new infections has remained high, and then slightly decreased, though it is still at a high level. New infections are gradually increasing outside Osaka City. The number of severe patients is continuing to increase, resulting in increasingly severe pressure on the medical care provision system. Nosocomial infections and community-acquired infections are continuing to occur. The proportion of cases with an unknown route of infection is approximately 60%. Infections are also continuing to occur in Hyogo. The medical care provision system is experiencing severe pressure. An increasing trend is also observed in Kyoto, etc. Infections are also continuing to occur in Nara.

(4) Chubu area The infection has spread in and around Nagoya City. In Nagoya City, the number of new infections remains high and no decreasing trend is observed. Mass infections have occurred at welfare facilities and workplaces. The medical care provision system is experiencing severe pressure. The infection has also spread in Gifu.　

(5) Okinawa The number of new infections is showing a decreasing trend, however infections are continuing to occur. The infection is spreading to daily situations of eating and drinking, and workplaces. The pressure on the medical care provision system is becoming increasingly severe.

*Other than the above, the tendency of new spreading and re-spreading of infections is observed in regions where large-scale infection has not previously been observed, e.g., Miyagi, Gunma, Hiroshima, Kochi, Fukuoka, Kumamoto, and Oita.

Analysis of infection status

• So far, spreading of infection has mainly been observed in metropolitan areas; however, it has also been observed in local regions. In the past 1 week, approximately 20% of all infected persons were in Tokyo and nearly 15% were in Osaka. The infected persons in these 2 areas account for 1/3rd of all persons infected in Japan. Furthermore, the infected persons in Hokkaido, Saitama, Chiba, Tokyo, Kanagawa, Aichi, Kyoto, Osaka, and Hyogo account for approximately 75% of all infected persons in Japan. Firstly, the infection continues/spreads in places with a large population, and then spreads to local regions. It becomes difficult to control the infection in local regions if the infection in large cities is not controlled. It is necessary to immediately suppress the spreading and continuation of the infection in large cities and to prevent the spread of infection in local regions.
• In recent cases of spreading of the infection, clusters related to restaurants or nightclubs serving food and drinks and hospitality services, which have been used for year-end parties, are increasing, especially in local regions. Scenes of eating and drinking have already been identified as places where the infection spread, also outside Japan. As seen in Materials 2-3 of the Advisory Board dated December 3, it is reported that restaurants are places with a high risk of infection (Chang S, et al., Nature 2020). In Sapporo, it has been suggested that shortening of business hours in entertainment districts to finish earlier may reduce infections. On the other hand, it is difficult to trace a link in large cities such as Tokyo because many unspecified people visit restaurants, and it is difficult to identify them as the infection sources. Therefore, such places may be involved in continuation of infection.
• There are also more cases of infection among people in their 20s-50s who are active in social activities such as eating and drinking compared to those in other age groups. Since these age groups often do not exhibit any symptoms or only mild symptoms, even when infected, they have spread the infection unintentionally, and this spread is considered to have caused infections at home, and in medical institutions and facilities for elderly people, leading to the increase in severe patients.

Necessary measures

• Various measures have already been taken in regions where the infection has spread. If the infection status does not improve, it is necessary to discuss strengthening of the efforts to prevent the spread of infection, including coverage of a request to shorten the business hours of restaurants serving alcoholic beverages.
• Infections have also occurred in regions where large-scale spreading of the infection has not yet been reported. The medical care provision system may deteriorate rapidly in regions where the system is relatively weak and rapid spreading of infection can occur, and it is therefore necessary to immediately prepare/secure the medical care provision system, including accommodation facilities.
• Increased infections during the New Year holiday season may lead to a crisis of the entire medical care provision system. Prompt implementation of appropriate measures based on the infection status and the preparation for measures are required. It is also necessary for citizens to spend their time quietly during the New Year holidays to avoid causing the spreading of the infection at New Year parties, end-of-year parties, and homecoming visits. Appropriate messages to citizens are required.
• Based on the previous recommendations from the Subcommittee to the government, the discussion at the government headquarters on December 14 presented the efforts to strengthen the preventive measures throughout the beginning of the new year. It is necessary to carefully monitor the effects of these efforts and promote the evaluation and analysis of the infection status. Based on these, necessary measures should be considered if such efforts are found to be insufficient.

Figures (Number of new infections reported etc.) (PDF)

17th meeting of the COVID-19 advisory board of Ministry of Health, Labour and Welfare (december 10, 2020).   Document 4

Latest infection status, etc

Trends in the number of new infections

• The number of new infections is still at a record high level, and the situation continues to require a maximum state of alert. Particularly in Hokkaido, the Tokyo metropolitan area, the Kansai area, and the Chubu area, many new cases of the infection are occurring every day. In addition, a tendency toward the spread of the infection is being observed in regions where no large-scale infection has been reported. As it is considered that factors that tend to cause an increase in the number of infections, such as the decreasing temperature, may strengthen, the infection may spread even in regions where a spread has not yet been reported, and caution is required.
  Effective reproduction number: Slightly below 1, nationwide (as of Nov. 22). The average weekly level also exceeds 1 in Hokkaido, Tokyo, and Aichi, etc. (as of Nov. 24).
• With the recent spread of the infection, the number of new infections is increasing to a greater extent, and the absolute number of elderly patients is also increasing. The numbers of inpatients and severe patients are increasing, as are the burdens being placed on the medical care provision system and the public health system. Further, the number of deaths is also increasing. An increase in the number of severe patients tends to be delayed, relative to that of new infections. Accordingly, the number of severe patients may continue to increase for a time, and the medical care provision system, which is currently responding to the large number of inpatients and severe patients, has already been affected by this situation. In some regions, the provision of support via nurses from other regions or the Self-Defense Force has been initiated. In addition, there have been cases where adjustments for the hospitalization of persons, such as those with dementia or those who require dialysis has become difficult, as well as cases involving limitations of scheduled surgeries and acceptance for emergency medical care, and the patient transfers to secure beds for persons infected with the virus. It continues to be difficult to balance treatment of the novel coronavirus disease with usual care, in various regions.
• Clusters of infected individuals who are difficult to detect or identify are considered to have contributed to the spread of the infection. Secondary infections have occurred more frequently via persons in their 20s to 50s with active social lives, who have a history of movement under the current coronavirus situation, compared to other generations. Because these generations often exhibit no symptoms or only mild symptoms even when infected, they are assumed to have spread the infection unintentionally, and this spread is considered to have caused infections in medical institutions and facilities for the elderly.

[Trends in regions where the infection has spread]

(1) Hokkaido The number of new infections is now showing a decreasing trend; however, many cases of the infection are continuing to occur, and the medical care system is experiencing severe conditions, mainly in Sapporo City. Also in Asahikawa City, nosocomial infections are continuing to occur, as are institutional infections and community-acquired infections, and the situation remains severe.

(2) Tokyo metropolitan area Many cases of the infection are continuing to occur throughout Tokyo, where the situation has not shifted to a decreasing trend, and the medical care system is experiencing very severe conditions. The proportion of cases with an unknown route of infection is approximately 60%. Infections are occurring in Saitama, Kanagawa, and Chiba throughout the metropolitan area, and the medical care system is experiencing severe conditions. In particular, no decreasing trend has been observed in Saitama.

(3) Kansai area New infections are occurring, mainly in Osaka City in Osaka. The number of severe patients is continuing to increase, resulting in increasingly severe conditions for the medical care system. Nosocomial infections and community-acquired infections are continuing to occur. The proportion of cases with an unknown route of infection is approximately 60%. The infection has also spread in Hyogo. The medical care system is experiencing severe conditions. A further increasing trend is being observed in Kyoto.

(4) Chubu area The infection has spread in and around Nagoya City. The proportion of cases with an unknown route of infection is approximately 50%. It has also become much more difficult for medical institutions to respond to the situation. Also in Shizuoka, clusters have occurred at restaurants and nightclubs with hospitality services, and the infection is continuing to spread. The infection has also spread in Gifu.　

(5) Okinawa Clusters have occurred at restaurants and nightclubs with hospitality services, and the infection is continuing to spread. The proportion of cases with an unknown route of infection is approximately 50%. The situation of the medical care system is becoming increasingly severe.

Future actions

• Particularly in regions where the infection is spreading, in order to focus medical resources on patients who are at risk of becoming severe, it is necessary to discuss the organization of a system of accommodation facilities and home recuperation for asymptomatic carriers and patients with mild symptoms who have been determined by physicians to not require hospitalization, including elderly patients requiring nursing care. In addition, in accordance with the needs of local governments, it is necessary to engage in supportive actions such as the dispatch of public health nurses to public health centers and support for adjustments for hospitalization among local governments, dispatch of medical staff such as nurses to regions where the medical care system is overwhelmed, and dispatch of specialist physicians in cooperation with related academic societies, particularly to regions that are experiencing an increase in the number of severe patients.
• On the other hand, infections are also occurring in regions where a large-scale spread of the infection has not yet been reported. The medical care provision system has deteriorated rapidly in regions where the system is relatively weak, and the infection may spread rapidly. In addition, an increase in the number of infections during the New Year holiday season may result in a crisis for the medical care provision system. Accordingly, even in regions where a large-scale spread of the infection has not yet been observed, it is necessary to engage in immediate preparations and secure the medical care provision system, including accommodation facilities for recuperation, with a sense of crisis that a rapid spread of the infection may occur in any area.
• In the midst of the spread of the infection, the customary behaviors of the New Year holiday season may lead to a further spread of the infection, under the severe conditions of the medical care provision system. It is necessary to prepare and promptly implement appropriate measures based on the status of the infection, under the leadership of the prefectural governors. In addition, the cooperation of citizens is necessary, with respect to spending quiet times during the New Year holidays, in order to avoid causing a spread of the infection at New Year parties, end-of-year parties, and homecoming visits. It will be necessary to deliver messages to citizens, in order to obtain their cooperation.
• In addition, secondary infections have occurred more frequently via persons in their 20s to 50s with active social lives, who have a history of movement under the current coronavirus situation, compared with other generations. It is necessary to make use of various channels, especially for young persons and those who are in the prime of life, to encourage them to change their behaviors, such as by thoroughly wearing masks in situations such as eating and drinking.
• The measures based on the recommendations from the Subcommittee to the government have thus far been taken under cooperation between the national and local governments. Although these measures have resulted in some effects in regions where they were taken early, it cannot necessarily be said that they have been successful in reducing the number of new infections, as a whole. If the spread of the infection still cannot be halted, the public health system, including measures against the novel coronavirus infection, and the entire medical care provision system may be at risk. The New Year holiday season, during which time the medical care provision system will become relatively weak, is fast approaching, and it is necessary to cope with the situation with a sense of urgency. It is necessary to evaluate whether or not the spread of infection will subside by the middle of December, and to promptly consider additional measures for the future.

Figures (Number of new infections reported etc.) (PDF)

16th meeting of the COVID-19 advisory board of Ministry of Health, Labour and Welfare (december 3, 2020).   Document 4

Latest infection status, etc

Trends in the number of new infections

• The increasing trend of new infections has been stronger since November; it has increased more than twice within 2 weeks and has reached a record high. Although there are some regions in which the infection has not spread significantly, remarkable increases in the number of cases of infection have been observed, particularly in Hokkaido and the Tokyo metropolitan, Kansai, and Chubu areas, which has led to a nationwide increase in infected cases. The infection has already spread rapidly in some regions, which may have a significant impact on the medical care provision system and the public health system if this trend continues.
     Effective reproduction number: On a national basis, it remains at a level that exceeds 1. It exceeds 2 in Osaka, Kyoto, and Hyogo. It essentially remains at a level that exceeds 1 in Hokkaido, Tokyo, Aichi, etc.
• Clusters that are causing the spread of the infection have diversified, and are spreading to neighboring regions. In addition, the existence of latent clusters is also expected, and clusters with infected individuals who are difficult to detect or identify are considered to have contributed to the spread of the infection.
• The factors behind the spread of the infection are considered to be a lack of proper implementation of basic measures to prevent infection and an increase in movements of people under such conditions, in addition to the effects of lower temperatures and population density.
• The numbers of inpatients and severe patients are continuing to increase. There are cases of limitations of scheduled surgeries and emergency admissions, transfers of patients to other hospitals to secure beds, and physicians from completely different departments who have been forced to treat patients with the novel coronavirus infection. While the number of beds and staff cannot easily be increased, it is becoming difficult to maintain a balance between treatment for the novel coronavirus infection and regular medical care. If this situation continues, it will become impossible to save lives that could be saved by regular medical care.

[Trends in regions where the infection has spread]

(1) Hokkaido The infection has spread throughout Hokkaido, including the suburbs of Sapporo City. Large clusters have occurred at welfare facilities and medical institutions. In addition, the number of available beds is decreasing due to an increase in patients and an outbreak of nosocomial infections, mainly in Sapporo City. There are cases where nosocomial infections have occurred in Asahikawa City, making it difficult to make adjustments for patient admissions.

(2) Metropolitan area The infection has spread throughout Tokyo. The infection route is unknown in more than half of these patients. The infection is also spreading in Saitama, Kanagawa, and Chiba in the metropolitan area, and clusters have occurred in a variety of facilities, including medical institutions, welfare facilities, and restaurants and nightclubs with hospitality services, resulting in severe conditions for the medical care system. The proportion of infected persons with unknown routes of infection has increased to approximately 40 to 50%. Also in Ibaraki, clusters have occurred at restaurants and nightclubs with hospitality services, and the number of infected persons has increased.

(3) Kansai area The infection has spread considerably, mainly in Osaka City in Osaka. Clusters have occurred at medical institutions and facilities for the elderly. The proportion of infected persons with unknown routes of infection has reached approximately 60%, and the number of severe patients is increasing, resulting in severe conditions for the medical care system. In Hyogo, clusters have occurred at facilities for the elderly and a university, etc. The medical system is experiencing severe conditions. The infection has spread also in Kyoto.

(4) Chubu area The infection has spread throughout Aichi. The proportion of cases with an unknown route of infection is approximately 40%. In Nagoya City, the number of infected persons has increased mainly in the entertainment district, and the burden on health centers has increased. Medical institutions are experiencing severe conditions in response to these conditions. Also in Shizuoka, clusters have occurred at restaurants and nightclubs with hospitality services, and the infection has spread.

Future actions

• The balance between “increasing factors” and “decreasing factors” for the infection is being lost. In order to maintain the public health system and the medical care provision system, including measures against the novel coronavirus infection, it is necessary to achieve a downward trend in infections, as soon as possible.
• In the “Recommendations from the Subcommittee to the Government” on November 20, the following were proposed as measures that are stronger than those currently in place: (1) shortening of business hours, (2) requests for voluntary restraint on movements across regions, (3) a review of the operations of the GoTo campaign project, (4) a more thorough implementation of existing measures, (5) consideration for the economy and employment, and (6) permeation of behavioral changes among individuals. On November 21, Headquarters announced policies regarding a request for a review of the GoTo Travel and the GoTo Eat projects, support related to requests for shortening business hours, and facilitation of testing for the novel coronavirus at medical care facilities and facilities for the elderly, with the aim of suppressing the occurrence of severe cases. The national and local governments are required to implement these policies, immediately.
• In regions where the infection is widespread, the conditions of the public health system and medical care provision system are becoming severe. The national government should proactively grasp such local situations, judge the local conditions regarding the infection and the medical care provision system under close cooperation with local governments, and promptly take the necessary measures to improve conditions. Particularly in such regions, in order to focus medical resources on patients who are at risk of becoming severe, it is necessary to allow asymptomatic carriers and patients with mild symptoms who have been determined by physicians to not require hospitalization, including elderly persons, to rest or receive treatments at other accommodations (home treatment, if possible). In addition, depending on the needs of local governments, the provision of coordination support will be continued, including the prompt and agile dispatch of specialized personnel such as health nurses, and approaches to securing beds.
• On the other hand, even in regions where major numbers of infections are not currently being observed, it is necessary to engage in immediate preparations and secure the medical care provision system, in preparation for a rapid spread of the infection.
• In addition, it is necessary to make use of various channels, especially for young people and those in the prime of life, to make them change their behaviors, such as by thoroughly wearing masks in situations such as eating and drinking. Also, it has been suggested that some persons may avoid undergoing testing for some reason, despite having noticed the possibility of infection, and may have caused secondary infections. It is necessary to again inform people to consult with their primary care physicians, which will lead to the necessary tests, in cases where symptoms of the infection are suspected.
• In regions where it has already become difficult to provide medical care, strong measures to reduce the number of infected persons (e.g., reducing chances for contact with infected individuals) are required. To prevent the spread of infection in the future, the national and local governments, citizens, and business operators should cooperate to promote measures against the spread of the infection.

Figures (Number of new infections reported etc.) (PDF)

15th meeting of the COVID-19 advisory board of Ministry of Health, Labour and Welfare (November 24, 2020).   Document 4

Latest infection status, etc

Trends in the number of new infections

• The increasing trend of new infections has been stronger since November; it has increased more than twice within 2 weeks and has reached a record high. Although there are some regions in which the infection has not spread significantly, remarkable increases in the number of cases of infection have been observed, particularly in Hokkaido and the Tokyo metropolitan, Kansai, and Chubu areas, which has led to a nationwide increase in infected cases. The infection has already spread rapidly in some regions, which may have a significant impact on the medical care provision system and the public health system if this trend continues.
     Effective reproduction number: On a national basis, it remains at a level that exceeds 1. It exceeds 2 in Osaka, Kyoto, and Hyogo. It essentially remains at a level that exceeds 1 in Hokkaido, Tokyo, Aichi, etc.
• Clusters that are causing the spread of the infection have diversified, and are spreading to neighboring regions. In addition, the existence of latent clusters is also expected, and clusters with infected individuals who are difficult to detect or identify are considered to have contributed to the spread of the infection.
• The factors behind the spread of the infection are considered to be a lack of proper implementation of basic measures to prevent infection and an increase in movements of people under such conditions, in addition to the effects of lower temperatures and population density.
• The numbers of inpatients and severe patients are continuing to increase. There are cases of limitations of scheduled surgeries and emergency admissions, transfers of patients to other hospitals to secure beds, and physicians from completely different departments who have been forced to treat patients with the novel coronavirus infection. While the number of beds and staff cannot easily be increased, it is becoming difficult to maintain a balance between treatment for the novel coronavirus infection and regular medical care. If this situation continues, it will become impossible to save lives that could be saved by regular medical care.

[Trends in regions where the infection has spread]

(1) Hokkaido: The infection has spread throughout Hokkaido, including the suburbs of Sapporo City. Large clusters have occurred at welfare facilities and medical institutions. In addition, the number of available beds is decreasing due to an increase in patients and an outbreak of nosocomial infections, mainly in Sapporo City. There are cases where nosocomial infections have occurred in Asahikawa City, making it difficult to make adjustments for patient admissions.

(2) Metropolitan area: The infection has spread throughout Tokyo. The infection route is unknown in more than half of these patients. The infection is also spreading in Saitama, Kanagawa, and Chiba in the metropolitan area, and clusters have occurred in a variety of facilities, including medical institutions, welfare facilities, and restaurants and nightclubs with hospitality services, resulting in severe conditions for the medical care system. The proportion of infected persons with unknown routes of infection has increased to approximately 40 to 50%. Also in Ibaraki, clusters have occurred at restaurants and nightclubs with hospitality services, and the number of infected persons has increased.

(3) Kansai area: The infection has spread considerably, mainly in Osaka City in Osaka. Clusters have occurred at medical institutions and facilities for the elderly. The proportion of infected persons with unknown routes of infection has reached approximately 60%, and the number of severe patients is increasing, resulting in severe conditions for the medical care system. In Hyogo, clusters have occurred at facilities for the elderly and a university, etc. The medical system is experiencing severe conditions. The infection has spread also in Kyoto.

(4) Chubu area: The infection has spread throughout Aichi. The proportion of cases with an unknown route of infection is approximately 40%. In Nagoya City, the number of infected persons has increased mainly in the entertainment district, and the burden on health centers has increased. Medical institutions are experiencing severe conditions in response to these conditions. Also in Shizuoka, clusters have occurred at restaurants and nightclubs with hospitality services, and the infection has spread.

Future actions

• The balance between “increasing factors” and “decreasing factors” for the infection is being lost. In order to maintain the public health system and the medical care provision system, including measures against the novel coronavirus infection, it is necessary to achieve a downward trend in infections, as soon as possible.
• In the “Recommendations from the Subcommittee to the Government” on November 20, the following were proposed as measures that are stronger than those currently in place: (1) shortening of business hours, (2) requests for voluntary restraint on movements across regions, (3) a review of the operations of the GoTo campaign project, (4) a more thorough implementation of existing measures, (5) consideration for the economy and employment, and (6) permeation of behavioral changes among individuals. On November 21, Headquarters announced policies regarding a request for a review of the GoTo Travel and the GoTo Eat projects, support related to requests for shortening business hours, and facilitation of testing for the novel coronavirus at medical care facilities and facilities for the elderly, with the aim of suppressing the occurrence of severe cases. The national and local governments are required to implement these policies, immediately.
• In regions where the infection is widespread, the conditions of the public health system and medical care provision system are becoming severe. The national government should proactively grasp such local situations, judge the local conditions regarding the infection and the medical care provision system under close cooperation with local governments, and promptly take the necessary measures to improve conditions. Particularly in such regions, in order to focus medical resources on patients who are at risk of becoming severe, it is necessary to allow asymptomatic carriers and patients with mild symptoms who have been determined by physicians to not require hospitalization, including elderly persons, to rest or receive treatments at other accommodations (home treatment, if possible). In addition, depending on the needs of local governments, the provision of coordination support will be continued, including the prompt and agile dispatch of specialized personnel such as health nurses, and approaches to securing beds .
• On the other hand, even in regions where major numbers of infections are not currently being observed, it is necessary to engage in immediate preparations and secure the medical care provision system, in preparation for a rapid spread of the infection.
• In addition, it is necessary to make use of various channels, especially for young people and those in the prime of life, to make them change their behaviors, such as by thoroughly wearing masks in situations such as eating and drinking. Also, it has been suggested that some persons may avoid undergoing testing for some reason, despite having noticed the possibility of infection, and may have caused secondary infections. It is necessary to again inform people to consult with their primary care physicians, which will lead to the necessary tests, in cases where symptoms of the infection are suspected.
• In regions where it has already become difficult to provide medical care, strong measures to reduce the number of infected persons (e.g., reducing chances for contact with infected individuals) are required. To prevent the spread of infection in the future, the national and local governments, citizens, and business operators should cooperate to promote measures against the spread of the infection

Figures (Number of new infections reported etc.) (PDF)

14th meeting of the COVID-19 advisory board of Ministry of Health, Labour and Welfare (November 19, 2020).   Document 4

Latest infection status, etc

Trends in the number of new infections

• The increasing trend of new infections has been stronger since November; it has increased more than twice within 2 weeks and has reached a record high. Although the infection has not spread considerably in some regions, remarkable increases in infection cases are observed especially in Hokkaido and the Tokyo metropolitan, Kansai, and Chubu areas, and these increases have led to a nationwide increase in infected cases. The spread of infection is accelerating. If this situation is left unsolved, it may even lead to rapid spreading of infection, and a severe situation is continuing.
     Effective reproduction number: On a national basis, it remains at a level exceeding 1. It basically remains at a level exceeding 1 in Hokkaido, Tokyo, Osaka, Aichi, etc.
• Clusters causing the spread of infection have been observed in the entertainment districts in local cities, as well as places where people eat/drink together, workplaces, communities of non-Japanese people, young people such as university students, medical facilities, and facilities for the elderly, etc., which indicate that they are spreading to other regions and diversifying. Potential clusters are also expected, and it is considered that clusters with infected persons who are difficult to detect or identify have contributed to the spread of infection.
• Although it is difficult to clearly determine the causes of such spread of infection, basic measures to prevent infection may not be taken properly, or an increase in the movement of people and a decrease in temperature under such circumstances may cause spread of the infection.
• On the other hand, the proportion of patients aged 60 years or older among the infected persons has remained stable although the number of infections is increasing. The number of inpatients and severe patients are increasing, and the bed occupancy rate is also increasing. If these conditions continue, it will be difficult to keep a balance with routine medical care, because it will inevitably be necessary to limit scheduled surgery, the acceptance of cases for emergency medical care, etc.

[Trends in regions where the infection has spread]

(1) Hokkaido Clusters occurred mainly in restaurants or nightclubs with hospitality services in Sapporo City; the infection spread, and also spread all over Hokkaido, including the suburbs of Sapporo City. Clusters increased in other places than restaurants or nightclubs with hospitality services, e.g., workplaces, schools, medical institutions and facilities for the elderly. It is becoming difficult to take actions for persons who have been in close contact with infected persons and the conditions are becoming severe. Conditions at medical institutions have also become severe, i.e., there are not enough available beds at medical institutions mainly in Sapporo City due to the increase in the number of patients and it has become difficult to adjust to the situation.

(2) Tokyo The infection is spreading all over Tokyo. The routes of infection include home infection, which occurs most frequently, followed by workplaces, facilities for the elderly, and places where people eat/drink together; the proportion of cases with an unknown infection route is more than half. Increased socioeconomic activities may increase the chances of enhancing the risk of the spread of infection mainly in young people, and the scenes of infection may have become diversified, including universities, etc..

(3) Osaka The infection is spreading all over Osaka. The proportion of cases with an unknown infection route is approximately 60%. Cases of infection have been identified in various scenes, e.g., between persons involved in/visitors at entertainment districts, at home, and in offices. Clusters occurred at facilities for the elderly, medical institutions, schools, etc..

(4) Aichi The infection is spreading all over Aichi. The proportion of cases with an unknown infection route is approximately 40%. In Nagoya City, infected persons have increased mainly in entertainment districts, and the burden on health centers has increased. The age of infected persons and the places where infection occurred have diversified, and infections have also occurred during extracurricular activities of universities, e.g., at facilities for the elderly. It has also become severe to take actions at medical institutions. Clusters other than those in Nagoya City have also been diversified and have sporadically occurred among communities of non-Japanese people, at universities, and in facilities for the elderly.

In some regions of Hokkaido, it is considered that strong measures such as reducing contact opportunities and restricting behavior are required. In Tokyo, Osaka, and Aichi, the conditions are almost reaching a state where such strong measures are required.

Future actions

• The increasing trend in infections is becoming strong; and to maintain the public health system and medical care provision system other than the measures against novel coronavirus infection, it is necessary to achieve a downward trend in the infections as soon as possible.
• It is urgent to take actions against diversifying clusters. Appropriate actions will be taken according to the situation for restaurants and nightclubs with group eating/drinking and hospitality services, workplaces, young people such as university students, communities of non-Japanese people, medical institutions and facilities for the elderly. Actions against clusters that are difficult to detect are also necessary.
• Based on an urgent proposal by the subcommittee on November 9, we need to take steady actions according to the characteristics of the clusters (e.g., thorough approach at restaurants and nightclubs providing hospitality services, and support for communities of non-Japanese people who have difficulty to receive medical care, etc.), as well as prompt actions (e.g., thorough testing at medical institutions and facilities for the elderly where infections are increasing).
• Therefore, as suggested under “Further Reinforcement of Measures Against Clusters to Respond to the Recent Spread of Infection” in a discussion at the government Headquarters on November 16, it is necessary to promptly take such actions as (1) to request for cooperation by the business operators of local public bodies and support for the cooperation, (2) measures against clusters that are difficult to detect early, (3) to secure a testing/medical care provision system, and (4) to secure personnel/support for health centers.
• In addition to these cluster measures, it is of utmost importance that individuals and business operators thoroughly take basic infection prevention measures to strengthen the “factors to reduce” infections. Information such as the “Five Scenes” where the risk of infection increases need to be provided mainly to young people who frequently go places and do many things. In addition, it is also necessary to enhance providing information that will change people’s actual behavior, including the thorough wearing of a mask, also at scenes of eating and drinking, and to thoroughly conform to the guidelines for each industry such as restaurants. Such basic infection prevention measures need to be thoroughly taken to prevent the movement of people from becoming a risk for the spread of infection.
• While such actions are taken, there is concern about situations where infections cannot be addressed only by taking these measures against clusters or thoroughly keeping basic measures against infection. It is necessary that each prefectural government should take prompt and necessary actions to concentrate on the status of beds, etc. for any regions where the infection is rapidly expanding in each prefecture and to take actions limited to regions, not only for the overall trend of prefecture.
• If the rapid spread of infection cannot be avoided and there are signs that hospital beds are being overwhelmed, etc. in the future, it will be necessary to promptly take even stronger measures. To avoid such situations, it is necessary for the public to unite and take measures.
• In the future situation of increasing infection, it will also be required to fulfill the necessary functions of consultation systems for DV, sexual violence, suicide, etc. Consideration should also be given to the influences on women and children when making decisions on whether to close schools and kindergartens/nursery schools.

Figures (Number of new infections reported etc.) (PDF)

13th meeting of the COVID-19 advisory board of Ministry of Health, Labour and Welfare (November 11, 2020).   Document 4

Latest infection status, etc

Trends in the number of new infections

• On a national basis, the number of new infections had continued to decrease after reaching a peak in the first week of August, and after that, it basically remained flat. However, the number has been increasing again since October, and this trend has been getting stronger since November. An increase in the number of infections is seen mainly in Hokkaido, Osaka and Aichi, leading to a nationwide increase.
  Effective reproduction number: On a national basis, it remains at a level exceeding 1. It basically remains at a level exceeding 1 in Hokkaido, Osaka, Aichi, etc. while it fluctuates at a level around 1 in Tokyo.
• Clusters causing the spread of infection have been observed in entertainment districts in local cities, as well as places where people eat/drink together, workplaces, communities of foreigners, medical facilities, welfare facilities, etc., which indicates that they are spreading to other regions and diversifying. As the rate of infection spread is increasing in some regions, “decreasing factors” for infection should promptly be enhanced. If left untreated, the infection may spread more rapidly.
• On the other hand, the proportion of patients aged 60 years or older among the infected patients has remained stable. The bed occupancy rate is slightly increasing while it is around 10% both for inpatients as a whole and for severe patients. However, the numbers of inpatients and severe patients have been increasing since the end of October, and the bed occupancy rate has also been increasing in some regions. We should pay attention to this situation.

Future actions

• Continuous social efforts by citizens, medical professionals, the staff at public health centers, business operators, etc. and the standardization of treatment have helped to control the fatalities and the rate of disease aggravation. However, to prevent excessive burdens on our public health system and medical care provision system, we should take actions to decrease the number of infections as quickly as possible.
• In regions where the spread of infection or its signs are seen, it is necessary to analyze factors for clusters that vary in different regions and to take prompt actions against them. Efforts in each region and support for them are also required to secure the availability of tests, public health center functions, and the medical care provision system in case of rapid spread of the infection.
• To enhance “decreasing factors” for infection under these circumstances where clusters arediversifying and spreading to other regions, (i) further cluster control, and (ii) thorough implementation of basic infection prevention measures ( enhancement of information provision utilizing the “5 High-risk Scenes,” etc. which can lead to actual behavior modifications) are required.
• Based on an urgent proposal by the subcommittee [Attachment], we need to take steady actions according to the characteristics of clusters (e.g., thorough approach to restaurants or nightclubs providing hospitality services, and support for communities of foreigners with difficulties in receiving medical care, etc.), as well as prompt actions (e.g., thorough testing at medical facilities, etc.) and speedy sharing of information on clusters, etc.
• For entry from overseas, measures at quarantine stations, sharing of necessary information with local governments, provision of the necessary information (e.g., on how to seek medical help at the onset) according to the characteristics of people entering Japan, and support for local governments and medical facilities are required.
• If the sudden spread of infection or a tight supply-demand balance of beds is observed while taking these actions, we need to take stronger measures, such as setting a certain level of restrictions on social and economic activities. To avoid such a situation, citizens should pursue measures together.

Figures (Number of new infections reported etc.) (PDF)

Urgent proposal:Further reinforcement of measures besed on the recent infection status

[Introduction:Basic concept of this urgent proposal]  

The 14th Meeting of the Subcommittee on Novel Coronavirus Disease Control

If we do not take appropriate infection control measures in the course of revitalizing social and economic activities, “increasing factors” for infection will get stronger and exceed the “decreasing factors” (e.g., basic infection prevention measures by people, and cluster control by local governments). Recently, clusters have been increasing, and moreover, they are diversifying. Under such circumstances, the infection is more likely to spread rapidly unless we enhance the “decreasing factors” immediately. Continuous social efforts by citizens, medical professionals, staff at public health centers, business operators, etc. and the standardization of treatment have controlled fatalities and the rate of disease aggravation. However, to prevent excessive burdens on our medical care provision system, we should take actions to decrease the number of infections as quickly as possible.

In this urgent proposal, we summarize the 5 specific actions required of each citizen, local governments and the national government, based on our past proposals and the broad direction by the national government (*) so that they can be compatible with social and economic activities during the first winter we will experience after the outbreak of novel coronavirus infection.

As a subcommittee, we make this proposal to the government.

* “Actions against Novel Coronavirus Disease” (Report of the 44th Meeting of the Headquarters for Novel Coronavirus Disease Control; October 30, 2020)

[5 Required Actions]

Action No.1 Further cluster control

Background

Clusters are increasing, and moreover, they are diversifying. In particular, the number of clusters that are “difficult to detect early” or “difficult to contain” is increasing. Actions against clusters have been taken only after infection was confirmed by PCR test, etc. (e.g., handling persons who had close contact with infected patients) so far. However, it is now more necessary than ever before to realize the signs of cluster infections before confirmation with a test.

Based on the results of analyses, clusters are divided into several categories according to their characteristics.

• “Difficult-to-detect early” cluster: It is defined as a cluster for which the evidence of infection itself is difficult to detect by the current system. Examples include clusters centered around (i) some communities of foreigners, and (ii) young people’s activities (e.g., university students’ extracurricular activities). The reason why these clusters are difficult to detect for (i) is probably that there are differences in the languages and tendencies to seek medical help, and for (ii) is probably that many young people present without any symptoms, even if they are infected.
• “Difficult-to contain” cluster: It is defined as a cluster that is difficult to contain because an infected patient had contact with many and unspecified people, making it hard to realize which persons had close contact with the patient. Examples include clusters at restaurants or nightclubs with hospitality services.

Specific actions

(1) Take effective and efficient measures according to the characteristics of each cluster.

• Restaurants/nightclubs with hospitality services: Promptly and surely proceed with the measures that have been proposed by the Working Group for Measures to Prevent the Spread of Infection in Entertainment Districts in Large Cities and summarized at the 13th Meeting of the Subcommittee (October 29, 2020) (e.g., the establishment of networks based on the relationship of trust, and the expansion of a consulting/testing system), expanding its target to other entertainment districts in local cities.
• Communities of foreigners: Support for communities of foreigners, and promotion of information provision and a consulting system in multiple languages and easy Japanese through multiple channels. For this purpose, collaboration with the embassy of each country, publicity activities by local governments, and cooperation with other organizations having networks and experience with communities (e.g., International Associations, NPOs and NGOs) are required.
• Higher education institutions (e.g., universities and professional schools): Concerning higher education institutions, clusters have been observed at drinking parties, dormitories, and other extracurricular activities rather than the classes as such. It is extremely important to achieve both infection prevention and to secure opportunities to learn. For this purpose, local governments should cooperate with the relevant organizations such as the health care centers providing advice for university students, etc. in the region to promote awareness raising with regard to infection prevention and speedy sharing of information when cluster infections occur. In addition, efforts should be taken so that people can promptly access medical consultations/examinations when necessary.
• Workplace: Concerning the workplace, clusters have been also observed at drinking parties after work, and rest places (e.g., smoking section) rather than the working place itself. Business operators should therefore pursue infection prevention measures more strictly in cooperation with industrial physicians, etc. In particular, they should take measures so that sick persons can take time off from work, and promptly cooperate with public health centers when the occurrence of cluster infection is suspected.

(2) To detect “difficult-to-detect early” clusters, a system to detect an unusual situation of unclear cause is required. This should be called “abnormal event detecting surveillance” and is also recommended as event-based surveillance (EBS) internationally. Local governments should therefore utilize an existing council on novel coronavirus disease control in each prefecture, etc. and cooperate with other organizations such as facilities for elderly persons and medical facilities. The (Nursery) School Absenteeism/Infectious Disease Surveillance System, and a system for analyzing data on SNS, etc. should also be utilized.

(3) Promptly establish a system to speedily share information among local governments and with the national government on (i) the onset date of infection, (ii) the latest information on the occurrence status of clusters,
and (iii) the best examples of cluster control, which have frequently been pointed out.

Action No.2 Information provision in an intera way  The 14th Meeting of the Subcommittee on Novel Coronavirus Disease Control

Background

We repeatedly sent out messages that the 3 Cs and speaking loudly increase the risk of infection. We have recently also proposed the “5 High-risk Scenes” and the “Ways to Enjoy Eating or Drinking Together while Reducing the Risk of Infection” to the government. Based on the recent infection status, however, it is possible that these messages have not always been delivered sufficiently to modify people’s actual behavior or maintain their modified behavior.

Specific actions

(1) Notify people, especially young people and participants of drinking parties (including year-end and new-year parties), of the “5 High-risk Scenes” and the “Ways to Enjoy Eating or Drinking Together while Reducing the Risk of Infection” (e.g., remove a mask only when eating/drinking and wearing it during conversation), etc. in a way that attracts their interests. In doing so, utilize various media including SNSs (e.g., video posting site).

(2) Provide information after understanding the possible feelings or reactions of recipients. Then, survey the effect and impact of the information, and make use of its result for the next provision.

Action No.3 Reliable implementation of infection prevention measures at stores, workplaces, etc.

Background

While the development of guidelines by industry type has been proceeded on site, clusters are still observed.

Specific actions

(1) Business operators should consider where the “5 High-risk Scenes” specifically exist at their own shops or workplaces and implement the guidelines by industry type on site without fail. In such cases, the relevant organizations such as the local government and local shopping district association should cooperate with them. The effectiveness of guidelines by industry type should be further improved based on past experience and new knowledge.

(2) For infection prevention measures in cold regions during the winter (e.g., ventilation), specific guidelines should be presented (e.g., carbon dioxide level should be monitored, especially at restaurants).

Action No.4 Reinforcement of efforts associated with the resumption of international traffic

Background

During the course of gradually resuming interactions with overseas countries, we should simultaneously implement joint quarantine measures and local infection control.

It is extremely hard for public health centers to individually monitor the health condition of people who have entered each regions in Japan because they have to handle such people in multiple languages. Increased numbers of people to follow up lead to a huge administrative burden and interfere with the operations of public health centers. In addition, increased numbers of infected patients from overseas require more beds.

Specific actions

(1) To simultaneously implement joint quarantine measures and local infection control, the government should (i) promptly organize and publicize information such as the number of quarantined persons as well as the numbers of persons who were tested and who tested positive by country/region where they stay at quarantine stations,  and (ii) speedily provide information related to quarantine to local governments.

(2) The government should immediately discuss a system to support the follow-up of foreigners in local governments. In addition, basic information on health monitoring, etc. should be provided in multiple languages during quarantine.

(3) Support for medical facilities that accept foreigners, etc. should be reinforced.

Action No.5 Promotion of genetic analysis to assess infection control

Background

Investigation of the viral gene sequence is effective to detect the origin of infection in regions where the situation concerning the spread of the infection is unclear. The number of cases where the link of the infected patient cannot be tracked in the region is increasing. Recently, cluster infections in communities of foreigners have also been reported by several prefectures. While some of them are found to be caused by domestically derived coronavirus, many of them are caused by coronavirus of uncertain origin.

Specific actions

(1) Investigation of the viral gene sequence is not only effective to detect the origin of a cluster, but also to assess infection control. Therefore, (i) make sure to send samples to the National Institute of Infectious Diseases via the Public Health Institute  or (ii) analyze the genetic sequences at the Public Health Institute and share the results with the National Institute of Infectious Diseases, and  (iii) share field epidemiological information at the same time.

[Conclusion]

1. In addition to the above 5 actions, the following proposals have been made at the subcommittee so far:

               Dispersing the New Year holidays,

               Promoting small-scale, decentralized travel, and

               Reinforcing public health center functions and the medical care provision system.

         Needless to say, it is essential to further promote these actions.

2. If the national or local government considers that the infection status has reached at least Stage III, which was proposed at the 5th Meeting of the Subcommittee (August 7, 2020), while taking the above 5 actions, we need to take stronger measures, such as setting a certain level of restrictions on social and economic activities. To avoid such a situation, citizens should pursue measures together.