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Assessing the Regional Impact of Japan's COVID-19

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Open access Original research BMJ Open: first published as 10.1136/bmjopen-2020-042002 on 15 February 2021. Downloaded from Assessing the regional impact of Japan’s COVID-19 state of emergency declaration: a population- level observational study using social networking services Daisuke Yoneoka ,1,2,3 Shoi Shi,4,5 Shuhei Nomura ,1,3 Yuta Tanoue,6 Takayuki Kawashima,7 Akifumi Eguchi,8 Kentaro Matsuura,9,10 Koji Makiyama,10,11 Shinya Uryu,12 Keisuke Ejima,13 Haruka Sakamoto,1,3 Toshibumi Taniguchi,14 Hiroyuki Kunishima,15 Stuart Gilmour,2 Hiroshi Nishiura ,16 Hiroaki Miyata1 To cite: Yoneoka D, Shi S, ABSTRACT Strengths and limitations of this study Nomura S, et al. Assessing Objective On 7 April 2020, the Japanese government the regional impact of Japan’s declared a state of emergency in response to the novel ► Using data from the social networking service (SNS) COVID-19 state of emergency coronavirus outbreak. To estimate the impact of the declaration: a population- level messaging application, this study, for the first time, declaration on regional cities with low numbers of observational study using social evaluated the impact of Japan’s declaration of a COVID-19 cases, large- scale surveillance to capture the networking services. BMJ Open state of emergency on regional cities with low num- current epidemiological situation of COVID-19 was urgently 2021;11:e042002. doi:10.1136/ bers of COVID-19 cases. bmjopen-2020-042002 conducted in this study. ► This study succeeded in capturing the real- time Design Cohort study. epidemiology of COVID-19 using SNS data in local ► Prepublication history and Setting Social networking service (SNS)- based online additional material for this Japan and identified several geographical hot spots. survey conducted in five prefectures of Japan: Tottori, paper are available online. To ► Caution is necessary as the data were limited to SNS Kagawa, Shimane, Tokushima and Okayama. view these files, please visit users. Participants 127 121 participants from the five the journal online (http:// dx. doi. ► The results might include recall bias as the data prefectures surveyed between 24 March and 5 May 2020. http://bmjopen.bmj.com/ org/ 10. 1136/ bmjopen- 2020- were based on questions asking COVID-19-rela ted Interventions An SNS- based healthcare system 042002). symptoms during the past 1 month. named COOPERA (COvid-19: Operation for Personalized DY, SS, SN, YT, TK and AE Empowerment to Render smart prevention And care contributed equally. seeking) was launched. It asks questions regarding postcode, personal information, preventive actions, and INTRODUCTION Received 25 June 2020 COVID-19, an infectious disease first reported Revised 02 December 2020 current and past symptoms related to COVID-19. Accepted 29 December 2020 Primary and secondary outcome measures Empirical in Wuhan, Hubei Province, China, has Bayes estimates of age- sex- standardised incidence rate given a lesson in the difficulty of preventing (EBSIR) of symptoms and the spatial correlation between emerging infectious disease epidemics in a on September 27, 2021 by guest. Protected copyright. the number of those who reported having symptoms and global society.1–3 About 1 month after the first the number of COVID-19 cases were examined to identify COVID-19 case report in early January, the the geographical distribution of symptoms in the five first case in Brazil, over 16 000 km away from prefectures. China, was confirmed, and as of May 11, 215 Results 97.8% of participants had no subjective countries and territories have been confirmed symptoms. We identified several geographical clusters of to have been infected, with 4 006 257 cases fever with significant spatial correlation (r=0.67) with the 4 5 number of confirmed COVID-19 cases, especially in the and 278 892 deaths. urban centres of prefectural capital cities. The WHO’s declaration of Public Health © Author(s) (or their Conclusions Given that there are still several high- Emergency of International Concern due to employer(s)) 2021. Re- use permitted under CC BY-NC. No risk areas measured by EBSIR, careful discussion on COVID-19 at the end of January triggered commercial re- use. See rights which areas should be reopened at the end of the state many countries to shut down their national and permissions. Published by of emergency is urgently required using real- time SNS borders. However, the virus has spread and BMJ. system to monitor the nationwide epidemic. domestic countermeasures were urgently For numbered affiliations see implemented, including lockdown of major end of article. cities or the whole country. Until 24 March Correspondence to 2020, around 20% of the global popula- Dr Hiroaki Miyata; h- m@ keio. jp tion were estimated to be in some form of Yoneoka D, et al. BMJ Open 2021;11:e042002. doi:10.1136/bmjopen-2020-042002 1 Open access BMJ Open: first published as 10.1136/bmjopen-2020-042002 on 15 February 2021. Downloaded from lockdown.6 The lockdown can surely prevent the spread non- specific symptoms (fever and strong feeling of weari- of virus, but it is difficult to maintain for a long period ness or shortness of breath) with the PCR testing in the because there is a trade-off between economics and epide- five prefectures; and (2) to identify potential risk areas miology.7 US President Trump has issued guidelines for by analysing the number of participants with non-specific restarting economic activity, but ultimately the decision symptoms and (3) to assess any change before and after is reserved for state and municipal leaders.8 However, the state of emergency. This social networking service to determine the optimal timing of restarting social and (SNS)- based epidemiological analysis would provide economic activities, the number of infected residents in pertinent information to control the COVID-19 epidemic the whole city, instead of the number of confirmed cases in real time, which requires rapid decision making. in hospitals, is a necessary information.9 To address it, a system to more easily and effectively track positive but unconfirmed cases in real time is urgently needed. METHODS In response to the gradual increase in PCR- positive Data sources and participants COVID-19 cases with an untraceable transmission COOPERA uses a chatbot that asks participants to report pathway, the Japanese government declared a state of individual information, including their medical condi- emergency for 7 of the 47 prefectures on the evening of tions (non-specific symptoms, such as fever and fatigue) 10 11 7 April and extended it nationwide on 16 April. This as well as personal characteristics (see the Outcomes of declaration has limited legal force to prohibit people interest section). The details of COOPERA can be found from moving, which distinguishes it from the so-called in Yoneoka et al.16 18 COOPERA recruits participants via ‘lockdowns’—city blockades with penalties—already in the LINE app using a QR (quick response) code page effect in the USA, UK, France, Germany, Italy and India, in the prefecture’s website. We obtained data on 127 964 and thus it is essentially driven by the voluntary efforts of participants who live in Tottori, Kagawa, Shimane, 10 11 Japanese residents. In this sense, Japan has a unique Tokushima and Okayama prefectures in Japan (figure 1) and voluntary- based lockdown policy to weaken the from 24, 26, 27, 30 and 31 March to 5 May 2020, respec- spread of the infection. Since the declaration, in propor- tively. In this study, those who were 15 years of age and tion to the decrease in the number of infected people, older were included. For those who used the COOPERA the importance of the discussion on how to announce multiple times, only the first answer was used in the anal- the end of the state of emergency and social confine- ysis. The five prefectures consist of relatively small and ment is increasing. However, even when the number of local cities with populations of 0.56 (47th among 47 COVID-19 cases has decreased, since it is affected by the prefectures), 0.96 (39th), 0.73 (44th), 0.67 (46th) and total number of PCR tests and the likelihood of mild cases 1.89 (20th) million, respectively, as of April 2020 (ie, 2.7% presenting for testing, it does not mean the epidemic is of the total population is covered in this study). In addi- completely controlled. tion to the COOPERA data, we extracted the number of http://bmjopen.bmj.com/ A questionnaire- based big data analysis can provide infor- PCR- confirmed COVID-19 cases from each prefecture’s 12 13 mation in support of economic reopening, but classic web page. monitoring methods of this kind are time-consuming and logistically challenging. In early April, in collabo- Outcomes of interest ration with LINE Corporation, Kanagawa Prefecture COOPERA collects personal information regarding (1) launched a novel healthcare support system in Japan, demographic characteristics, including age, gender, occu- called COOPERA (COvid-19: Operation for Personal- pation and postcode; (2) medical information, including ized Empowerment to Render smart prevention And medical history and preventive actions for COVID-19; on September 27, 2021 by guest. Protected copyright. care seeking).14 LINE provides one of the most famous and (3) health conditions, including onset dates of social network services in Japan, with over 80 million current and past 1 month symptoms related to COVID-19 users. Through the LINE app, COOPERA provides (ie, fever, strong feeling of weariness or shortness of users a questionnaire that collects information on demo- breath) and the duration of these symptoms. For those graphics, preventive actions, and medical and physical who report any symptoms, COOPERA further asks about conditions. In response to the provided information, medical visits and clinical diagnoses, as well as psycho- COOPERA provides personalised support, such as tele- logical conditions,15 which are out of focus of this study.
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