Japan's National Scheme for - Public Health Ontario · Japan's National Scheme for Public Health Security ... tsunami and nuclear power plant accident in March 2011 ... -Elucidation

Japan's National Scheme for Public Health Security

Tomohiko Makino, MD, MPH, MBA

Office of Public Health Emergency Preparedness and Response (IHR National Focal Point of Japan)

Health Science Division, Minister’s Secretariat

Ministry of Health, Labour, and Welfare (MHLW) of Japan

[email protected]

Today’s Topic 1. Introduction

2. MHLW’s response to the combined Great East Japan Earthquake, tsunami and nuclear power plant accident in March 2011

3. Mechanisms for Health risk management and coordination in MHLW

4. IHR core capacity implementation: IHR NFP function in Japan

5. Topics: Tokyo Sarin and Pandemic H1N1 2009

[Disclaimer] This presentation was prepared or accomplished by Tomohiko Makino in his personal capacity. The opinions expressed in this presentation are the author's own and do not reflect the view of the Ministry of Heath, Labour and Welfare, or the Government of Japan.

No conflict of interests to disclose.

Landscape of Health Risk of Concern in Japan

• 1940s ～ 1950s Infectious Diseases • 1960s ～ 1970s Environmental Pollution • 1980s Medication Scandal (e.g. HIV-tainted blood incident)

• 1990s ～ Earthquake Emerging Disease Medical Malpractice WMD/Terrorism Climate change

Year Health Crisis Event Mass Gathering Event

1995 Hanshin-Awaji Earthquake Tokyo Subway Sarin Attack

1997 O157 Food Poisoning

1998 Arsenic-laced Curry Incident

1999 Criticality Nuclear Accident

2000 Contamination of Daily Products by S.aureus Volcanic Eruption (Miyakejima)

Kyushu-Okinawa G8 Summit

2002 SARS FIFA World Cup

2004 Niigata-Chuetsu Earthquake Acute Encephalopathy caused by Mushroom

2005 Railway Crash

2007 Niigata-Chuetsu Earthquake

2008 Imported Contaminated Dumplings Incident Tohyako G8 Summit

2009 Pandemic Flu

2010 APEC Japan

2011 Tohoku-East Japan Earthquake, Tsunami & Fukushima NPP Accident

Key Public Health Crises in Japan

Combined Disaster – another issue of public health challenge

Ministry of Health, Labour and Welfare

• Minister’s Secretariat

– Health Sciences Division

• Office of Public Health Preparedness and Response

• Health Policy Bureau

• Health Service Bureau

• Pharmaceutical and Food Safety Bureau

• Labour Standards Bureau

• Employment Security Bureau

• Human Resources Development Bureau

• Equal Employment, Children and Family Bureau

• Social Welfare and War Victim’s Relief Bureau

• Health and Welfare Bureau for the Elderly

• Health Insurance Bureau

• Pension Policy Bureau

• Director-General for Policy Planning and Evaluation

Office of Public Health Emergency Preparedness and Response

Our role

•Intelligence (consolidating information, investigation, analysis and communication) on domestic/international health crisis event

– IHR National Focal Point (since 2007)

•Coordinating emergency response to health emergency event by unknown causal (or in the uncertain phase)

– Secretariat for Health Risk Management Coordination Meeting

•Preparedness

– Table Top Exercises (TTX)

– Medical Countermeasure Preparedness: Smallpox Vaccine etc.

Enhancement of Function of Cabinet Secretary

• In November 2003 Cabinet reorganized first response scheme of the government, integrating different response schemes for different risks and threats.

• In case of a major incident,

“Emergency Assembly Team”

(members are responsible persons of relevant agencies) are convened .

Assessment of Scale of Incident

Is made on following criteria:

-Severity

-Range of Effect

-Availability of Countermeasures

-Elucidation Status of Causes

Incident

Press

report

report Report/instruction

Report/instruction

Cabinet Intelligence & Research

Office Situation Center (24h/day) - Deputy CCS for Crisis Management

- Assistant CCS for National Security and

Crisis Management

- Cabinet Councilor for Crisis Management

If necessary to collect information & coordinate consultation to emergency incidents

Consequence Management Office

Public/private sector Ministries

Prime Minister

Chief Cabinet Secretary (CCS)

Deputy CCS

Dispatch

members

Crisis Management Center Assembling member

ministries

Emergency Assembly Team

Emergency Response Policies

Task Force for Emergency Response Situation

Cabinet Meeting

National Security Council

Special Advisory Committee for

Contingency Planning

Consequence Management Headquarter

(Prime Minister may establish CMHQ.)

Recognize “emergency response situation”

（in case of an

“emergency

response

situation”)

First Response Scheme to Major Incidents

Under

the Cabinet Office

Each phases for Health Security

Prevention

Early

Detection

Response

Mitigation

International cooperation

Intelligence

CIQ

Surveillance

Local response

Control of terrorists/agents

Disaster Management

Medical and health care

Reconstruction

Simultaneously collaborated

Police

Self Defense Force

Intelligence, Embassies

Coast Guard (MILT)

Nuclear Powerplant (MEXT)

Medical response (MHLW)

Immigration (MOJ)

Quarantine (MHLW & MAFF)

Custom (MOF)

Natio

nal re

sp

on

se

event

(Prophylaxis)

(Checkups)

(Treatment)

Lifestyle (e.g. No smoking)

Routine Examination

(Rehabilitation)

Intensive Care, Surgery, etc

Outpatient Follow-up

1. Public health emergency response to the combined Great East Japan Earthquake, tsunami and nuclear power plant accident: perspective from the Ministry of Health, Labour and Welfare of Japan.

Damage by the Great East Japan Earthquake

at 14:46 on March 11th, 2011

Human Suffering

Death 15,878

Missing 2,713

Wounded 6,126

Housing Damage

Total Collapse 129,724

Half Collapse 267,663

Partial Collapse 731,673 ×

（As of December 25th, 2012 by Cabinet Office）

March 11th

Epicenter

Pacific Plate

North American Plate

Philippine Plate

Eurasian Plate

Sufferers

Evacuees 321,433

Rescued victims 27,157

Damaged

Property

Total $210 billion

（As of June 24th, 2011 by Cabinet Office）

Characteristics of 3/11 Disaster

• The 4th largest earthquake in the history

(Mw 9.0)

• Followed by numerous aftershocks (>M7.0, 6 times; >M6.0, 93 times; >M5.0, 560 times)

• Huge tsunami

– Wetted surface: 561 km2

13

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

15

morioka-times

16 http://www.coastal.jp/

17

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

Tsunami Evacuation Area

Mw Wetted

Surface Area

Dead

& Missing

Destroyed

houses

Great East-

Japan 2011 9.0 561 km2 >17,000 >120,000

Anticipated

Scenario

8.6 270 km2 2,700 9,400

18

Characteristics of 3/11 Disaster

• The reality far exceeded the anticipated scenario

• Many municipal office had a destructive damage; lost their functions.

19

Characteristics of 3/11 Disaster

http://www.city.anjo.aichi.jp/mayor/message/2011/07.html

Town Mayor and many executives died by Tsunami during the emergency meeting at Otsuchi Town Municipal Office Building, Iwate Prefecture

automaticshut down

coldshut down

Unit 1 524 MW, 1984-Unit 2 825 MW, 1995-Unit 3 825 MW, 2002-

Unit 1 460 MW, 1971-Unit 2 784 MW, 1974-Unit 3 784 MW, 1976-Unit 4 784 MW, 1978-Unit 5 784 MW, 1978-Unit 6 1,100 MW, 1979-

Unit 1 1,100 MW, 1982-Unit 2 1,100 MW, 1984-Unit 3 1,100 MW, 1985-Unit 4 1,100 MW, 1987-

Unit 1 1,100 MW, 1978-

Tokai Dai-ni

Onagawa

Fukushima Dai-ichi

Fukushima Dai-ni

4 Nuclear Power Stations with 14 Units

Nuclear Power Stations Nuclear Reactors near Epicenter of the Earthquake

Periodical

inspection

21

Earthquake and Tsunami hit the Nuclear Power Plant

Epicenter

The height of tsunami which attacked Fukushima NPP#1 was higher than 15 m

The earthquake and tsunami destroyed the external power supply of the nuclear reactors.

The prime minister declared the nuclear emergency at 19:03 on March 11th.

Fukushima Dai-ni NPP

Fukushima Dai-ichi NPP Source: www.tepco.co.jp

Source: www.tepco.co.jp

Earthquake

Ship accident

Release of Radiation

High tide

Others (train, plane)

Storm

Volcano eruption

Heavy rain

Other natural phenomenon Heavy snowfall

Fire or wildfire

Flood

Explosion

Disasters

Tsunami

Combined Disaster This is the first time that the world has experienced such a complex

emergency involving earthquake, tsunami and nuclear accident.

What happened in Tokyo?

23

×

Tokyo

24

Stranded Commuters

25

26

Do you poo more than usual due to the earthquake?

27

Rolling Blackouts

MHLW’s Response

• 14:46, March 11th – M9.0 Earthquake hit in Sanriku offshore

• 14:50, March 11th

– Disaster Response HQ of MHLW was set up

• 09:00, March 12th

– Local Disaster Response HQ of MHLW was set up in 3 prefectures (Miyagi, Iwate, Fukushima)

MHLW’s Response

• Rescue and Relief – Dispatched 340 teams (1,500 members) of

Disaster Medical Assistant Team (DMAT) from March 11th to 22nd

– DMAT engaged in medical relief operations such as hospital support, transfer of patients within the area, wide-area medical transport and transfer of hospitalized patients.

29

Damage at hospitals and clinics in the affected areas

（as of 11 July, 2011）

Prefecture Number of hospitals Damage by the Great East Japan Earthquake

Completely destroyed Partially destroyed

Iwate 94 3 59

Miyagi 147 5 123

Fukushima 139 2 108

Total 380 10 (2.6%) 290 (76%)

Prefecture

Number of clinics Damage by the Great East Japan Earthquake

Medical Dental Completely destroyed Partially destroyed

Medical Dental Medical Dental

Iwate 927 613 38 46 76 79

Miyagi 1,626 1,065 43 32 581 367

Fukushima 1,483 919 2 5 516 374

Total 4,036 2,597 83 (2%) 83 (3.2%) 1,173 (29%) 820 (32%)

MHLW’s Response

• Coordination of dispatching healthcare professionals such as

– 2,662 Medical Assistance Teams • From Japan Medical Association, etc.

– 1,394 Nurses

– 1,915 Pharmacists

– ~2,900 dentists

– 11,255 Public Health Practitioners

– 57 Mental Healthcare Teams • Psychiatrists and Nurses

A meeting of a medical team

MHLW’s Response

• Securing Pharmaceutical Supply

– Assisting nation-wide procurement

– Assisting logistics of drug whole-salers and distributors

• priority supply of gas and emergency pass for vehicles which carries pharmaceutical supplies were granted

• Self Defence Forces and US military Helicopters were used for shipping

32

Other MHLW’s Roles

• Nursing care and welfare services

• Health Insurance System/Pension

• Employment

• Provisional Housing

• Water supply

• Food and Water Safety

2. Mechanisms for Health risk management and coordination in MHLW

34

Establishment of Health Risk Management Framework in MHLW

• Triggered by HIV-tainted blood scandal in 1980’s

– More than 1,800 haemophilia patients

contracted HIV via tainted blood products

– A Review Report by the Project Team for

Preventing a Recurrence of Medication-related

Health Disaster (July 1st, 1996) pointed out the

importance of sharing health risk information

and early alerting and response to

prevent such a health risk event .

Memorial stone

• “Basic Guideline for Health Risk Management in MHLW” (January, 1997)

– Office of Public Health Emergency Preparedness and Response was established

– To enhance sharing information on health risk event among relevant departments and coordinate response in MHLW, “Health Crisis Management Coordination Meeting” was established.

Establishment of Health Risk Management Framework in MHLW

Health Risk Management in MHLW

“Operations for prevention, mitigation, and medical countermeasures for threats and risks for public health caused by medication, food poisoning, infectious diseases, drinking water and other causes”

37

“Basic Guideline for Health Risk Management in MHLW” (January, 1997)

Health Risk Management Coordination Meeting

• A key platform for information sharing, risk assessment and coordination of managing health risk event

• Bimonthly (2nd & 4th Friday) Regular Meeting for information sharing and consulting

• Agenda

– Drug-related incidence, Food Safety, Outbreaks, Nosocomial infections, Natural Disasters, Medical incident report, &etc. (e.g. missile launch by North Korea etc.)

• May hold a provisional meeting for initial risk assessment and response when a potential health hazard was recognized.

Guidelines and Manuals for Health Risk Management

• National level

– Basic Guideline for Health Risk Management

– Health Risk Management Manuals in

• each department responsible for Drugs/ Infectious Diseases/ Drinking water/ Food poisoning

• Public health research institutes (e.g. NIID)

• MHLW’s local branch

• Local level

– A guideline for Health Risk Management at the local level

Public Health Risk Management in MHLW

Information on Domestic/International Health Risk

Relevant Org overseas

Office of Public Health Emergency Preparedness and Response （Information Gathering and Analysis, Early Phase Response, Planning and Implementation of Training)

Relevant Org. e.g. Cabinet Secretariat

Information Sharing

Cooperation

Coordination Command

Report Regular/Provisional Coordination Request

for Response

Report

Information Sharing

Public./ Local Health Center/ Hospitals/ Local Government/ Regional Bureau/ National Research Institutes/ Relevant Org Overseas, etc.

Health Crisis Management Coordination Meeting Sharing Info, Coordinating Response & Intervention

Offices responsible for Health Crisis

Implementation of Response & Intervention

Minister (& Vice Minister) of MHLW, etc. HQ Command Report

Health Crisis Management

Committee

Consultation

Relevant Divisions

National Research Institutes

NIID/NIPH/NIHS, etc

e.g. Safety Division, Pharmaceutical and Food Safety Bureau (Drug

Adverse Events), TB and Infectious Diseases Control Division (Infectious Diseases), Water Supply Division (Drinking Water), etc.

Local Government

Hospitals Local Health Center

Regional Bureau

Scientists

Health risk information report from research projects funded by MHLW

Health Risk Info

Assessment by relevant departments and experts

Health Risk Management Coordination Meeting

Response Feedback

to Investigators

Grading by investigators A：Critical B：Calling for attention C：Reference

IHR Core Capacity Implementation

~ IHR NFP Function in MHLW ~

Implementation of revised IHR

IHR(2005)

• Is an international agreement which is legally binding on all WHO Member States.

• Was adopted at the 58th WHA in 2005.

• Has come into force on 15 June 2007 replacing the previous IHR(1969).

The purpose of the IHR(2005)

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

→ take all measures to prevent international spread of disease.

The major changes in the IHR(2005)

1 Broader scope “Public Health Emergency of International Concern”

(PHEIC) “PHEIC is an extraordinary event:

i. to constitute a public health risk to other States through the international spread of disease and

ii. to potentially require a coordinated international response.”

※ Disease means “an illness or medical condition, irrespective of origin or source, that presents or could present significant harm to humans.”

The broadened scope of the IHR covers existing,

new and re-emerging diseases, including

emergencies caused by

non-infectious disease agents.

The major changes in the IHR(2005)

2 Notification - mandatory notification of any event to WHO that may

constitute a PHEIC within 24 hours assessment of

public health information

i. Use of the decision instrument (Annex 2)

ii. Notify within 24hours of assessment of all event that may constitute a PHEIC (Article 6)

iii. Continue to communicate with WHO… including case definitions, laboratory results, source and type of the risk, number of cases and deaths, conditions affecting the spread of the diseases, health measures employed…(Article 6)

Decision Instrument (Annex2)

Assess the event whether to notify the WHO based on the following points

1 public health impact serious ?

2 unusual or unexpected ?

3 risk of international spread ?

4 risk of travel/trade restriction ?

* A case of the following diseases shall be notified: Smallpox, Poliomyelitis due to wild-type poliovirus, Human influenza caused by a new subtype, SARS.

The major changes in the IHR(2005)

3 National IHR Focal Points (Article 4 ) - be accessible at all times

4 Definition of core capacities (Annex 1) - strengthen and maintain the capacity to detect, report and respond rapidly to public health events.

5 Recommended measures (Article 15-18) - make every effort to implement WHO- recommended measures

6 External advice regarding the IHR (Article 48-49)

NFP Functions under IHR (2005)

Senior

Management

NFP (24/7)

WHO

(24/7)

National PHE command

& response structure

Functions

within the country

• Consolidating info

• Disseminating info

Functions (with WHO):

• Consultation

• Notification of a potential PHEIC

• Information sharing

• Other reports

• Verification

• Determination of a PHEIC

• Coordinated response to a PHEIC

Relevant depts/agencies •Surveillance & response

•POE

•Food safety authority

•MoA

•Others

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Public Health Risk Management in MHLW

Information on Domestic/International Health Risk

Relevant Org overseas

Office of Public Health Emergency Preparedness and Response （Information Gathering and Analysis, Early Phase Response, Planning and Implementation of Training)

Relevant Org. e.g. Cabinet Secretariat

Information Sharing

Cooperation

Coordination Command

Report Regular/Provisional Coordination Request

for Response

Report

Information Sharing

Public./ Local Health Center/ Hospitals/ Local Government/ Regional Bureau/ National Research Institutes/ Relevant Org Overseas, etc.

Health Crisis Management Coordination Meeting Sharing Info, Coordinating Response & Intervention

Offices responsible for Health Crisis

Implementation of Response & Intervention

Minister (& Vice Minister) of MHLW, etc. HQ Command Report

Health Crisis Management

Committee

Consultation

Relevant Divisions

National Research Institutes

NIID/NIPH/NIHS, etc

e.g. Safety Division, Pharmaceutical and Food Safety Bureau (Drug

Adverse Events), TB and Infectious Diseases Control Division (Infectious Diseases), Water Supply Division (Drinking Water), etc.

Local Government

Hospitals Local Health Center

Regional Bureau

Scientists

C country A Country

B Country

Domestic relevant organization,

ministries and agencies etc.

Member Countries

WHO IHR Contact Point

Emergency Committee

Notice Consultation Provision of information

WHO

MHLW

Transmission of the information

Food Safety Division

Surveillance Quarantine

Operations and Management

Division

Community Health Division

Local information gathering

Other Health Risk Management

Divisions

Tuberculosis and Infectious

Disease Control Division

Information gathering

IHR Secretariat

Certifying “Public Health

Emergency of International

Concern“.

Health Risk Management

Coordination Meeting

Health Risk Management Committee Evaluation of the potential event which

may fulfill the component of "Public

Health Emergency of International

Concern“.

Flow of Information Based on the Revised IHR(2005)

D country

Focal Point of Japan (Health Science Division, MHLW )

NFP of Japan’s activities

• Notification of PHEIC to WHO – A/H1N1(2009)pdm

• First case at quarantine (May 9th, 2009)

• Identification of Tamiflu-resistant strain (July 3rd, 2009)

– Nuclear Power Plant accident after March 11th Earthquake and Tsunami in 2011

• Disseminating information to relevant sectors – recommendation from WHO DG

– Information on the Event Information Site

• Exchanging information with other NFPs – Notification of patient/close contacts with patient among travelers

(e.g. Measles, TB, Shigellosis)

• Inquiring WHO for health emergency event in other countries