JMA Policy on Crisis Management Policy According to SARS Countermeasure Levels
By Kunio Yukishita, Chief, JMA Infectious Disease Crisis Management Countermeasure Office

Introduction
Information about JMA's SARS countermeasures was published in the JMA News (July 5, 2003 issue). Detailed information was provided on coping with suspected cases of SARS and countermeasures on what action to take if a patient who unknowingly visited outpatient services was diagnosed with SARS (suspected case or possible case).

In addition, "Guidelines for Diagnosis and Treatment of Infectious Diseases", edited by JMA and the Ministry of Health, Labor and Welfare (MHLW) that provides information on SARS examination, treatment and patient management was published in the Sept. 1, 2003 issue of the JMA Journal as supplementary information.

There have been no reported cases of SARS in Japan at present. But in preparation for a possible occurrence, measures have been divided according to the following three levels and the optimum countermeasures that should be taken are explained.

An explanation of SARS crisis management countermeasures for each level is shown below.

(1) Organizing medical facilities (see Fig. 1)

1) Organizing Medical Facilities with Hospitalization Capacity for SARS Patients

There are 287 medical facilities with 739 beds throughout Japan that have been organized (as of May 27, 2003) to accept SARS patients. Following confirmation with each prefectural and city governments, information will be provided to all medical facilities.

2) Medical Facilities Assisting SARS Outpatient Examinations

There were only about 100 medical facilities designated to handle infectious diseases (Type 1, Type 2) that were capable of coping with outpatients. In view of the shortage, health facilities that could assist with outpatient examinations were publicly solicited and 759 facilities were recruited nationwide (as of October 6, 2003 to the present). Emergency subsidies of about 500,000 yen for partitions and other facilities and 400,000 yen for masks, gowns, gloves and other infectious disease protection gear were provided. Of the number of recruited health facilities, on average, there are two facilities for each secondary health care zone that will be in charge of conducting outpatient examinations for SARS during the initial stages of the disease.

3) General Health Care Facilities: Coping with Unexpected Outpatients

Suspected or possible cases of SARS patients who visit general health facilities should be reported promptly to the Public Health Center and the patient will be transported to a designated medical facility (for hospitalization, initial examination). A set of required protective gear, N95 mask, gown, and gloves (the JMA triple set) will be sent to each district, city, and ward medical association, the city and prefectural medical associations, and the JMA. In addition, each Public Health Center will be provided a stock of 100 sets by the government. Each district, city, and ward medical association will hold meetings with Public Health Centers in advance and will set up a system that will enable health care personnel to cope rapidly with the situation in the event of a SARS epidemic.

(2) Training and Cultivating Physician Awareness

"Guidelines for Diagnosis and Treatment of Infectious Diseases", edited by the JMA and the MHLW that provides information on SARS examination, treatment and patient management was published in the Sept. 1, 2003 issue (p805 to p810) of the JMA Journal (JMAJ) as supplementary information and distributed all JMA members. In addition, information from the WHO, the MHLW, and the National Institute of Infectious Diseases (NIID) has also been disseminated each time. In the event there is an occurrence of SARS in Japan, preparations should be made to cope courageously and confidently with the disease through early detection and treatment to minimize any damages.

(3) Organizing an Information and Contact Network (see Fig. 2)

The JMA Infectious Disease Information Network will enable an interactive exchange of information among members as well as improve the exchange of opinion with the MHLW and NIID as part of the strategy to establish a crisis management system.

(4) Influenza Countermeasures (Vaccinations) for the Elderly and Health Care Personnel

(1) Strengthen water's-edge operations

Taking advantage of the revisions that have strengthened the Infectious Disease Law and the Quarantine Law that were put into effect in November 2003, water's-edge operations that implement drastic protection measures against infectious diseases entering Japan.

1. Advice on traveling, restricting travel to infected areas
2. Ascertain health awareness through questionnaires (air flights from infected areas)
3. Check body temperature using thermography and thermometers
4. Health check after disembarkation

Mandatory report on the health conditions of personnel who had worked at a SARS examination health center and persons entering the country, who have had contact with a SARS patient, by the quarantine station for a specified period of time (incubation stage of the disease).

5. Import Ban on Animals (enforced at all times)

(2) Referring SARS Outpatients to Health Facilities Through Telephone Counseling

Telephone counseling services for referrals to a health center for either outpatient services or hospitalization will be actively carried out for patients who have a fever higher than 38°C, experience coughing, shortness of breath and other respiratory symptoms and who have returned to Japan from an infected area within the past ten days or have been in close contact with a SARS patient in the last ten days.

(3) In-depth SARS Information

It is important to quickly disseminate detailed information about the occurrence of SARS in other countries to health facilities and the general public.

(4) Designate Potential Epidemic Areas and Strengthen Countermeasures

In some cases, when the area of origin of the disease in other countries is designated, it is possible to project the potential area where the disease may enter Japan by implementing intervention methods in that district. Strengthening surveillance and preventive measures in districts designated as potential epidemic areas is effective.

(5) Setting Up a Base of Operations for Countermeasures

The JMA Infectious Disease Crisis Management Room will act as a base of operations that will be responsible for implementing crisis management countermeasures. This strategy was reported in the JMAJ article, "Information on Infectious Diseases and Food Poisoning". A base of operations for JMA SARS countermeasures will be created for Level 2. Information will be collected from the MHLW, NIID, quarantine stations, health facilities, and others and published in the JMAJ as SARS related information, which will be disseminated to JMA members and the general public.

Full effort will be focused on early detection. If SARS is discovered, it must be contained. Countermeasures to contain one occurrence of SARS include shutting down the facility, restricting the work of health care personnel, and other mandatory acts if disinfection alone is inadequate to prevent the onset of an epidemic. Efforts to contain the disease will inevitably produce losses. Therefore, such losses must be kept to a minimum and subsidies must be provided for health facilities.

More than 30 percent of health care personnel had fallen victim to the SARS epidemic in Guangdong province in China, which spread throughout the global community. It is said that one Chinese physician was the carrier that spread the disease. The carrier who created the SARS panic in Japan was a physician from Taiwan. Physicians must acquire accurate knowledge and awareness of the disease, in order to confront it. It is their responsibility to be able to reassure the general public during an epidemic. We must expend all possible means to allow physicians to fulfill this responsibility safely.