We are a voluntary independent group of experts who have been advising the government of Japan and its prefectures regarding the COVID-19 pandemic since early 2020. On June 18, 2021, we published this paper and handed it to the president of the Tokyo Organizing Committee of the Olympic and Paralympic Games and to the Prime Minister. We asked the president of the organizing committee to deliver it to the presidents of the International Olympic Committee (IOC) and the International Paralympic Committee (IPC).

A voluntary independent group of experts for for COVID-19 response in Japan:
Hideaki Anan, Yuki Furuse, Hideki Hasegawa, Akifumi Imamura, Satoshi Kamayachi,Akihiko Kawana, Yoshihiro Kawaoka, Hideo Maeda, Kazutoshi Nakajima,Yoko Nakazawa, Hiroshi Nishiura, Norio Ohmagari, Nobuhiko Okabe,Shigeru Omi, Ken Osaka, Hitoshi Oshitani, Yoshihiro Ota, Ayumi Seiko, Motoi Suzuki,Yoshihiro Takayama, Kiyosu Taniguchi, Kazuhiro Tateda, Kazunori Tomono,Koji Wada, Takaji Wakita, Masaki Yoshida(In alphabetical order)

Note
This recommendation was originally released in Japanese on June 18th, 2021. This recommendation has been partly submitted to the Japan Medical Association Journal.
Frequently asked questions were newly added in English version on June 27th, 2021.
Corresponding to: Koji Wada (kwada@iuhw.ac.jp)

Summary

1. As the COVID-19 pandemic continues through the duration of the Tokyo Olympic and Paralympic Games in Tokyo (hereinafter, the Games), it is necessary to avoid increases in the number of infected patients in communities and the resulting overwhelming of healthcare capacity until widespread vaccination can suppress the number of patients with severe symptoms. Even if vaccination efforts progress, it is possible that the number of patients with severe symptoms will increase again between July and August 2021. Additionally, the potential impact of new variants must be considered.

2. Compared with ordinary sporting events, the Games are in a league of their own in terms of scale and public attention. Additionally, the Games coincide with summer vacation and the nationwide Obon festival period. These conditions create risks for increased virus transmission and the overwhelming of healthcare systems resulting from the increased movement of people and social contact around the country triggered by the Games.

3. Depending on how spectators are admitted to the venues, there is also a risk of disseminating contradictory messaging to people around the country watching the Games at home. Organizers should consider this carefully when making decisions on the number of spectators who will be allowed at the venues.

4. We believe that the ideal option is to have no spectators in the venues at all, as the risk of transmission would be the lowest compared with other options. If spectators are to be allowed, the following three points should be considered:
a. Apply a stricter standard on the number of spectators allowed than what is currently set for large-scale events;
b. Limit spectators to area residents so as to minimize the flow of people and contact across prefectural lines. Additionally, the spectators should be limited to those who can adhere to prevention measures, including during travel to and from the venues;
c. If signs of increasing numbers of infections or strain upon healthcare capacities are detected, immediately and without hesitation switch to no spectators in the venues. Do not miss the opportunity to act before the situation worsens.

5. We would like for the Organizers to collaborate with government agencies to cancel supporting events and watch parties where crowds of unspecified numbers of people may gather, and to request that restaurants and bars refrain from hosting similar events with large crowds. Additionally, we request that the Organizers lead Japan in advocating for adapting available technology in new ways to enjoy sporting events that allow safely sharing the inspiration of sports around the globe.

6. The government should prepare to take necessary measures (such as declaring a state of emergency) if signs of an increase in COVID-19 infections or strain on healthcare capacities is detected, even if this occurs during the Games, without hesitation or missing the opportunity to act before the situation worsens.

7. The Organizers and the government must immediately share with the public and maintain public understanding of how the risks that have been communicated to them are being recognized, how such risks are going to be reduced, and what situations will result in more drastic measures.

[1] Introduction

We are a voluntary independent group of experts who have been advising the government of Japan and prefectures regarding the COVID-19 pandemic since early 2020.

We are neither in a position nor have the authority to make decisions on whether the Games should be cancelled or how the Games should be held.

With that stated, moving forward with the Games could possibly put more stress on the country’s healthcare system in addition to the existing risks of increased transmission and strained healthcare systems. As such, we believe that it is our duty to evaluate the risks associated with the Games and state our opinions; therefore, we have compiled these recommendations.

These recommendations have two purposes: The first is to advise how to avoid an increase in COVID-19 transmission and overwhelming of healthcare systems during the Games and after June 20th, when the state of emergency will be lifted in many areas, until such time as vaccination efforts result in the suppression in the number of patients with severe symptoms. The second is to evaluate the direct and indirect risks associated with the Games so that Organizers and other stakeholders can make appropriate decisions.

[2] Status of COVID-19 around the globe

Even today, around 400,000 new cases and 10,000 deaths are reported daily worldwide. In the Northern Hemisphere, countries that had successfully controlled transmissions previously are seeing a rapid increase in the number of cases. In the Southern Hemisphere, African and South American countries are seeing upward trends in number of deaths.

In the Northern Hemisphere, numbers of cases are declining in high-income countries such as those in Europe and North America. While vaccination efforts in these countries have clearly contributed to the decline in number of cases, lockdown measures and weather patterns are both likely also contributing to the decline in cases; thus, it is important to note that it is not vaccinations alone that are responsible for the declining number of cases. For example, Great Britain, where vaccination rates are relatively high, is still seeing an increase in number of cases. In the United States as well, cases are rising in some areas despite high vaccination rates. It will be important to continue to monitor these trends (Figure 1).

Additionally, there are many countries in Africa and the Pacific where no large waves of COVID-19 have occurred or that have not experienced significant impact from the new variants. It is important to remember that these countries may not have the same medical resources as others.

[3] Status of COVID-19 in Japan

Currently, compared with other countries, Japan’s number of COVID-19 cases per capita is relatively low; however, a state of emergency was declared through June 20, 2021 in 10 prefectures as maintaining standard levels of healthcare became difficult between ordinary care and COVID-19. Of these 10 prefectures, one prefecture has extended the state of emergency through July 11, and seven prefectures have moved to “Measures Implemented to Prevent Spread”.

Measures such as requesting citizens to refrain from going out and limiting alcohol service as well as limiting operating hours at restaurants and bars to reduce the flow of people and contact to minimize number of new cases remain in effect.

In Tokyo, the primary site of venues for the Games, the decline in number of new cases has plateaued. This is raising concerns around resurgence of cases as the movement of people begins to increase.

[4] Risk for increase in transmissions and overwhelming of healthcare systems after late June 2021

(1) Risks that exist regardless of whether the Games are held
Up to this point, Japan has repeatedly experienced a cyclical pattern of lifting of the state of emergency and reduction in new cases, leading to an increase in flow of people that is followed by a renewed increase in new cases after 2–3 weeks.

While it may appear as if virus transmission is being suppressed, the movement of people in metropolitan areas has only continued to increase even during the state of emergency; thus, the probability of increase in transmission into July is high (Figure 2).

During the summer in particular, people travel long distances, have social contact with those who are not in their usual circles over vacation, and then travel to return home. Even in areas where transmission rates have fallen, the possibility that the transmission rates will suddenly increase becomes high (Figure 3a, Figure 3b, Figure 4).

Additionally, we have also repeatedly experienced that when infections spread in metropolitan areas, after some time they eventually spread across the country. As such, if the Olympics occurring in late July cause people to begin to travel across prefectural borders, the flow of people and contact will increase, potentially increasing transmission risk across the country. Furthermore, by the time the Paralympic Games are held in late August, there is a risk that the number of patients with severe symptoms will increase, and healthcare systems will be overwhelmed (Figure 5, Figure 6a, Figure 6b).

 In terms of the trends in COVID-19 variants, the Alpha variant is currently the dominant variant in Japan; however, the Delta variant is also increasing in incidence. This Delta variant is suggested to have higher transmissibility, which could increase the speed of transmission compared with previously (Figure 7).

Vaccinations are underway mainly among the elderly, thanks to the efforts of many healthcare workers and local governments. The vaccine is thought to be effective in preventing onset as well as severe disease, so it is expected that new cases and patients with severe disease among the elderly will decrease towards the end of July as vaccination progresses. A certain level of risk of severe disease will remain for the elderly who are not vaccinated, as well as for older adults. An increase in transmission could increase the number of patients with severe disease and overwhelm the healthcare system. In the event of such a scenario, progress in vaccination could also be greatly affected.

(2) Additional risks that arise by holding the Games
There are two categories of risks that can arise by holding the Games:
a) Risks that are the Organizer’s responsibility to control
b) Risks that are controlled under the collaborative responsibility of the Organizer, the government, and local governments of the venues where the Games will be held

For risks in category a), there have been discussions and preparations by the Organizer. With the efforts taken by the Organizer, it is expected that the transmission risk will be sufficiently controlled.

However, the risks in category b) cannot be controlled without the collaboration of the Organizer, the government, and local governments of the game venues. Additionally, these risks are much more likely to induce transmission and overwhelm the healthcare system. Unfortunately, discussions around b) have not been conducted sufficiently. As such, this document will focus on the importance of controlling risks in this category.

a. Risks that are the Organizer’s responsibility to control
1) Cluster occurrence among athletes and other personnel related to the competition
It is expected that the transmission risk among athletes and other personnel related to the competition can be controlled sufficiently by the Organizer’s efforts. However, it should be noted that there are those in this group who remain unvaccinated, and that there are limits to the testing technology.

2) Leaking of transmission from within the bubble to outside of the bubble
Staff other than athletes (sponsors, media, etc.) have a higher likelihood of spreading the infection outside of the bubble compared with the athletes. These personnel should adhere strictly to the Playbook which the organizing committee published and use sufficient prevention measures.

3) Transmission at the venues
Transmission risks are lowest if the Games are held without spectators.

If spectators are to be allowed, enforcing a strict cap on attendance and strictly adhering to the Playbook could minimize transmission at the venues.

As the number of spectators increases, it becomes more difficult to enforce prevention measures and the risk of transmission increases. Higher numbers of spectators also mean an increase in the number of necessary staff (volunteers, security, etc.).

Even with similar numbers of spectators, transmission risk may vary depending on each venue’s local community transmission rates.

4) Spread to other countries from the Games
If prevention measures are not enforced and adhered to in the bubble during the Games, there is a risk that athletes and other personnel could return to their home countries as carriers of the virus.

b. Risks that are controlled collaboratively by the Organizer, the government, and local governments of the venues
1) Increase in flow of people and contact as a result of holding the Games
These Games are in a league of their own in terms of scale and public attention when compared with ordinary sporting events.

On the basis of documents from the Tokyo Organising Committee of the Olympic and Paralympic Games, the peak number of tickets sold per day across the venues in four prefectures (including Tokyo) is around 430,000. In comparison, on an average day, the same four prefectures’ sports audiences add up to around 47,000 in professional baseball and 7000 in professional soccer. The Olympics are clearly in a different league at a much larger scale. The flow of people and social contact, as well as opportunities to eat and drink, are expected to increase tremendously.

The Games will entail various categories of events scattered across the country, mainly in Tokyo, in a short amount of time. The degree of popular attention and social impact will also be significantly different from any other type of event. People moving across prefectural lines to attend an event will necessarily require eating and drinking as well as lodging at the origin and the destination, increasing opportunities for high transmission risk scenarios to emerge.

Additionally, previous experience shows that increases in the movement of people and social contact related to annual events and vacations especially contribute to increases in viral transmission. While summer vacation may mean that commuting by students should decrease, the increase in travel due to the Olympics will have different characteristics, because the purpose of this travel is to watch in-person sporting events and not to attend school.

These Games are also a once-in-a-lifetime, extraordinary event for many citizens as well. Opportunities for social contact with people who are not in their usual circles will increase at restaurants, bars, and at home. This would increase the risk of transmission. Public viewing and support events are also expected to contribute to increases in the movement of people, social contact, and opportunities for eating and drinking. There could be high-risk behavior among those whose adherence to social distancing and prevention measures have worn thin, such as people who are excited by the Games giving high-fives to strangers in a large crowd of people.

2) Contradictory public messaging about transmission prevention
To prevent an increase in transmission and overwhelming of healthcare systems, the leadership of the national government and local governments combined with cooperation from ordinary citizens is absolutely necessary. If people see the Games contributing to increases in social contact in the media while being asked to cooperate with restrictive prevention measures, it could appear to be a contradicting message. Such contradiction could inhibit further cooperation from the public.

If Games are held late into the night, this likewise will be a contradicting message to the public who are being asked to limit hours of operation and refrain from going out at night. Such contradiction could similarly inhibit further cooperation from the public.

[5] Choices to reduce the risk of increased transmission

Japan’s COVID-19 response relies heavily on the voluntary cooperation of the public. The will of the people has had a major role in the successes and failures of response measures. We believe that it is the responsibility of the government to provide an explanation that can gain understanding and support from the people on response measures and the need for them going forward. This explanation and request for cooperation must be undertaken as soon as possible. This will also be an important foundation for continuing with prevention measures that will outlast the Games.

1. Recommendations to the government: Transmission risk reduction measures that should be implemented beginning in late June
The government must do everything possible to avoid putting serious pressure on our healthcare system until we can expect the vaccines to suppress the number of patients with severe symptoms after June 20th through the end of the Games. We would like for the following to be considered:

1.1 Continued prevention measures and economic support
Continue strong prevention measures past late June. At the same time, we recommend swiftly implement measures to support those who have voluntarily cooperated with prevention measures for over a year and have been forced into economic hardship or are at risk of economic hardship.

1.2 Preparation period to hold the Games
Once the state of emergency is lifted, the number of cases may once again increase. We urge the government to prepare to continue to monitor and evaluate signs of rapid increases in transmission. Additionally, it is necessary to prepare to make decisions and implement measures swiftly once those signs are observed.

1.3 Immediately before the Games
If there is a possibility that our healthcare system will be overwhelmed just before the opening of the Games and there is a need to declare a state of emergency, it would be extremely difficult to hold the Games as planned. To avoid such a situation, the government must implement strong measures once signs of an increase in transmission are observed, without hesitation and without missing the opportunity to act before the situation worsens.

1.4 During the Games
If there is a high likelihood that our healthcare system will be overwhelmed during the Games, strong measures must be implemented in appropriate areas without hesitation and without missing the opportunity to act before the situation worsens.

2. Recommendation to the Organizer: transmission risk reduction measures at the Games
The organizer should have a plan of measures in place now based on transmission status in the country for when the Games are held and make announcements to the public regarding those plans early.

2.1 Reduce the scale of the Games
The Tokyo Organising Committee of the Games is already considering limiting the number of media and sponsors that can be present at the Games and working towards reducing capacity. Such reduction efforts should continue.

2.2 Adopt a policy on spectators
On the basis of risk analysis, events without spectators obviously show the lowest transmission risk and present the ideal option.
If spectators are to be allowed into the Games, we recommend the organizers to consider the following:
a) The Olympics are in a league of their own in terms of scale and attention compared with ordinary sports events. As such, in limiting the number of spectators, current large-scale event standards are insufficient, and a stricter standard should be applied.
b) Spectators should be limited to local residents so as to limit the flow of people across prefectural lines. Additionally, attendance should be limited to those who are able to adhere to prevention measures, including during travel to and from the venues. (For example, an idea might be to invite elementary school students from local areas with permission from their parents and local governments.)
c) If there are signs of increasing transmission or overwhelm of the healthcare system, immediately switch to no spectators in the venues. Do not miss the opportunity to act before the situation worsens.

2.3 Make a statement regarding measures that will be implemented if domestic transmission status is to worsen
Immediately announce the measures that will swiftly be taken by the Organizers if the status of COVID-19 in Japan should worsen.

2.4 Propose a new style in viewing and supporting sports during a pandemic
We recommend that the organizers cancelling watch parties and subsidiary events where an unspecified number of people gather in crowds (such as public viewings), cancelling streaming live events on large screens on the streets, and requesting that restaurants and bars, etc., refrain from public viewings with the purpose of supporting the Games.
We also request that the stakeholders of the Games and the media share “new styles in viewing and supporting sports during a pandemic” beyond Japan utilizing various technologies available, and advocate for new methods to enjoy sports events that allow safely sharing the inspiration of sports around the globe.

[6] Final remarks

Organizers and the government must immediately share with the public how the risks that have been communicated to them are being recognized, how they will be reduced, and what situations will result in more drastic measures.

Organizers, the government, and prefectures with Olympic venues should work toward operations that will continue to foster cooperation with prevention measures among the public and will not waste all the cooperation and effort by the public in adhering to prevention measures thus far.

On the basis of past experience, we believe that if signs of increased transmission or strain on healthcare systems are detected, it will be necessary to implement strong measures without hesitation and without missing the opportunity to act before the situation worsens. We will continue to monitor the status of COVID-19 transmission and will make recommendations around necessary response measures.

Acknowledgements

In developing these recommendations, we would like to extend our gratitude to Mr. Harumi Ishikawa, Dr. Kaori Muto, Dr. Taisuke Nakata, and Dr. Atsushi Nishida (in alphabetical order) and others who have helped compile this document. We also appreciate Mieko Kikuchi-Conbere for her translation of this document into English. We thank John Daniel from Edanz (https://jp.edanz.com/ac) for editing a draft of this document.

Frequently asked questions

Q. Why has a voluntary independent group of experts published the recommendations instead of the government advisory panels?
A. Over several months, the risk of Olympic-linked infections has not been discussed as an official agenda at any of the government advisory panels, despite the need to do so. For this reason, we decided to publish the recommendations as a voluntary independent group.

Q. Did the IOC and the IPC receive the recommendations?
A. According to the organizing committee, they translated our recommendations into English and transferred them to the IOC and the IPC before June 20.

Q. Why didn’t you recommend that the Olympic and Paralympic Games be canceled?
A. The decision to hold or cancel the Games rests with the organizers of this event, and not with us. However, in the process of preparing this paper over almost two months, we discussed several times whether we should recommend the postponement or cancelation of the Games. As time went on, it became clear that the government and the organizing committee had decided to hold the Games as scheduled. In fact, it was reported that the Prime Minister had obtained firm support for holding the Games on June 13 at a G7 summit meeting in Britain. For this reason, we perceived that recommending cancelation would be pointless. Instead, we inserted sentences such as ‘Events without spectators obviously show the lowest transmission risk and present the ideal option’ and ‘If there are signs of increasing transmission or overwhelm of the healthcare system, immediately switch to no spectators in the venues. Do not miss the opportunity to act before the situation worsens’.

Q. Japan has the most hospital beds per 1,000 people among all 37 members of the OECD. According to the WHO Coronavirus (COVID-19) Dashboard, confirmed cases and deaths are both low in Japan. Why do you recommend that the risk of Olympic-related infections is important?
A. Japan is a super-aging country and has the highest proportion of elderly citizens of any country in the world. Most of Japan’s hospitals are small or midsized private entities with limited human resources. This system is suited to elderly patients with chronic diseases but not suitable for the pandemic. In addition, the percentage of people fully vaccinated is still under 10%. We must prevent another large wave of infection until most of the population is fully vaccinated.