1. The Great East Japan Earthquake Countermeasures Against Infectious Diseases in the Disaster-hit Area Kotaro Herai Supervisor for Infectious Disease Control Section, Health Safety Division, Bureau of Social Welfare and Public Health Tokyo Metropolitan Government

2. 1-(1) Overview of the Earthquake Intensity 7 Upper Intensity 6 Lower Intensity 6 Upper Intensity 5 Lower Intensity 5 Intensity 4 Intensity 3 Intensity 2 Intensity 1 Epicenter

3. 1-(2) Overview of the Tsunami Miyagi Prefecture Iwate Prefecture Fukushima Prefecture Legend Tsunami Alert Tsunami Warning Large Tsunami: Higher than 3m at its peak Around 0.5m at its peak Tsunami: Higher than 2m at its peak Epicenter

5. 1-(3) Earthquake and Tsunami Related Damage Prefecture Dead (people) Missing (people) Injured (people) Destroyed (fire) or Washed Away(homes) Partially Destroyed (fire) (homes) Flooded (homes) Iwate4,6641,51118820,1824,5392,084 Miyagi9,4922,0584,00876,07892,23418,255 Fukushima1,60423724118,18253,754401 Other6641,5054,26232,5064,084 Total15,8263,8105,942118,704183,03324,824 *Based on National Police Agency information as of October 20, 2011.

6. 1-(4) Earthquake and Tsunami Related Damage (People)

7. 1-(5) Earthquake and Tsunami Related Damage (Buildings)

8. 2-(1) Overview of the Earthquake and Tsunami in Miyagi Prefecture ○Occurred: Around 2:46 p.m. March 11, 2011 ○Epicenter Location: Off the Sanriku Coast (depth at seismic center: 24km) ○Scale: Magnitude 9.0 ○Max. Seismic Intensity: 7 (Kurihara City, Miyagi Prefecture) ○Tsunami: ・ As announced by the Sendai District Meteorological Observatory: Ayukawa, Ishinomaki City: Over 8.6m Port of Sendai: 7.2m *Reference (Research Group Estimates) Shizugawa, Minamisanrikucho: 15.9m Onagawa Fishing Port: 14.8m Utatsu, Minamisanrikucho: 14.7m *Compiled based on meeting documents from Miyagi Prefecture’s Disaster Response Headquarters Kurihara City Ayukawa Port of Sendai Onagawa Fishing Port Utatsu Shizugawa

9. 2-(2) Loss of Life Near Epicenter (Miyagi Pref.) Cities and Towns with More Than 500 Dead *As of September 13, 2011. *Compiled based on meeting materials from Miyagi Prefecture’s Disaster Response Headquarters and the Miyagi Prefectural Government’s website Sendai City (Pop. 1,046,902) Dead: 704 Missing: 26 Natori City (Pop. 73,576) Dead: 911 Missing: 72 Yamamotocho( Pop. 16,633) Dead: 670 Missing: 20 Kesennuma City (Pop. 73,279) Dead: 1,014 Missing: 392 Minamisanrikucho (Pop. 17,382) Dead: 558 Missing: 343 Ishinomaki City (Pop. 160,336) Dead: 3,170 Missing: 759 Higashimatsushima City (Pop. 42,859) Dead: 1,044 Missing: 94 Onagawacho (Pop. 9,965) Dead: 565 Missing: 411 Kurihara City Tome City Kesennuma City Minamisanrikucho Osaki City Kami-machi Shikamacho Wakuyacho Misatomachi Ishinomaki City Higashimatsuyama City Onagawacho Sendai City Taiwacho Ohiramura Osatocho Matsushimamachi Shichirigahamamachi Tomiyamachi Tagacho City Shiogama City Rifucho Natori City Iwanuma City Wataricho Yamamotocho Kawasaki machi Zaomachi Shiroishi City Kakuda City Shichikashuku machi Marumorimachi Murata machi Ogawara machi Shibatamachi

10. 2-(3) Number of Evacuees (Miyagi Pref.) Electricity Utility gas (Sendai-shi) Peak evacuees Number of evacuees declining *Compiled based on meeting materials from Miyagi Prefecture’s Disaster Response Headquarters, the Miyagi Prefectural Government’s website and Tohoku Electric Power Company’s website. People / Homes Homes without power Applicable homes which utility gas has yet to be restored Evacuees

12. 2-(4) Temporary Emergency Housing (Miyagi Pref.) *Compiled based on meeting materials from Miyagi Prefecture’s Disaster Response Headquarters Homes Housing completed Construction work started

15. 2-(5) TMG Assistance ・ Physical support ・ Material support ・ Cremation assistance ・ Enhanced transport structure for relief supplies, etc.

16. 3-(1) Risk Assessment of Infectious Diseases in the Disaster-hit Areas People in disaster-hit areas were forced to live communally in shelters (resulting in a new risk for the spread of infectious diseases). Taking this into account, the National Institute of Infectious Diseases presented its approach to an “infectious disease risk assessment.” Based on this, the National Institute of Infectious Diseases recommended the need for close monitoring of infectious diseases with a relatively higher risk of spreading in disaster-hit areas and shelters.

17. 3-(2) Infectious Disease Risk Assessment ①地域・避難所で流 行する可能性の評価 ②公衆衛生上の重要 性の評価 ③リスク評価 Opportunities for Transmission Transmission Risk Status Immunization Rate FewSettledHigh Some Worsened in certain areas High, but some susceptible individuals present ManyWorsened overallNo immunizations or vaccines CategoryPrevalence Rate / Fatality Rate 1 (Low)Low 2 (Medium)Higher than acceptable levels 3 (High)High Consequence to public health Potential to spread locally and in evacuation centers Low risk Medium risk High risk 1.Potential to spread locally and in shelters 2. Consequence to public health 3. Risk assessment

18. 3-(3) Risk Assessment Chart Potential to Spread in Disaster-hit Areas and Shelters Public Health Consequence Risk Assessment Comment Acute Diarrheal Illness ３２３ Reports of occurrences in shelters Acute Respiratory Tract Infection ３２３ Reports of occurrences in shelters Influenza / Influenza- like Illness ３３３ Reports of occurrences in shelters Measles ２３３ *Recognized case where a journalist spending time in the disaster-hit zone contracted the disease Tetanus ２３３ Reports of cases related to the earthquake disaster

19. 3-(4) Cases of Infectious Gastroenteritis Post-Quake (Miyagi Pref.) *The Great East Japan Earthquake struck in the 10 th week Kurihara Tome Kesennuma Osaki Ishinomaki Shiogama Sendai Sennan Ishinomaki Kurihara Sennan Sendai Shiogama Osaki Tome Kesennuma All of Miyagi Prefecture Number of cases per fixed-point surveillance medical institution (people) Infectious Gastroenteritis 11 th week (3/14) to 20 th week (5/22) of 2011Infectious Gastroenteritis 21 st week (5/23) to 30 th week (7/31) of 2011 (c)Miyagi Prefectural Institute of Public Health and Environment

20. 3-(5) Cases of Influenza Post-Quake (Miyagi Pref.) *The Great East Japan Earthquake struck in the 10 th week Kurihara Tome Osaki Kesennuma Sendai Shiogama Ishinomaki Sennan All of Miyagi Prefecture Number of cases per fixed-point surveillance medical institution (people) Kurihara Osaki Sendai Sennan Tome Shiogama Kesennuma Ishinomaki All of Miyagi Prefecture Number of cases per fixed-point surveillance medical institution (people) Influenza 11 th week (3/14) to 20 th week (5/22) of 2011Influenza 21 st week (5/23) to 30 th week (7/31) of 2011 (c)Miyagi Prefectural Institute of Public Health and Environment

21. 3-(6) Epidemic Situation of Infectious Diseases in Japan (Infectious Gastroenteritis) : 2011 *The Great East Japan Earthquake struck in the 10 th week Week Number of reports per fixed-point surveillance medical institution Infectious Gastroenteritis *Including cases reported as “children’s vomiting and diarrheal illnesses” up to March 1999

22. 3-(7) Epidemic Situation of Infectious Diseases in Japan (Influenza) Week : 2011 *The Great East Japan Earthquake struck in the 10 th week Influenza Number of reports per fixed-point surveillance medical institution

23. 3-(8) Occurrence of Tetanus Cases (Miyagi Pref.) WeekOccurrences 11 th 1 12 th 1 13 th 2 14 th 1 15 th 0 16 th 0 17 th 0 18 th 0 19 th 1 20 th and after0 In Japan: ・ DPT vaccines are given a total of 4 times to build basic immunity. 3 times between the age of 3 months and 7 years 6 months, and once one year after the 3 rd vaccination. ・ Additional immunity is provided with a single DT vaccination provided between the age of 11 and 12. Tetanus 11 th Week 14 th Week 17 th Week 20 th Week and After Cases

24. 4-(1) Increased Surveillance at Shelters Health consultations and visits performed by physicians and public health nurses Surveillance implemented in shelters Raised awareness about preventative measures, such as hand washing, gargling and coughing etiquette.

25. 4-(2) Shelter Surveillance Purpose: To ascertain occurrences of infectious diseases prone to shelters and quickly detect mass outbreaks. Performed surveillance by signs and symptoms, not by disease name. Reported by health volunteers, not by healthcare practitioners. Sent via fax not over the Internet. Critical to secure health volunteers that can make prompt and accurate reports. FAX Cough XX persons Diarrheal XX persons Fever XX persons FAX Shelters ： Public Health Center Weekly Report Detection of outbreak Health Volunteers

26. 4-(3) Flow of Shelter Surveillance Information Data registration Data shared Data analysis Data collection Flow of Shelter Surveillance Information Purpose of this surveillance program: For use in public health response to preventing illnesses and their spread Shelter Signs and symptoms Information collection Public health measures implemented by local governments, etc Infectious Disease Surveillance Center Shared with local governments, etc.

27. 4-(4) Shelter Surveillance Map Increase in cases Digestive symptoms Influenza Respiratory symptoms (excluding Influenza) Rash accompanying a fever People

28. 4-(5) Actual Conditions of Shelter Surveillance Not sufficient information was obtainable because many of the medical institutions that normally report fixed-point surveillance data were damaged in the disaster. Given the huge number of shelters, a system was set up to utilize permanent staff from these shelters as health volunteers to identify those exhibiting symptoms. In this regard, a call was made for cooperation. Even if electronic devices and specialized medical services are not available, a surveillance program could be initiated by those with the basic knowledge of epidemiology of infectious diseases. This could be possible even when medical infrastructure was damaged by the disaster.

29. 4-(6) Challenges and Solutions in Shelters from a Infectious Disease Countermeasure Perspective Epidemic season for the norovirus and influenza, etc. Large numbers of evacuees living communally in confined spaces. Unsanitary conditions found in facilities, such as restrooms, etc. People’s physical and mental strength decreases in the aftermath of the disaster. Countermeasures against source of infections Quick detection of occurrences Quarantine of people exhibiting symptoms Hygiene control of food Countermeasures against transmission routes Ensure sound interior environment by ventilating air, etc. Ensure proper environment for hand washing Sanitary control of restrooms Countermeasures for susceptible individuals Nutrition management Mental care Protective inoculations

30. 5-(1) Earthquakes and Infectious Disease (Japan) YearEarthquakeDeathsOccurrence of Infectious Disease 1923 Great Kanto Earthquake 105,385Increase in rabies cases the following year. 1948 Fukui Earthquake 3,769No particular occurrences noted. 1995 Great Hanshin- Awaji Earthquake 6,434No particular occurrences noted. 2004 Niigata Chuetsu Earthquake 68No particular occurrences noted.

31. 5-(2) Earthquakes and Infectious Disease (World) YearEarthquakeDeathsOccurrence of Infectious Disease 1999 Taiwan Earthquake 2,415 Increase in reported respiratory illnesses. Otherwise, no particular occurrences noted. 2004 Sumatra Earthquake 227,898 Increase in diarrheal illnesses in certain areas. Otherwise, no particular occurrences noted. 2008 Sichuan Earthquake 87,000 Trauma patients experiencing complicated symptoms of gas gangrene occurred on a several tens of thousands of people scale. 2010 Haiti Earthquake Over 220,000 Cholera outbreak with 270,000 infected, Led to 4,700 deaths.

32. 5-(3) Future Challenges Establish infectious disease countermeasures for situations when logistics and lifelines are cut- off. Provide support to public health activities and information sharing in disaster-hit areas and emergency rescue teams. Improve surveillance system for infectious diseases. Secure channels of communication during an emergency.

33. 6 Wrap-up Japan experienced an unprecedented natural disaster in the Great East Japan Earthquake and ensuing tsunami. With serious secondary and even tertiary damage, such as the nuclear power accident caused by the tsunami, a long-term support is required. Although a large-scale infectious disease epidemic did not occur, we need to keep relevant records from this disaster to utilize in future countermeasures.

34. Thank you very much. Tokyo Sky Tree