Public Relations Magazine for NCGM

Feel the NCGM
National Center for
Global Health and Medicine

Office of Public Relations

Special
Issue
No. 2

July 2021
Special Issue
No. 2

NCGM Fights against COVID-19– Lessons Learned (2nd Edition) –Photos: NCGM COVID-19 on-line seminar for the press (top left), Vaccination for NCGM staff (top right), Nursing care in the High Care Unit (bottom)

Feel the NCGM

Special Issue July 2021

The NCGM COVID-19 Task Force and Organization

Foreword

Chairman (Hospital Director)

Vice Chairmen- Deputy Hospital Director- Director, Disease Control andPrevention Center- Director, Department of Emergency
Medicine & Critical Care
- Nursing Director- Secretary General, General
Administrative Department

Norihiro Kokudo, President
National Center for Global Health and Medicine

Members of the Task Force- Hospital Management and Planning
Board- Heads of departments- Manager, Clinical Laboratory
Department- Persons/individuals appointed by the
ChairmanCommittee for the Severe and Seriously Ill

Committee for the Moderately Ill◎ Director, Department ofEmergency Medicine &Critical Care
○ Head, Intensive Care
Department○ Head, Department ofEmergency Medicine &Critical Care

◎ Deputy Hospital Director(in charge of patient
examination/care)○ Administering physicianof the 5F West ward
○ Chief Physician, Divisionof Preparedness andEmerging Infections

Infection Control Team
◎ Director, Disease Control andPrevention Center○ Deputy Manager, the Infection
Control Team

Committee for the Fever Clinic

Committee for the Surgical Division◎ Director, Disease Control
and Prevention Center○ Chief Physician,
Department of Infectious
Diseases◎ Deputy Hospital Director(in charge of surgeries)○ Director, Operation
Management Department

Feel the NCGM Special Issue No. 2 July 2021
Table of Contents/The NCGM COVID-19 Task Force and Organization 
Foreword 
1. Overview of NCGM History in Response to Various Health Issues and Our Multifaceted Role 
2. Treatment and Nursing of COVID-19 Patients and Suspected Patients 
3. Policy Recommendations 
4. Countermeasures against COVID-19 at Our Emergency Department 
5. Health Checkups and Tests Conducted on Returnees on Chartered Flights from Wuhan 
6. Cruise Ships: Diamond Princess and Costa Atlantica 
7. Accomplishment and Future Outlook of Development Research of COVID-19 Therapeutics
Led by NCGM 
8. Responses to COVID-19 Outbreak in Hospitals/Facilities 
9. From COVID-19 Registry Japan (COVIREGI-JP) to REBIND 
10. International Cooperation and Joint International Research 
11. Releasing of Academic Achievements 
12. The Fever Clinic and the Community-Based “Shinjuku Model” System 
13. Creation of a New Model for Recovery in Accommodation Facilities for COVID-19 Mild or
Asymptomatic Cases 
14. In Closing: Preparing for the Post-COVID-19 Era 

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National Center for Global Health and Medicine (NCGM) is a National Center whose primary
missions include infection control. Our staff members have strived as a team to tackle Coronavirus
Disease 2019 (COVID-19). We carried out physical examinations and PCR testing of Wuhan
returnees in late January 2020. In February, the following month, some staff members boarded
the cruise ship anchored in Yokohama to cooperate in addressing the COVID-19 cluster amongits passengers. Affected passengers included some severe cases. We started to provide them withintensive care while struggling to find effective ways to control this unknown virus. Examination
data from 11 early cases, and their treatment methods and clinical courses, were promptly
published on our website, and were actively used nationwide as a reference by institutions thatwere then treating COVID-19 patients.
Reflecting back on NCGM’s long history of over 150 years, we have responded to numerous
pandemics in the past, starting with the Spanish flu of 1919, SARS of 2003, swine flu of 2009,
Dengue fever of 2014, the Ebola outbreaks of 2014, 2018, and 2019. We have always been fully
trained and prepared for such crises as one of the four medical institutions in Japan designated fortreatment of specific infectious diseases, having a total of four beds available for this treatment(which is the most out of all four institutions). Due to our efforts and preparedness, we were able
to act swiftly in the midst of this pandemic, and we are thankful that no nosocomial clusters of
COVID-19 cases have been reported in NCGM as of the writing of this message.
For our activities in responding to COVID-19, we addressed a wide range of needs regarding
the treatment and research of COVID-19, including development of new therapeutic drugs,
convalescent plasma therapy, and advanced medical care for the severely ill, establishment of
COVID-19 Registry Japan (COVIREGI-JP), fever clinic, and the Shinjuku City COVID-19 Testing
Center, support for the mildly ill accommodated in hotels, and vaccination to government VIPs.
Since the beginning of the pandemic, we had felt an urgent need for organizational researchand development to contain the spread of this unknown disease, and we launched a “Novel
Coronavirus Infection Academic Advisory Board” in the beginning of February 2020. This Board
covered a wide range of fields related to COVID-19, including treatment, testing, pathophysiology,
and epidemiology. They also aided in the development of research protocols, coordinated with
the IRB, managed and advised through the course of trials. More than 100 projects are currently
underway, and as many as 124 papers have already been published in academic journals. The
above NCGM activities to address the COVID-19 pandemic are recorded in this booklet.
In Japan, vaccination began in February 2021 first for healthcare providers, followed by elderly
people and high risk patients. Vaccination is rapidly progressing, and a workplace vaccination
program has also begun. However, as of the writing of this message, the fourth wave of thepandemic and the spread of virus variants are matters of great concern. It is still unclear when thispandemic will end. We at NCGM will continue to strive as a team to confront this challenging
disease. Through this booklet, I would like to express my respect and gratitude to all of thehealthcare workers and NCGM staff who are fighting against COVID-19.
July 2021

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Feel the NCGM

Special Issue July 2021

Overview of NCGM History in Response to Various Health Issues and Our Multifaceted Role

1

Akira Harita, Director General, Bureau of Strategic Planning, NCGM

Health issues that NCGM confronted in the past

COVID-19

A/H1N1swine flu

Japanese Embassy
hostage crisis in Peru
Army Temporary
Hospital
SARS
China, Vietnam

Tokyo Army Hospital

Spanish flu

MERS

Ebola hemorrhagic fever
West Africa

Dengue fever

Ebola hemorrhagic fever
Democratic Republic of the Congo

COVID-19 Responses by NCGM
The one and only medical institution capable of undertaking
a multifaceted role in public health and medical treatment

Providing info/advising the
National and Tokyo
Metropolitan
Governments
Development oftreatment methods
Novel drugs, andconvalescent plasma
therapy(vaccines)
Development of
diagnostic tests
Antibody/antigen tests
Severity prediction
methods

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Quarantine
Response to
COVID clusters

Functions as
general hospital
Treatment ofmoderate andsevere cases

Community healthcare
PCR testing center
Management of hotels
for mild cases

Ever since the establishment of the “Army Temporary Hospital”(currently NCGM) in 1868, we have always played a pivotal role inresponding to health issues in Japan. We still have medical records
preserved of numerous patients that were treated at Tokyo Daiichi
Eiju Hospital during the Spanish flu pandemic in 1918-1920, over
100 years ago.
The accumulation of our experience within this century in
confronting emerging/re-emerging infectious diseases such as
SARS, H1N1 swine flu, MERS, Ebola hemorrhage fever, andDengue fever outbreaks is being put to use in our current

COVID-19 response. NCGM is not only a general hospital offering
advanced medical care to patients with various diseases, including
infections, but a medical institution capable of undertaking a
multifaceted role in public health and medical treatment. This
includes providing advice and information to government policymakers, conducting quarantine/responding to COVID-19 clusters,
studying and developing treatment methods, novel drugs, andvaccines, developing diagnostic tests and severity prediction
methods, conducting epidemiological studies, performing genome
analysis, creating a patient registry, and taking part in the local
healthcare cooperation system as seen in the “Shinjuku Model.”Epidemiology
Genome analysis
Patient registry5Feel the NCGM

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Special Issue July 2021

Treatment and Nursing of COVID-19 Patients and Suspected Patients
Norio Ohmagari, Director, Disease Control and Prevention Center (DCC), Center Hospital, NCGM
Tatsuya Okamoto, Head, Intensive Care Department, Center Hospital, NCGM
Tomoko Sato, Nursing Director, Center Hospital, NCGM
Yuko Sugiki, Deputy Manager, 5th Floor West Ward, Center Hospital, NCGM

Miho Takahashi, Manager, HCU, Center Hospital, NCGM
Masayuki Hojo, Head, Department of Respiratory Medicine, Center Hospital, NCGM

Treatment of COVID-19 patientsAt NCGM, the first COVID-19 patient was identified among thepatients consulting with the Department of Infectious Disease inlate January 2020. Since then, our Hospital has treated numerous
patients. We also performed COVID-19 screening tests andprovided medical care to the patients who arrived in Japan on theflights from Wuhan, China chartered by the Japanese government
on January 29, 2020.
We initially had limited knowledge about the clinical featuresand natural course of this disease and its treatment as well. Thus,
we treated patients with Lopinavir/Ritonavir, of which in vitro
activity against SARS-CoV2 had been confirmed by applying our

experience and expertise. In February, many critically-ill patientswere frequently identified among the patients aboard the cruise
ship Diamond Princess, which had been anchored in YokohamaPort. In order to treat these patients, we ordered Remdesivir which
is an anti-viral drug from Gilead Science, Inc. in the USA, andstarted its compassionate use on the patients. In the same month,
we started preparing for multiregional clinical trials in collaboration
with the NIH (National Institutes of Health, USA) using Remdesivir,
and the investigator-initiated clinical trials were launched on March
25, 2020. Four different trials were conducted over about one year,
and the results demonstrated that the efficacy of remdesivir was
significantly higher compared to a placebo, and that the efficacy

Medical cases were quickly reported to deliver information to healthcare
providers nationwide.

of remdesivir in combination with baricitinib was significantly
higher compared to remdesivir alone. Based mainly on these data,
remdesivir and baricitinib were approved in Japan for the indicationof COVID-19 and have become clinically available. As of May 2021,
we are conducting a randomized comparative trial at NCGM toevaluate the efficacy of convalescent plasma. We also participatedin a global study of hyperimmune intravenous immunoglobulin(IVIG), and conducted a multicenter randomized comparative trial
to evaluate the efficacy of ciclesonide. While the expected efficacy
was not demonstrated in either investigated drug, it is important to
conduct clinical trials expeditiously to find effective drugs in order
to cope with emergency situations. In this sense, we think we haveplayed a prominent role in Japan.
Aside from the patients who disembarked from the Diamond
Princess, from February to March 2020, many patients who had
a travel history to Wuhan visited our outpatient department, andwere diagnosed with COVID-19 infection. However, in March, webegan to observe a pronounced rise in the number of COVID-19
patients who had not apparently traveled to Wuhan. Critical cases,
mainly of elderly patients began to be identified. Correspondingly,
the number of COVID-19 inpatients increased. In spite of
the nationwide state of emergency declared by the Japanese
government on April 7, 2020, as many as 48 patients including
eight patients on ventilators were admitted to our Hospital at thesame time in the following week.
After late April, the number of new inpatients gradually decreased,consequently, the total number of the patients in our Hospital
gradually decreased. However, the number of patients began
to increase again after the lifting of the state of emergency,
leading to the so-called “second wave” of the pandemic. In thisoutbreak, as opposed to the outbreak from March to May, fewer
patients were in a critically ill condition - probably because there
were fewer elderly patients - and most of the affected people wereyoung adults in their 20s-30s who acquired the infection mainly
in downtown areas. Therefore, the Japanese government did notdeclare a state of emergency during the second wave.

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The Japanese government made an effort to enhance economic
activity while trying to prevent COVID-19 transmission. However,this was not an easy task. The number of new COVID-19-positive
cases remained high in Fall, and began to increase with thedecrease in temperature in Tokyo in December 2020. With a rapid
increase in the number of new cases, the so-called third wave set
in at the end of December.
Under these circumstances, we also began to accept many
moderately or severely affected patients around this time. The
Japanese government declared its second state of emergency inJanuary 2021. During the third wave of the pandemic, in whichmost patients were elderly and most moderate or severe cases
were reported in Tokyo, many medical institutions in Tokyo
struggled to accept these patients. Even after February, clustersof COVID-19 cases were identified one after another in elderly
facilities and medical institutions, preventing a decrease in thenumbers of new positive cases and severe cases. The situation
finally settled in March, when long-awaited vaccinations began
for the NCGM staff members. With the cooperation of many staff
members from various departments, vaccination was conductedsmoothly and swiftly. Prime Minister Suga also came to NCGM to
receive his vaccination.
As of the writing of this section (May 1, 2021), the fourth wave of
the pandemic has reached Japan, and the government has declared
its third state of emergency. In Tokyo, there are currently about
2000 inpatients with COVID-19, and the number of moderatecases admitted is increasing. The situation in the Kansai region
is becoming of more concern. The number of severe cases has
already exceeded the hospital bed capacity for COVID-19 patients,
leaving about 15 thousand patients staying at home or waiting at
home for a hospital bed. The condition of some of these patients
at home has taken a sudden turn for the worse. We at NCGM
have renovated the High Care Unit (HCU) to prepare to accept
COVID-19 patients with severe symptoms.
(Norio Ohmagari)

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Feel the NCGM

Special Issue July 2021

Installing positive pressure ventilation system in Nurses’ station (Designation ofGreen Zone)

Treatment of critically ill COVID-19 patients in the ICU
On February 15, 2020, the first patient in critical condition(a Diamond Princess passenger) was admitted to room 10(negative pressure isolation room with an anteroom) in the ICU,
and underwent intensive care including bronchial intubation and
ECMO therapy, which was conducted without interrupting ournormal intensive care operations (Phase 1).
As the first wave surged in late March, we came to experience
difficulties in treating patients using the only bed provided for
COVID-19 patients during Phase 1. Correspondingly, five isolation
rooms were renovated in a week, installing ventilation systems
to achieve negative pressure environments and using vinyl sheets
to achieve positive pressure ventilation in the nurses’ station(designation of Green Zone). From April 2, these six beds wereconverted to exclusive use as an ICU ward for COVID-19 patients(Phase 2).
The healthcare providers of the ICU and the Departments ofEmergency Medicine and Critical Care, Respiratory Medicine, DCC,
ACC, Nephrology, Physical Medicine and Rehabilitation, Thoracic
Surgery and many others collaborated in providing medical care.
We also, held cross-sectional clinical conferences with healthcare
providers including nurses, ICT, PT, MT, twice a day including
Saturdays and Sundays to disseminate information about thecondition of the patients and treatment courses.

Daily clinical conferences

In comparison with typical acute respiratory distress syndrome(ARDS), COVID-19 patients are mechanically ventilated for a longer
period (longer than three weeks), and have a higher incidence ofcomplications such as pneumothorax, mediastinal emphysema,
oxygen toxicity, and ventilator-associated pneumonia (VAP). Manypatients required tracheostomy due to difficulties extubating.
Also, patients were required to engage in long-term rehabilitation
during the ICU admission and after leaving the ICU because of
severe muscle weakness. We were able to provide the mostadvanced medical care possible by conducting clinical trials of
antiviral drugs such as Remdesivir, Chloroquine, and AVIGAN®,
combining with treatments such as steroid therapy and blood
purification therapy using PMX to treat cases of cytokine storm.
We were able to enlist the help of young doctors from theEmergency Medicine and Critical Care Department and the Surgery
Department to supplement the shortage of healthcare providers.
Since December, Dr. Sekihara from the Thoracic Surgery
Department has also joined the dedicated staff to further enhance
our medical care.
We treated a total of 37 intubation patients (including three casesin the New Infectious Diseases ward) in about one year up to theend of March 2021. Among the ICU inpatients, 11 patients died(30%), seven patients were on ECMO (19%) and 25 patients were
eventually discharged (68%).
(Tatsuya Okamoto)

Performing tracheostomy wearing PPE/PAPR

ICU (0)5W (0)
DCC/HCU (7)

Total
Died
Discharged
Remaining hospitalized
ECMO
FemaleICU/HCU admission

2nd wave

New Infectious Disease ward
Admission of three patients (two on ECMO) between February
19 and March 29, 2020
Nurses: eight-hour shift (three or four nurses on day shift, twonurses on night shift)
Nursing care was provided to critically ill patients including
those on ECMO by nurses who were concurrently assigned to
the New Infectious Disease ward and were reinforcement staff
from the ICU.
ICU: Six beds (critically ill patients)
The first patient was admitted to the ICU from February 14 toMarch 5, 2020, and six beds were allocated for COVID-19
patients from April 1.
As infection prevention measures, the use of personal protective
equipment (PPE) was strictly implemented, and we also allocatedstaff to engage in ward environment preparation. Since alarms
became muffled due to the partitions, a nurse was stationed
inside of the partitions to communicate with the outside using atablet device, etc.
Since family members were not able to visit the patients, we
encouraged on-line visits using tablet devices and tried to help thefamily to understand and accept the medical condition of the patient.

West ward on 5th floor: 40 beds (patients in mild tomoderate condition, suspected patients)
Passengers on the chartered flights from Wuhan who wereconfirmed as being infected with COVID-19 or suspected of being
infected were admitted to this ward. When the number of criticallyill patients increased, four patients on ventilators were acceptedin this ward. Since it was a tuberculosis ward originally, nurses
were trained to administer nursing care using protective gear
(PPE), however, when there was a surge in the number of criticallyill patients, the reinforcement of personnel became necessary.
Normally, three nurses work the night shift, however, five to six
nurses were deployed on the night shift to address the situation.
14th floor (partial use), 13th floor (partial use), east
ward of 7th floor (one bed)
Due to an increase of the number of patients and critically illpatients, a shortage of beds had occurred in the west ward 5th
floor, so, that suspected patients with low clinical probabilities
were admitted to those floors. We installed partitions andimplemented infection prevention measures since those wards
were concurrently allocated to non-COVID-19 patients. Also, we
strived to ease the increasing anxieties experienced by both thepatient in isolation and their families by listening carefully to theirconcerns and providing detailed explanations.
(Tomoko Sato, Yuko Sugiki)

Yasutoshi Nishimura, the Minister in charge of the
COVID-19 response, visited NCGM on March 29, 2020.

Changes in numbers of intubated patients (up to March 31, 2021)
1st wave

Nursing of COVID-19 patients and suspected patients

Nursing in New Infectious Disease ward

Partitions in ICU nurses’ station

Anterooms were created in ICU rooms
Areas for PPE donningwere designatedwith posted manual.
Instructions for doffing
were posted insideward rooms.

3rd wave

DP

Designated area for PPE donning with posters
instructing their use.

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PAPRs (powered air-purifying respirators) were worn
during ECMO treatment.

9Feel the NCGM

Special Issue July 2021

3
Negative pressure beds in HCU

Necessity for remodeling
Air conditioning duct work was needed to make the HCU available
as a care unit for COVID-19 patients. Acrylic walls and doors were
installed to divide the ward into the infection-free area and thepotentially contaminated area. Before starting the remodeling, we
had a number of meetings with the parties concerned to discuss
the location of the anteroom and zoning. Three negative pressure
booths were installed to minimize the risk of transmission during
treatment or care provision.
Arrangement for necessary materials/devices
Arrangement for medical materials/devices was more difficult than
expected due to limited preparation time. Under the effects ofthe pandemic, infection prevention goods were thinly distributed
and the shipping took longer. We had to acquire various types ofgoods after opening the ward.
Staff training
Training related to infection prevention, such as the donningand doffing of PPE, zoning and the cleaning operation, wasrepeatedly implemented under the instruction of certified infection
control nurses, and training related to ECMO and CHDF was
also performed with the aid of doctors and clinical engineers.
We produced an educational video for nurses working in shifts,
creating an environment that allowed all the staff to be
sufficiently trained.
Opening of the ward
We started gradually reducing the number of patients admitted
into the HCU at the beginning of February. All patients were
removed from the HCU by the morning of February 15. In theafternoon of the same day, COVID-19 patients with severe
symptoms were admitted and the newly-opened ward started
its operation with seven beds. Working in PPE in the potentiallycontaminated area, healthcare workers were exposed to heatstress and had trouble breathing. N-95 masks made it hard tocommunicate. Work in this area was far more inefficient thanthat in the infection-free area, and the staff looked exhausted.
Being in an unfamiliar environment and feeling nervous about

Norio Ohmagari, Director, Disease Control and Prevention Center (DCC), Center Hospital, NCGM

HCU photographed from the station

Care and treatment at the High Care Unit (HCU)
At the beginning of 2021, there was a sharp rise in the numberof COVID-19 patients. We hurriedly decided to open the HCU asa ward for severe COVID-19 cases so that we would be able toaccept more patients with severe symptoms.

Policy Recommendations

caring for severely-ill patients, some of the staff members said they
were scared or they wanted the HCU to be remodeled back into
its original state. Meanwhile, some other staff members actively
discussed what to do to improve efficiency and to reduce the workburden. They eventually began recommending each other to takebreaks when working long hours, and the strained communication
between the infection-free area and the potentially contaminatedarea became much milder.
At the HCU, care and treatment were also provided to patientson ECMO. Because caring for these patients requires advanced
knowledge and skills, some mid- to high-level nurses who hadreceived relevant training, and who were nominated by certified
ICU nurses and the Manager, were assigned to this task. Less
experienced nurses wished to help these experienced nurses when
they saw them looking nervous and caring for patients on ECMO
with strained looks on their faces, despite having dealt with any
situation calmly and perfectly so far. The Manager of the ICU
promptly proposed to conduct a training program about carefor severely-ill patients. The training started in the ICU for young
nurses, mainly those with less than one year work experience.
These nurses, who had had difficulty performing many of theirtasks, began to actively study in advance for the next training
session. I still clearly remember them, eyes lit up, telling me thedetails of their ICU training.
Closing of the ward
Up until March 7, only COVID-19 patients with severe symptoms
were admitted to the ward. In response to requests to accept postsurgery patients as well, we divided the ward into the area for
COVID-19 patients with severe symptoms and the area for postsurgery patients, and started the operation the following day. Witha higher possibility of persons or materials crossing the infectionfree area and the possibly contaminated area, the relevant staff
members were required to be even more cautious. Later, COVID-19
patients tested negative for PCR, and the ward returned to theordinary HCU from March 22 onward.

Medical institutions and the administration must work in unison tohandle the COVID-19 pandemic. We at NCGM have contributed tovarious cases from administrative issues to policy recommendations.
From January 29, 2020, we started performing screening tests
for Japanese returnees from Wuhan, China followed by hospital
admissions of symptomatic patients. Our staff members weredispatched to support the Ministry of Health, Labour and Welfare(MHLW) in their mission to address the issues on the Diamond
Princess which had anchored in Yokohama Port in February.
Also, we supported the members of the United States Public
Health Service Commissioned Corps, a subordinate body of the
Department of Health and Human Service (HHS) that visited Japanto help American citizens on the cruise ship return to their homecountry. Their mission was to assess the situation of American
COVID-19 patients who were critically ill and support them andtheir family. NCGM helped the team collaborate with Japanese
medical institutions in helping the patients and theirfamilies (Photo 1).
Due to these circumstances, Remdesivir which was an unapproved
drug was decided to be subject to compassionate use not
only to critically ill American patients but also Japanese andother international COVID-19 patients. It was administeredto nine patients in Japan. In order to develop necessary drugs
for COVID-19 treatment speedily, we started preparing for
multiregional clinical trials using Remdesivir collaborating with
the NIH in USA, which was commissioned by MHLW, and began
investigator-initiated clinical trial on March 25 (Photo 2). The resultof this investigator-initiated clinical trial became the evidence for

special approval of Remdesivir for COVID-19 treatment on May 7.
A multicenter, randomized comparative trial using Ciclesonide
which was another candidate therapeutic drug for COVID-19 was
conducted principally at NCGM, which was also commissioned by
MHLW. Additionally, we created COVIREGI-JP, which is a registry
study, and as of June 21, 2021, clinical information on more than
42,000 patients has been accumulated.**Registration status as of June 21, 2021: 909 collaborating
institutions, 42,932 registered cases including 627 cases from
NCGM (including cases in the registration process).
Our staff members have been dispatched to the “Expert Meetingon Novel Coronavirus Disease Control” convened by MHLW in
response to the request for participation from the chairperson fromFebruary 2020, where we provide advice and make proposals to
the government from the standpoint of medical experts engaged intreating COVID-19. In addition, our staff participates in the Weekly
Novel Coronavirus Infection Monitoring Meeting established by the
Tokyo Metropolitan Government to assess the spread of COVID-19
and the status of medical institutions and provide advice on
policies as well (Photo 3). We also dispatch staff specialists to othermedical institutions in Tokyo experiencing incidents of nosocomial
infections.
In addition, we dispatched staff specialists as members of
the Development Committee for “Coronavirus Disease 2019
(COVID-19) Treatment Guidelines” and “Coronavirus Disease 2019
(COVID-19) Pathogen Testing Guidelines,” and contributed to theestablishment of national treatment guidelines.

Unfortunately, the COVID-19 pandemic has not yet ended. We
are ready to open the ward for COVID-19 patients with severe
symptoms at any time when there is a rapid rise in the number ofsevere cases.
(Miho Takahashi)
Photo 1 Commemorative photo taken on the day before departure of UnitedStates Public Health Service Commissioned Corps

Healthcare system at COVID-HCU
Three departments (Intensive Care Department, Respiratory
Medicine Department, and DCC) collaborated in taking care ofpatients admitted into the HCU. Treatment started under thefollowing two preconditions: 1) Up to seven patients (up to twopatients in each department) would be admitted into the HCU; and
2) The Intensive Care Department would be in charge of patientson ECMO with the aid of the Department of Emergency Medicine
and Critical Care. In order to have support from on-call doctors

10from the Internal Medicine and the ICU during the nighttime andholidays, a joint conference was held from 17:30 every weekday
to share detailed information. With the cooperation of the nursing
staff, doctors from their respective departments, infection control
team (ICT) specialists, and medical engineers (MEs), we werecapable of safely treating severe cases during the third waveof the pandemic.
(Masayuki Hojo)

Photo 2 Taken with two
doctors who visited us fromthe NIH in USA for the
meeting of multiregional
clinical trials

Photo 3 Press conference with Tokyo Governor Yuriko Koike

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Feel the NCGM

Special Issue July 2021

Countermeasures against COVID-19 at Our Emergency Department

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Akio Kimura, Director, Department of Emergency Medicine and Critical Care, Center Hospital, NCGM
Ryo Sasaki, Head, Department of Emergency Medicine and Critical Care, Center Hospital, NCGM
Kentaro Kobayashi, Chief Physician, Department of Emergency Medicine and Critical Care,
Center Hospital, NCGM

One of the crucial issues regarding COVID-19 measures at ourEmergency Department (ED) has been to identify and isolate
suspected patients to prevent them from becoming a sourceof nosocomial infection and protecting the safety of healthcare
providers at the same time, while providing initial management for
all kinds of emergency patients. As community transmission wason the spread, all patients with fever and respiratory symptoms
brought by ambulances were treated as suspected patients, so,
we are required to respond as through we are confronting aconsiderable number of COVID-19 patients. All suspected patients
have been triaged by using a checklist for screening indicated in
Figure 1, which enquires into the history of overseas travels, close
contacts, symptoms of fever and respiratory system, etc.

Figure 1
Release fromCOVID-19 countermeasures

From mid-June in 2020, when the second wave presumably
began, new items were added to the screening questionnaire to
visiting occasions to nightlife districts, due to an increase in thenumber of COVID-19 clusters among night-time workers in therelevant districts.
Regarding infection prevention in the ED, we began mandatory
protective mask wearing for all patients against droplet
transmission. Also, strict requirements were placed on healthcare
providers to use standard precautions against droplet and contact

Figure 2 shows flow of inpatients who underwent normal
emergency care, suspected COVID-19 patients and confirmed
COVID-19 cases. From late March 2020, when community
transmission was prevalent, the number of inpatients suspectedwith a COVID-19 infection increased rapidly, and in the weekfrom April 19 to 25, almost half of the inpatients were suspected
or confirmed with COVID-19 infections during a social alert
for COVID-19. Later, it became possible to admit patients after
confirming their COVID-19 infection status using more rapid resultof PCR testing. However, due to the limitations of test kits number,
we have to keep basic precautions for all emergency patientsduring stay at the ED because we cannot test them all.

transmissions as well as to wear N95 masks and goggles at all
times to prevent aerosol transmission (Photo 1). However, intreating many patients, donning and doffing such equipment wasa time-consuming task.
In addition to these precautions, we have used transparent plastic
boxes as shown in Photo 2 and used video laryngoscopes during
intubation, a procedure in which substantial droplet exposure
might be anticipated.

Checklist for COVID-19

Surgical masks must be provided to all patients!!
[Social history in suspected COVID-19 infections]
Fever over 37.5°C (99.5°F)
Respiratory symptoms, cold symptoms
Loss of sense of taste and/or smell
Close contact with a COVID-19 patient
Fever and respiratory symptoms of individuals in thesame household
Overseas travel history in past 2 weeks
Contact with returnees from oversea countries
Attendance of mass gathering events in past 2 weeks
Visit to city center/nightlife district

Figure 2
140

Number of inpatients
who underwent normal
emergency care

120

Number of inpatients suspectedof a COVID-19 infection

0
3

100
1
2

36

0
0
0

4
0
2

0
2

0

1

1

10

13

8

3
20

60

5

25

23

88

84

79

73

32

22

3

0

0

17

1

20

22

68

68

2

32

Photo 1 All healthcare providers at the ED wore N95 masks and goggles
at all times.

Photo 2 A transparent plastic box usage in addition to PPE during intubation.

Photo 3 Entrance to the ED.
The negative pressure room
is located to the right of theentrance.

17

25

28
85

76
62

20

4

0
15

1
3

99

40

1

2

80

66

63

53

46

55

49

65

71

80

75

73

81

/2
2/
23 2
-2
/2
9
3/
13/
7
3/
83/
1
3/
15 4
-3
/2
3/
22 1
-3
/2
8
3/
29
-4
/4
4/
54/
1
4/
12 1
-4
/1
4/
19 8
-4
/2
5
4/
26
-5
/2
5/
35/
5/
10 9
-5
/1
5/
17 6
-5
/2
5/
24 3
-5
/3
0
5/
31
-6
/6
6/
76/
1
6/
14 3
-6
/2
6/
21 0
-6
/2
7
6/
28
-7
/4

5

-2

/1

16
2/

2/
9

-2

2/

/1
-2

22/

26
1/

8

34

0

12

Number of inpatients
confirmed with COVID-19
0Photo 4 Negative pressure room. Patients suspected with COVID-19 have beenbasically treated in the negative pressure room installed in the ED. If the room is
occupied, other two rooms are available for isolation purposes.

13

Feel the NCGM

5Special Issue July 2021

Health Checkups and Tests Conducted

on Returnees on Chartered Flights from Wuhan

Satoshi Kutsuna, Former Chief Physician, Division of Preparedness and Emerging Infections, Disease
Control and Prevention Center (DCC), Center Hospital, NCGM
Takeo Kawamata, Special Advisor to the President, NCGM

On January 23, 2020, the Chinese government imposed a
lockdown in Wuhan and its nearby cities, trapping many Japaneseand their families who were unable to travel back to Japan. The
Japanese government evacuated a total of 829 nationals on
chartered flights from January 29 (the first flight) to
February 17 (the fifth flight).
NCGM responded to the government’s urgent request to conduct
health checkups and PCR tests on returnees. It was a mission
carried out under a critical situation, in which the WHO declareda Public Health Emergency of International Concern (PHEIC) on
January 30.
Individuals detected with fever at the Haneda Airport quarantine
were directly taken to a hospital, and other returnees weretransported to NCGM on five to seven buses. First, temperatures
were taken and questionnaires were filled out on the bus. After
disembarking, returnees were checked in at the entrance of theconference room (auditorium) and received medical consultation bya physician. Those with symptoms were taken to the Department
of Infectious Diseases, and those suspected of infection were
hospitalized. Those who were asymptomatic underwent blood
tests and PCR nasopharyngeal swab tests. Rice balls, bread,and tea were distributed, and they were taken on the bus toaccommodations provided by the government.

Buses carrying returnees on the first chartered flight from Wuhan
arrives at NCGM

NCGM staff awaiting the arrival of Wuhan returnees at the site of healthcheckup and PCR testing

NCGM staff in protective clothing, awaiting the arrival of Wuhan returnees

Returnees receiving health checkups

Returnees undergoing PCR nasopharyngeal swab tests

mission topped 356 within an approximate span of five days (107physicians, 115 nurses, 24 clinical technicians, and 110 clerical staff).
Of the 793 returnees who received PCR tests at NCGM, eighttested positive (Refer to the table below). Here, a striking new fact
was discovered in our country, that positive cases were seen inasymptomatic individuals. This had a huge impact on the public. It
was the beginning of our challenge against the novel COVID-19.

Many of the returnees included small children under age six andChinese speakers, requiring attentive care, such as help frompediatric specialists, provision of nursing rooms and rest areas, andmedical interpreters. The number of NCGM staff involved in this14

FlightDate of arrival

Nnumber of returnees

Tested cases at NCGM

1

Thursday,January 29

206

199

2

Thursday,January 30

210

197

3

Friday,January 31

150

140

4

Friday,February 7

198

194

5

Monday,February 17

65

63

PCR testing results(Positive/Negative)(Positive)

3(Negative)

196(Positive)

2(Negative)

195(Positive)

2(Negative)

138(Positive)

1(Negative)

193(Positive)

0(Negative)

63

A staff meeting held on the initial day after caring for returnees on the first chartered flight from Wuhan

15

Feel the NCGM

6Special Issue July 2021

Cruise Ships: Diamond Princess and Costa Atlantica
Hajime Inoue, Former Director General, Bureau of Strategic Planning, NCGM

A major spread of COVID-19 was seen on board the Diamond
Princess cruise ship, which docked in Yokohama on February
3, 2020. We were faced with an unprecedented challenge
of isolating, quarantining, and providing medical care toapproximately 3,700 passengers and crews, with limited clinicalknowledge of this disease.

The Diamond Princess
docked in Yokohama Port

Furthermore, a crew boarded on the Costa Atlantica cruise ship
docked in Nagasaki Port was confirmed with COVID-19 on April
20. Making use of the Diamond Princess experience, NCGM
dispatched staff to Nagasaki in an effort to contain the virus.

NCGM dispatched a team of medical providers including physicians
and nurses to the Diamond Princess, and accepted many severelyill patients for treatment. This was done in response to a request
made by MHLW taking command of the situation. From early
March until late April, an on-land quarantine of the captain andcrew members totaling near 240 took place at the dormitory of
the National Tax College in Wako City, Saitama Prefecture. Thismission was commanded by NCGM specialists who supervised
a diverse team of professionals gathered from around the world
for support.
Inside the captain’s cabin. Meeting held every evening at 9:00 PM with the captain.
Captain Gennaro Arma (seated second from the left)
Gaku Hashimoto, former State Minister of Health, Labour and Welfare(seated third from the right)
Hanako Jimi, former Parliamentary Vice-Minister of Health, Labour and Welfare(seated second from the right)

On-Land Quarantine of Diamond Princess Crew Members Conducted by a Multinational TeamAn NCGM staff boarding the Costa Atlantica
docked in Nagasaki Port, in response to a request
for quarantine (Hajime Inoue)

Wako

NCGM
On-land quarantine check-in

Taken in front of a message board filled with wordsof gratitude from the captain and crew members who
underwent quarantine

Commemorative photo taken of multinational team members after completionof quarantine inspection

Yokohama
Quarantine team members of the Diamond Princess crew
Meeting held every day by quarantine team members

1617

Feel the NCGM

7

Special Issue July 2021

Accomplishment and Future Outlook of Develop ment Research of COVID-19 Therapeutics Led by NCGM
Hiroaki Mitsuya, Director-General, Research Institute, NCGM
Wataru Sugiura, Director, Center for Clinical Sciences, NCGM

On February 15, 2020, H. Clifford Lane MD, who leads ClinicalResearch and Special Projects of the U.S. National Institutes of
Health (NIH), and Robert Walker MD of the U.S. Department
of Health and Human Services visited Japan and conveyed the
proposal to NCGM of involvement in the NIH initiated Adaptive
COVID-19 Treatment Trial 1 (ACTT-1) of Remdesivir (RDV). NCGM
deemed the trial top priority and agreed to conduct a domestic
investigator-initiated trial in Japan (Representative institution:
PMDA) on February 17. Starting with this, NCGM has been leadingand participating in numerous clinical studies inside and outside ofJapan (Figure 1).

Specified clinical trials led by NCGM currently inprogress
1. Convalescent plasma therapy RCT(Investigator: Satoshi Kutsuna)February 22, 2021 – in progress
A specified clinical trial to evaluate the efficacy of convalescentplasma transfusion therapy on COVID-19 patients. It is inprogress, supported by Health and Labour Sciences Research
Grants and a grant from the Japan Agency for Medical Researchand Development (AMED). As a single-arm study conducted
on 11 cases confirmed its safety, a two-armed, open-label,

Figure 1: Anti-COVID-19 Drug Development Studies at NCGM (as of June 23, 2021)

randomized, controlled trial (target sample size: 100 for eacharm) is in progress from February 22. It is for COVID-19 patientswith mild to moderate stratum because it aims for potent
antiviral activity of neutralizing antibodies containedin convalescent plasma collected from patients recoveredfrom COVID-19.
2. PMX specified clinical trial [X-code trial](Investigator: Shinyu Izumi)
September 28, 2020 – in progress
A trial to evaluate the efficacy and safety of a blood purification
therapy (PMX-DHP) for moderate to severe COVID-19

Many clinical studies were executed. Some arestill on-going

patients. Removal of endotoxin in blood by TORAYMYXIN™
(PMX™), polymyxin B-immobilized polystyrene column-direct
hemoperfusion (PMX-DHP) is expected to prevent disease
exacerbation.

Specified clinical trials that NCGM is currently
participating in
1. AMP-2 trial (Led by University of Miyazaki: NCGM
Investigator: Norio Ohmagari）
October 12, 2020 – in progress
Adrenomedullin is a circulatory adjusting peptide which exhibits
anti-inflammatory effect. It is expected to prevent further
exacerbation of severe COVID-19 patients on ventilator.
2. Ephedra Herb extract (Led by Kitasato University: NCGM
Investigator: Norio Ohmagari）
April 30, 2021 – in progress
An exploratory Phase I / II trial of Ephedrine alkaloids-free
Ephedra Herb extract (EFE).

Specified clinical trials and investigator-initiated trials
which have completed or have completed enrollment
1. Ciclesonide specified clinical trial [RACCO trial](Investigator: Haruhito Sugiyama)
March 27, 2020 – September 17, 2020
Ciclesonide, an inhaled corticosteroid was reported to beefficacious for the treatment of COVID-19 by doctors andresearchers in Japan.
NCGM started an exploratory phase 2 trial on March 27, 2020.
Twenty-two facilities in Japan participated in the trial, and thenumber of enrollments reached 90, its targeted sample size, on
September 17, 2020. Analysis of the pneumonia exacerbation
rate, which was the primary endpoint of the study, indicatedthat exacerbation was significantly higher (p=0.057) in theciclesonide treatment group, 39% (16/41), than in the control
group, 18% (9/48). On the basis of this result, NCGM released astatement not recommending its use on December 23, 2020.
2. Compassionate use of Remdesivir (RDV): (Investigator:
Norio Ohmagari)
In February 2020, the U.S. Embassy in Japan conveyed aproposal to the Chief Medical and Global Health Officer at
MHLW of compassionate use of RDV in patients who got
infected on board the Diamond Princess. On February 23,
critically ill patients admitted to NCGM received RDV for the firsttime in Japan. Three patients received RDV at NCGM and all ofthem recovered and were discharged from the Hospital (1).

18

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Special Issue July 2021

3. Adaptive COVID-19 Treatment Trial-1 (ACTT-1)[NCT04280705: Domestic COVRA-1 trial in Japan](Investigator: Norio Ohmagari)February 21, 2020 – May 21, 2020
ACTT-1 was a double-blind, two-arm trial to evaluate theefficacy and safety of RDV on moderate to severe hospitalized
adult patients. Enrollment for ACTT-1 began on February 21,
2020, and ended on April 20, 2020 (n=1063). Fifteen cases
were enrolled from NCGM in total.
On April 27, an interim report which showed the efficacy of
RDV was made public. On receiving the results, the Second
Committee on New Drugs of the Pharmaceutical Affairs andFood Sanitation Council (PAFSC) evaluated RDV and granted
special approval on May 7. The result of ACTT-1 was publishedin the May 22 issue of the NEJM (2).
4. Adaptive COVID-19 Treatment Trial-2 (ACTT-2)[NCT04401579: Domestic COVRA-2 trial in Japan](Investigator: Norio Ohmagari)
May 26, 2020 – July 31, 2020
Following ACTT-1, ACTT-2 was conducted to evaluate the
combination of baricitinib, an inhibitor of janus kinase (JAK),
and RDV compared to RDV alone. ACTT-2 was a double-blind,
two-arm trial to evaluate the combination of RDV and baricitinib
compared to the combination of RDV and placebo in moderate
to severe hospitalized adult patients. The first case from NCGM
was enrolled on June 23, 2020, and enrollment of 1,034 cases
was completed in the entire trial by July 1, 2020. Recovery time
for the group receiving the combination of RDV and baricitinib
was significantly shorter (p=0.03) by about a day, comparedto that of the control group receiving RDV and placebo, andefficacy of the combination use has been confirmed. These
results led to the approval of baricitinib by the pharmaceuticalaffairs on April 23, 2021 as the third therapeutic agent for
COVID-19, following remdesivir and dexamethasone (3).
5. Adaptive COVID-19 Treatment Trial-3 (ACTT-3)[NCT04492475: Domestic COVRA-3 trial in Japan](Investigator: Norio Ohmagari)
July 30, 2020 – December 21, 2020
Following ACTT-1 and ACTT-2, the NIH/NIAID team started
ACTT-3 to evaluate the efficacy of the combination of RDV andinterferon beta-1a on July 30, 2020. ACTT-3 was a double-blind
two-arm trial to evaluate the combination of subcutaneous
injection of RDV and interferon beta-1a compared to the
combination of subcutaneous injection of RDV and placebo.
There were 969 enrollments worldwide and 19 enrollmentsfrom NCGM. The analysis results of the trial have not been
published yet. (As of June 23, 2021)

20

6. Adaptive COVID-19 Treatment Trial-4 (ACTT-4)[NCT04640168: Domestic COVRA-4 trial in Japan](Investigator: Norio Ohmagari)
November 23, 2020 – April 14, 2021
ACTT-4 is a double-blind two-arm trial with the combinationof subcutaneous injection of RDV and dexamethasone and the
combination of subcutaneous injection of RDV and baricitinib toevaluate the efficacy.
It started on November 23, 2020 and the enrollment wascompleted on April 14, 2021. A total of 1,010 cases wereenrolled worldwide and four cases were enrolled from NCGM.
The analysis results of the trial have not been published yet. (Asof June 23, 2021)
7. Inpatient Treatment with Anti-Coronavirus
Immunoglobulin（ITAC）clinical trial (NCT04546581:
Investigator: Norio Ohmagari)
September 14, 2020 – February 15, 2021
ITAC trial is a randomized, double-blind, placebo-controlled twoarm trial with hyper immune intravenous immunoglobulin, hIVIG
and placebo groups led by NIH and INSIGHT. Total enrollmentsof 593 worldwide. From Japan, Fujita Health University and
NCGM participate in the trial, and enrolled eight cases and six
cases respectively. The official results of the ITAC trial have notbeen published yet. (As of June 23, 2021)

Sponsor initiated clinical trials
For development of treatments, NCGM is proactively involved insponsor initiated clinical trials. To date, NCGM has participatedin trials studying tocilizumab (an anti-IL-6 receptor antibody),
acalabrutinib (a selective Bruton’s tyrosine kinase inhibitor) andotilimab (an anti-GM-CSF antibody) and completed enrollment ofcontracted number of cases for each of them. Multiple trials are in
progress at present. (As of June 23, 2021)

References
1) Grein J, et al. N Engl J Med . 2020;382(24):2327-2336
2) Beigel JH, et al. N Engl J Med . 2020;383(19):1813-1826
3) Andre C. Kalil, et al. N Engl J Med . 2021;384:795-807
4) Hattori S, et al, mBio 11:e01833-20 https://doi.org/10.1128/mBio.01833-20
5) Hattori S, et al. Nat Commun . (2021) 12:668 https://doi.org/10.1038/s41467021-20900-6

Basic Research
Development of therapeutic agent for COVID-19
Approximately 20% of COVID-19 patients develop moderate tosevere respiratory symptoms requiring ventilator or ECMO
support and the mortality is high in older patients and thosewith complications such as diabetes, chronic kidney/pulmonary
diseases, and obesity. On the other hand, 70 to 80% of SARSCoV-2-infected individuals either remain asymptomatic ordevelop only mild symptoms. The fact that many infected
people do not have symptoms and recuperate without
treatment makes is complicated to conduct clinical trials ofpotential anti-COVID-19 therapeutics. Those with no or only
minor symptoms when they receive “hopeful anti-COVID-19
drug(s)” are, if not tested with formal randomized blindedclinical trials with sufficient numbers of enrollees, erroneously
judged to have benefited from such hopeful drug(s), leading toa false conclusion that “that therapeutic candidate” wasefficacious. On top of that, many observational clinical studies
of “therapeutic candidate drugs” was started without sufficient
basic in-vitro data or animal testing [4, 5]. It is argued thatgroundless expectations such as “repurposed drugs (identifying
new therapeutic activity in existing unrelated drugs)” may haveworsened such inclination. Indeed, the development of antiviraldrugs against SARS-CoV-2 2019 has been much delayed in suchchaotic circumstances. In fact, only a few compounds examined
to have antiviral activity against SARS-CoV-2 2019 are currently
under clinical trials, such as PF-07304814, molnupiravir, andT-527.

Development of SARS-CoV-2 M pro inhibitor guided by the
structure of M pro
The main proteases (Mpro) of coronaviruses take a dimeric
structure and function as a proteolytic enzyme, which processes
polyproteins of the virus (Figure 2). Based on the notion that
Mpro of SARS-CoV-22019 and that of SARS-CoV2002, which also
originated in China in 2002 and produced casualties in multiple
countries, maintain very high amino acid sequence identity of
about 96%[4], we postulated that SARS-CoV2002 proteaseinhibitors that were generated in 2003 and later may havepotential activity against SARS-CoV-22019. We, therefore,
synthesized the existing SARS-CoV2002 protease inhibitors andtheir derivatives, and identified GRL-0920 [4], GRL-1720[5], andGRL-2420(5h) [5]. These three small molecule compounds
specifically block Mpro’s enzymatic activity by forming covalentand hydrogen bonding with the enzyme active site of Mpro of
SARS-CoV-22019 (Figure 2) and potently inhibit the infectivity
and replication of SARS-CoV-22019 at concentrations that do
not exert cytotoxicity in cell-based assays [4, 5]. Even thoughthese three Mpro inhibitors are not applied to clinical use as
therapeutic agents for COVID-19, they offer suggestions as
prototypes for future therapeutic agents for treating COVID-19.
(Hiroaki Mitsuya)

Figure 2 Legends
While GRL-2420(5h) (compound on the upper right inset)
forms a covalent bond with Cys-145 (shown in a redarrow on the lower right inset) of M pro , it also forms
hydrogen bonds (shown in black dashed lines on thelower right inset) with amino acids forming the enzyme
active site and specifically blocks enzymatic activity of
M pro . Thereby, it inhibits the infectivity and replication of
SARS-CoV-2. The left inset shows M pro in the dimeric
form to which two GRL-2420(5h) molecules (in magenta)
bind. (Cited from reference 5)21Feel the NCGM

8Special Issue July 2021

Responses to COVID-19 Outbreakin Hospitals/Facilities
Yoshiaki Gu, Former Chief, Information and Education Division, AMR Clinical Reference Center,
Center Hospital, NCGM
Yumiko Fujitomo, Chief, Information and Education Division, AMR Clinical Reference Center,
Center Hospital, NCGM

The Disease Control and Prevention Center (DCC) and the AMR
Clinical Reference Center form part of MHLW’s National COVID-19
Cluster Taskforce and the Infection Control Team of Tokyo
Center for Infectious Disease Control and Prevention (iCDC). As
such, we help hospitals and elderly facilities in Tokyo and manyother prefectures deal with the COVID-19 outbreak. We as
infection control specialists assist in the specialized tasks involvedin epidemiological studies and nosocomial infection control in
the respective hospitals/facilities in response to requests frommunicipalities. As of March 2021, we have helped 20 hospitals/
facilities deal with outbreaks.
We have made various efforts by collaborating with relevantorganizations. Specifically, we conducted epidemiologicalinvestigations to take countermeasures by assessing the spreadof infection and the cause of outbreaks, and gave advice
after infection control rounding to assess the current status of

prevention measures at each division of hospitals.
These efforts were aimed to promote successful COVID-19
responses, with the ultimate goal of ending outbreaks as soon as
possible. Furthermore, in several hospitals, we provided support inresuming healthcare services that closed down due to the outbreak
and helped establish a foundation for voluntary/continuous quality
improvement of infection prevention and control.
Insights gained from our mission were reported to MHLW and
the Tokyo Metropolitan Government, which are being utilizedin establishing a new
system and preparing
for outbreaks expectedin healthcare facilities.

9

From COVID-19 Registry JAPAN(COVIREGI-JP) to REBIND
Nobuaki Matstunaga, Chief, Division of Clinical Surveillance, AMR Clinical Reference Center, Center
Hospital, NCGM
Wataru Sugiura, Director, Center for Clinical Sciences, NCGM

Introduction
Starting with the identification of pneumonia clusters due to novel
coronavirus in Wuhan, China in December 2019, novel coronavirus
cases are still on spread worldwide. COVID-19 keeps changing inclinical manifestations, clinical course, severity rate, case fatality
rate, etc. over time under the influence of the spread of variants.
To comprehend these information in real time as much as possible
and to directly return the achievements to public health andclinical settings, we have implemented a registry of COVID-19
hospitalization cases, “COVIREGI-JP”(https://covid-registry.ncgm.go.jp/). (Figure 1)
Figure 1

Official COVIREGI-JP website

Infection control rounding being conducted to assess
current prevention measures

Problems were addressed on the spot and changes were
implemented.

Rounding was conducted in wards.

Summary of registry study
This is an observational study which is being conducted underapproval of the ethical committee of NCGM with financial support
from MHLW grant-in-aid for Scientific Research (Titled: COVID-19
Development of treatments for critically ill patients, Principal
investigator: Norio Ohmagari, NCGM).
We have created a CRF (case report form) to collect epidemiologicalinformation in clinical settings and treatment-related information
within Japan by referring data originally collected by the ISARIC(International Severe Acute Respiratory and emerging Infection
Consortium) with some alterations (https://isaric.tghn.org/covid-19clinical-research-resources/). Its design is centered on basic patient
information, demographic data, epidemiological data, clinical data
regarding hospitalization or treatment, and infectiological data.
In parallel with issuing revisions of the report depending on thesituation, an on-line registration system along with preparing
case reports has been set up. They have been available on our
website since April 2020. As of May of the same year, the numberof registry enrollments surpassed 1,000 and recorded 10,000 in
October of the same year. As of May 2021, data of over 40,000
cases have been collected.

Infection control education is vital for healthcare providers to work safely. Implementing basic measures in a constant and continuous manner is the key.

22

Achievement of registry study
Aside from obtaining academic results, we promptly analyze
collected data and provide outcomes to the administrations andmunicipalities. We also return the outcomes to participating
institutions with a view to advance the study in a multi-facetedmanner. Our current achievements are as follows.
Academic publications
We conducted an epidemiological investigation on 2,638 casesthat had been registered by 227 medical institutions as of July
2020. Median age of inpatients was 56 (interquartile range［IQR］:
ages 40-71). More than half of the cases were male (58.9%,
1542/2619) and nearly 60% of inpatients had history of close
contact with suspected or confirmed COVID-19 cases. Medianlength of symptoms in inpatients until their hospital admission
was seven days (IQR: 4-10 days). The most frequently reported
comorbidities were hypertension (15%, 396/2638) and diabetes
mellites without complications (14.2%, 374/2638). Non-severecases (68.2％, n=1798) were twice as many as severe cases on
admission (31.8％, n=840). As regards to respiratory support,
patients without respiratory support (61.6%, 1623/2636) were
followed by patients on supplemental oxygen (29.9%, 788/2636)
and patients on IMV/ECMO (invasive mechanical ventilation or
extracorporeal membrane oxygenation), (8.5%, 225/2636). On thewhole, 66.9% of the patients (1762/2634) were discharged home,whereas, 7.5% (197/2634) of the patients died. In comparison
with studies on inpatients conducted in other countries, lesspatients have comorbidities and mortality rate tends to be low (1) .
We conducted a comparative analysis on the first and second
waves in Japan. The result showed that the percentage of severecases on admission during the second wave was lower than in
the first wave (12.0% and 33.1% respectively). Also, the period
from onset of COVID-19 to admission was shorter than during
the first wave (median of each were four days and seven days).
Patients during the second wave were younger than in the firstwave (median age of each was 37 and 56), and was less frequently
transferred from other hospitals (3.8% and 15.0% respectively),tending to have fewer comorbidities such as cardiovascular (1.9%
and 5.9% respectively) and cerebrovascular diseases (1.8% and6.1% respectively). It also showed that mortality rate during thesecond wave was lower than in the first wave (1.2% and 7.3%
respectively). Data from the second wave indicated that patientswere demographically younger, had fewer comorbidities, had alower percentage of severe cases on admission and had lower
rate of mortality. Even though the data on age and severity werestratified, mortality rate was still lower during the second wave. It isconsidered that this was due to shorter period of time from onset
until admission, differences in backgrounds and comorbidities,
advances in treatment, etc.(2)Furthermore, we reported the case fatality rate of each age groupbased on the COVID-19 registry data to IASR(3). We included
12,599 patients who had been admitted to hospitals by September
30, 2020 in the report and 37.6% of them were 60 years of age
or older. The case fatality rate was 4.2% for the entire case (therate was 0.3% for patients under age 60, and 10.7% for patientsover 60), that is, fatal cases among patients under 60 years ofage were rarely seen. We also investigated whether the patients23

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Special Issue July 2021

We are striving to provide information and promoterelevant studies via a dedicated website (https://rebind.
ncgm.go.jp/).

had underlying health conditions or not. The case fatality rate ofpatients who had no underlying health conditions was only 0.1%
for patients under 60 years of age, which was extremely low.
Whereas, the case fatality rate increased with age (the rate was
3.7% for patients aged 70-74, and 12.8 % for patients over 80.
The case fatality rate of patients with underlying health conditions
was 1.0% even in patients under age 60. Case fatality rates wereshown to be 4.4% for patients aged 60-64, 7.2% for patients
aged 65-69, 7.5% for patients aged 70-74, 12.8% for patients
aged 75-79, and 20.5% for patients over 80, indicating that thepercentages for patients with underlying health conditions washigher than those without health conditions and it increased withage. We strived to gain public understanding for the situation
where case fatality rate is high among COVID-19 patients with
underlying health conditions and even among the elderly withno such conditions. Besides, our advices regarding information
dissemination to individuals at high risk of fatality from COVID-19
is being reflected in the national policy (Figure 2).
Providing information to the administration andmunicipalities
In parallel with preparing academic papers, we provide information
to the administration and municipalities in a timely manner toreflect our study in the national policy. Here, we will introduce apart of our achievements.
In the COIVD-19 Advisory Board of MHLW held on August 24,
2020, we reported a study comparing the first and second waves
as previously mentioned. This report was used as a valuable

resource in obtaining an objective view of the clinical course of
COVID-19 and the features of each wave. In the 41st Health
Science Council of MHLW held on November 9, 2020, we provided
supplemental data to the committee of basic immunization andvaccination policy discussing “COVID-19 Vaccine Prioritization”.
We reported that those aged 60 or older tended to have higher
risk of mortality than those under 60. Furthermore, those withpre-existing conditions had higher risk of mortality than those
without conditions in each age group. These data have helped
the committee develop a criterion on how to prioritize COVID-19
vaccine distribution.
So far we have disclosed three conference materials and provided
essential information as needed to the Tokyo Novel Coronavirus
Response Headquarters. We have also reported various features of
COVID-19 and made a comparison between the first, second,
and third waves. These features include epidemiologicalcharacteristics of COVID-19 patients, clinical rates of medication
use and respiratory support care, severity of patients, andcorrelation between the infected and the so-called “three Cs”(closed spaces, crowded places, close-contact settings).
We hope to obtain further findings from epidemiological studies
by sharing data with participating facilities and further analyzing
factors associated with exacerbation and death from various
aspects. We also plan to do cross-sectional and longitudinal studies
concerning efficacy of medication and association with lifestyle,as well as evaluation of long-term prognosis. It is our vital role toanalyze data periodically and contribute to both the academic fieldand government policy-making.

From COVIREGI to REBIND

The developments in inspection method, therapeutic agent andprophylactic vaccine are indispensable to fight against emerging/re-emerging infectious diseases such as SARS-CoV-2, the biggest
threat at present. This development requires biospecimens suchas blood and saliva samples, and viral/human genomic data alongwith medical records of infected patients aggregated through
COVIREGI. Nevertheless, researchers are often confronted bydifficulties in the access to such information and in obtaining
biospecimens, where the lack of cooperation can be seen between
research & development and medical practice, namely researchersand practitioners who provide medical care to patients.
Thus, the implementation of organization, biobank or repository inparticular, is waited to eliminate the obstacles of this kind, and topromote the development. Such organization will liaise researcherswith healthcare providers, consequently, researchers can easily
access to sufficient biospecimens as well as genomic data andmedical records. In fact, biobanks have already been establishedand even functioning in many countries including Europe andNorth America. Some of them succeeded by applying the resourcein the control of the spread of COVID-19 infection in the relatively
early stage.

Entrusted by the government, NCGM launched the project named
REpository of data and Biospecimen of INfectious Diseases (REBIND)
in 2021. The nationwide project is driven by four key organizations:
National Institute of Infectious Diseases (NIID); The University ofTokyo (the affiliate hospital and the Institute of Medical Science);
Tohoku Medical Megabank Organization; NCGM. Based on theexperiences and expertise accumulated through COVIREGI, wehave started the operation of REBIND in July 2021 along withresearchers throughout the country.
Last but not least, we would like to express our sincere gratitude
for the cooperation provided by patients and the healthcare
providers, who have been taking care of COVID-19 patients
and who supported our registry. Your further cooperation andguidance for REBIND would be greatly appreciated.

References
1) Matsunaga N, et al. Clinical epidemiology of hospitalized patients with COVID-19
in Japan: Report of the COVID-19 REGISTRY JAPAN. Clinical Infectious Diseases.
2020. ciaa1470. https://doi.org/10.1093/cid/ciaa1470
2) Saito S, et al. First and second COVID-19 waves in Japan: A comparison of
disease severity and characteristics. J Infect. 2021;82(4):84-123.
https://doi.org/10.1016/j.jinf.2020.10.033
3) Management office and committee of COVID-19 REGISTRY JAPAN. Age specified
fatality rate among patients with novel coronavirus by COVID-19 registry data.
IASR. January 2021; vol.42: 19-20.

Figure 2 Case fatality rate by age group setting 60 year-old as threshold.

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10Special Issue July 2021

International Cooperation and Joint International Research
Hidechika Akashi, Director, Department of Health Planning and Management, Bureau of International
Health Cooperation, NCGM
Tatsuo Iiyama, Director, Department of International Trial (DIT), Center for Clinical Sciences, NCGM

COVID-19 and International Cooperation
The Bureau of International Health Cooperation (BIHC) is engaged
in the following international cooperation activities.
1.Contribution of experts dispatched from theBIHC through World Health Organization (WHO):
Philippines and Laos
The BIHC also sends an expert to WHO Western Pacific Regional
Office (WHO-WPRO) in the Philippines. The Japanese expert has
joined the WPRO infection control department to engage in
COVID-19 response measures in the region and have provided
support to the Ministry of Health in the Philippines (Photo 1 and 2).
In response to a request from the said department, the BIHC
collaborated with DCC to hold an on-line conference with
the WHO and the Ministry of Health in the Laos to share ourexperiences in accommodation facilities for COVID-19 mild or
asymptomatic cases in Japan.

Joint International Research Projects

2. Re-dispatch of experts from the BIHC to foreigncountries through Japan International Cooperation
Agency (JICA)
The BIHC sends experts to provide technical assistance for JICA
projects. Although the COVID-19 pandemic forced many experts toevacuate to Japan temporarily, the BIHC had re-dispatched theseexperts by the Fall of 2020. They worked to provide the BIHC with
the information on the status of the respective countries and toshare the information related to Japan with local people as needed.
In Myanmar, public safety has been deteriorating since the coup.
Under such circumstances, experts dispatched to the country had
to temporarily return to Japan again (Figure 1).
（Hidechika Akashi）

Figure 1
Photo 1

Masato Ichikawa, Manager, Public Relations Section, Department of International Trial (DIT), Center for Clinical
Sciences, NCGM

“Cooperating with other countries in the researchand development of medical products to combat
COVID-19”
Researchers and industrial companies around the world are
currently committed to develop diagnostic tools, treatments,and vaccines to tackle the COVID-19 pandemic. Humanity has
never witnessed in history such an unprecedented number of
research and development projects for a single infectious disease
being carried out simultaneously throughout the world. In thecourse of its involvement in international cooperation, NCGM
has participated in numerous research and development projects
with various countries, and has mounted a global response tothis current pandemic by carrying out research and development
activities.
The Department of International Trials of the NCGM Centerfor Clinical Sciences, which conducts overseas trials and clinicalresearch, participates in international actions, such as the
WHO R&D Blueprint, to acquire information about the global
situation. They also respond to requests from other countries forpharmaceutical and technological assistance, providing assistancein the areas of clinical research and regulatory affairs. They areproviding academic and technical assistance in order to conductlocal clinical trials, gain local regulatory approval, and make clinicaldevices developed in Japan usable in the respective countries, aswell as conduct clinical trials in each country (Photo 2 Clinical trial
in Thailand).

to respond to increasing global demand and the emergence ofvariant strains. Through clinical research and evaluations carriedout in cooperation with research groups in and outside Japan, we
will investigate and develop medical products to fight against the
COVID-19 pandemic through international cooperation (Photo 1
WHO R&D Blueprint on-line conference).
As long as globalization and international travel continue toaccelerate, there will always be a risk of infection by viruses andother pathogens. Therefore, a global response is required tocounter the threat of a pandemic. As a research institution whose
mission is to promote international cooperation, we will continue
to work in collaboration with institutions both inside and outsideof Japan in order to conduct tests, diagnoses, treatments, andvaccine development to overcome the COVID-19 pandemic.
(Tatsuo Iiyama, Masato Ichikawa)
Photo 2

Although the leading nations in the development of vaccines thatare anticipated to contribute to end the pandemic are the UnitedStates and Europe, a number of other countries, including Japan,
are also working on the development of new vaccines in order

A BIHC doctor engaging in surveillance andassistance provision at a local medical institution

Photo 1

Local staff participating in a
Japan-Thailand international
joint research project at
Mahidol University, Bangkok

Photo 2The BIHC doctor at a press conference for the Vice Minister of Health in the Philippines

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11

Special Issue July 2021

Releasing of Academic Achievements
Tatsuhiro Iida, Director, Division of Medical Research Management, NCGM
Takehiro Sugiyama, Chief, Division of Health Services Research, Diabetes and Metabolism Information
Center, Research Institute, NCGM
Pei Pei Song, Chief, Division of Global Health & Medicine, Center for Clinical Sciences, NCGM

Figure 2

COVID-19-related papers are available on the NCGM website.
https://www.ncgm.go.jp/en/covid19/academic_articles.html

The “NCGM Novel Coronavirus Infection Academic Advisory
Board” was established on February 7, 2020 to discuss theeffective use of limited resources within NCGM and crossfunctional support based on aggregated information on COVID-19
research and development, and has so far held 37 meetings (asof May 2021). The Advisory Board consists of executive members
from NCGM including the President and doctors from Center
Hospital and Research Institute. In April, Wataru Sugiura, Directorof Center for Clinical Sciences, became the Chairperson, replacing
Tamami Umeda, the former Director General of the Bureau ofInternational Health Cooperation.

Since the outbreak of COVID-19, many articles containing the latest
research findings have been published on Global Health & Medicine(https://www.globalhealthmedicine.com) – an international, openaccess, peer-reviewed journal, published by NCGM. In particular,
the two issues of “GHM Special Topic: COVID-19” (April 2020,
Vol.2, No.2; April 2021, Vol.3, No.2) collected a range of articles
describing COVID-19 based on frontline data from Japan, China,
the United States, Italy, the United Kingdom, and other counties
and areas worldwide. As of the end of June, 53 articles including
31 from NCGM have been published. In addition, as the journal
was included in PMC (PubMed Central, a free full-text archive of
biomedical and life sciences journal literature at the U.S. National
Institutes of Health’s National Library of Medicine) in December
2020, all published articles can be accessed on PubMed/PMC,with the goal of creating a global information network for the
publication of high-quality original research.
NCGM will continue to strive to accumulate its experiences through
COVID-19 responses and research results as the common heritageof mankind and pass them down through academic papers, etc.

development projects on COVID-19 to register their projects with
the Board in advance and to explain their research projects to theBoard. The Board also tries to perceive the ever-changing state of
COVID-19 research and development by updating the progress ofongoing projects regularly, with 121 projects have been registeredso far.

Aside from the Academic Advisory Board, the “NCGM COVID-19
Publication Committee” (Chairperson: Haruhito Sugiyama,
Hospital Director of NCGM Center Hospital [for fiscal 2020],
Wataru Sugiura, Director of the Center for Clinical Sciences[for fiscal 2021]) was established in March 2020 to support thestrategic and prompt paper publications of NCGM researchers.
The Advisory Board engages in discussions, consultation andWith the attendance of executive members from NCGM including
support to achieve the strategic promotion of research and
the President and doctors involved, the Committee has helddevelopment concerning COVID-19 (Photo). The Board requests
26 meetings as of the end of April 2021. The Board has been
researchers who are planning or preparing research anddiscussing strategies for the timely
publication of academic papers related
Figure 1 Number of papers which include NCGM researchers as authors (124 articles)
to COVID-19, sharing the progress
charts uploaded by the researchers
on Teams of Office 365.
As far as the Publication Committee
understands, 124 papers, which
include the NCGM researchers as theauthors, have been published (as ofthe end of June 2021, including online releases). We appreciate the great
efforts of the researchers (Figure 1).
Abstracts in Japanese and the literature
information of published papers whose
first or corresponding authors are
NCGM researchers are available on the
NCGM website (Figure 2).

28

Global Health & Medicine (GHM), an international academic journal published by NCGM. The two issues of “GHM Special Topic: COVID-19” (April 2020, Vol.2, No.2; April
2021, Vol.3, No.2) collected a range of articles containing the latest research findings.

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Feel the NCGM

Special Issue July 2021

The Fever Clinic and the CommunityBased “Shinjuku Model” System

12

Makoto Tokuhara, Director, Division of Regional Medical Liaison and Public Relations,Center Hospital, NCGM
Photo 1 Katsunobu Kato, then Minister of Health, Labour and Welfare(front row, 3rd from the right) inspects the “Shinjuku Model”(April 23, 2020)

Chart 1

• PCR Testing Center established at NCGM by commission from Shinjuku City
• Clinics such as Shinjuku City Medical Association refer patients to the PCR
Testing Center• Hospitals in the City coordinate efforts to secure hospital beds
• Shinjuku City Medical Association cooperates in the care of patientsrecuperating at home

Shinjuku Model Medical Care
System flowchart• Shinjuku City
Medical Association• Hospitals and clinics

It has been about one year since the initiation of the “Shinjuku
Model” system. During the third wave of the pandemic, the daily
number of COVID-19-positive cases exceeded 2,000 in Tokyo,
causing difficulty in the control of hospital beds. Under suchcircumstances, the “Shinjuku Model” system greatly contributed
to the facilitation of functional bed control, enabling hospital
admission of new patients soon after the discharge of recovered
patients, and admission of patients depending on the severityof their symptoms, through close communication between the
personnel in charge in each core hospital and those in the Public
Health Office.

The “Shinjuku Model” is based on two major strategies of setting
up a PCR Testing Center and of assisting in the management of
hospital beds for COVID-19 patients. The purpose of the system isto enable smooth and efficient PCR testing by establishing a PCR
Testing Center to which patients could be referred by local clinics
and medical offices if so required. Another function of the system
was to assist in securing a sufficient number of hospital beds
required by the City’s Public Health Office, by coordinating efforts

Negative

Positive rate

66
81

54
46

18 9
0 0

22 19
17
0 2 0

28
0

0

3
0

2
1

23 19 20 27
0

3

3

1

3

6
8

1

63 66
59

54
67

46 51

22 22 72
15 14 13
1
1

66
49

36

32

17 16
3 0 1 2

47

46

66

0%

121

35
7
3

41
24

43

29 28
4
4

8
8

24

33
17 16

30

Seibo
LiaisonWorsening of condition
HotelsLow severity

Negative•Shinjuku City
Medical Assoc.
•Shinjuku City
Pharmaceutical
Patient Care Assoc.
•Shinjuku City Office

Rest at home

Result not yet in/submitted for retesting

40%
0

250

210

0

215

150

101
97

100

59

85

69

37

54

51

50

60

59

46 41 80

156

107

68

74

107

185
146

148

136

0

66

79
40 43 34 49

79
44

48

47

69

0

10%
0%

154
123
134
109

135

92
81

58

40
44
56
42
66 37 28 38 28 33 17 14 21 30 21 17 20
53 48
67
45 50
32 29 32 35
39
36
32 37
51
34 44
28
4 4 1 2 2 5 5 0 1 0 0 1 3 0 3 0 2 3 2 1 3 4 7 3 2 2 1 5 11 7 9 8 12 7 5 8 8 9 12 11 18 26 15

49

0

20%

0

0

0

168

30%
0

1

200

50

50%

0

0

Positive rate

34

15 10
15
12 11 9 13 11 12
6 6
2 3

Ohkubo

83
56 48

58

33 39

40

4/
2
4/ 7
2
4/ 8
30
5/
1
5/
6
5/
7
5/
5/ 8
11
5/
1
5/ 2
1
5/ 3
14
5/
1
5/ 5
1
5/ 8
1
5/ 9
2
5/ 0
21
5/
2
5/ 2
2
5/ 5
2
5/ 6
2
5/ 7
28
5/
29
6/
1
6/
2
6/
3
6/
4
6/
5
6/
8
6/
6/ 9
10
6/
1
6/ 1
1
6/ 2
15
6/
1
6/ 6
1
6/ 7
1
6/ 8
1
6/ 9
22
6/
2
6/ 3
2
6/ 4
2
6/ 5
2
6/ 6
29
6/
30
7/
1
7/
2
7/
3
7/
6
7/
7
7/
8
7/
7/ 9
10
7/
1
7/ 3
1
7/ 4
15
7/
1
7/ 6
1
7/ 7
2
7/ 0
2
7/ 1
22
7/
2
7/ 7
2
7/ 8
2
7/ 9
3
7/ 0
31

76

PCR + Sat O2

JCHO Tokyo
YamateJCHO Tokyo
Shinjuku

moderate severity

positive results

Tokyo Metropolitan
Government Bed
Management

Positive

Number of patients

36

Keio University

Cooperation
Shinjuku City
COVID-19 PCR
Testing Center
Shinjuku City Public(located in the
Health Office
Low toNCGM)
Notification of

300

30%

10%

NCGM coordinates
securing of hospital beds

Graph 2: Transition patient numbers at Shinjuku City COVID-19 Testing Center (2020)

50%

20%

NCGM
Tokyo Women’s
Medical University
Tokyo Medical
University

SevereSource: The Shinjuku City press conference on April 15, 2020

40%

3/
9
3/
10
3/
11
3/
12
3/
13
3/
14
3/
15
3/
16
3/
17
3/
18
3/
19
3/
20
3/
21
3/
22
3/
23
3/
24
3/
25
3/
26
3/
27
3/
28
3/
29
3/
30
3/
31
4/
1
4/
2
4/
3
4/
4
4/
5
4/
6
4/
7
4/
8
4/
9
4/
10
4/
11
4/
12
4/
13
4/
14
4/
15
4/
16
4/
17
4/
18
4/
19
4/
20
4/
21
4/
22
4/
23
4/
24
4/
25
4/
26

Number of patients

Positive

Hospitals

Hospital bed management

MedicalQuestionnaire*Required tests andmedications*Numbers between March 9 and April 26, 2020 include PCR testing ofGraph 1: Transition of outpatient fever clinic consultations*2020年3月9日〜4月26日の期間中は救急搬送症例や外来、病棟でのPCRand検査も含まれた数字となっている
emergency medical care patients, outpatients
inpatients
140
130
120
110
100
90
80
70
60
50
40
30
20
10
0

Commissioned by Shinjuku City to NCGM and conducted incooperation with Shinjuku City Medical Association andother bodies

Dispatch of staff

Clinics such as
ReferralShinjuku City Medical
Association engage intelephone andface-to-faceconsultation

A medical system for speedy
testing and appropriate care forpatients’ symptoms in addition tothe outpatient clinic for returnees
and close contact persons

Condition improves

Shinjuku City commissioned NCGM to establish the “Shinjuku
City COVID-19 PCR Testing Center” within the Hospital (Photo 1，2). This was an unprecedented undertaking for NCGM, and were
faced with many obstacles, but with the cooperation of the various
departments, the Testing Center was able to commence operations
on April 27. The launch of the Testing Center was only madepossible by the knowledge and experience we gained through our
involvement in the medical crises of the charter plane returnees
from Wuhan, the passengers of the Diamond Princess cruise ship,
and our outpatient fever clinic. The Testing Center is staffed solely
by those working within Shinjuku municipality, with doctors,
nurses, clinical laboratory technicians, and clerical workers from
Shinjuku’s seven core hospitals as well as doctors of the Shinjuku
City Medical Association. The Testing Center was set up to
enable the testing of 200 people on weekdays between 9:00 and
11:00 AM, but in actuality we conducted testing for almost 300
patients on some days (Graph 2). The operation of the “Shinjuku
City COVID-19 PCR Testing Center” was started by Shinjuku
City in August 2020 and was relocated onto the compound of
Shinjuku Public Health Office. Core hospitals are cooperating in its
operation, and NCGM is also continuing to perform testing.

During a meeting between the President, the Hospital Director
and other top-level NCGM officials, the creation of a COVID-19
response network was proposed, connecting the Shinjuku
municipality office, Shinjuku Medical Association, and core
hospitals in Shinjuku City. We were able to garner support fromthe Shinjuku City Medical Association President Seiichi Hirasawa
and the directors of seven core hospitals in Shinjuku City (Yuko
Kitagawa of Keio University Hospital, Tamotsu Miki of Tokyo
Medical University Hospital, Kazunari Tanabe of Tokyo Women’s
Medical University Hospital, Nobuo Sekine of JCHO Tokyo Shinjuku
Medical Center, Tetsu Yano of JCHO Tokyo Yamate Medical
Center, Toshihiko Tujii of Ohkubo Hospital, and Tatsu Nakazawa of
Seibo Hospital).
On April 11, we met with Shinjuku Mayor Kenichi Yoshizumi topresent our proposal of the “Shinjuku Model” COVID-19 Medical
Care System (Chart 1).

COVID-19 Shinjuku Model Medical Care System

Condition improves

between the seven core hospitals in the municipality.
Mayor Yoshizumi made the bold decision to go forward with our“Shinjuku Model” proposal, and the plan was announced at apress conference on April 15 held by the Shinjuku City Mayor, thePresident of the Shinjuku City Medical Association, and thePresident of NCGM.

Condition becomes severe

The spread of COVID-19 infections gave rise to serious problems
concerning the need for widespread PCR testing and securing asufficient number of hospital beds. NCGM started an outpatient
fever clinic on March 9, 2020, establishing a system of PCR testingfor patients with referrals from other medical institutions or who
were residents of Shinjuku City. However, by April the number ofpatients visiting the outpatient fever clinic grew to more than 100
per day, overwhelming its capacity, since doctors were required to
conduct medical consultations, perform various medical tests, andprescribe medications in addition to PCR testing. Furthermore, theincreased workload strained the staff of the Hospital’s Department
of Infectious Diseases which managed the outpatient fever clinic,
leading to concerns that the care of severely ill patients would
suffer (Graph 1).

Photo 2 “Shinjuku City COVID-19 PCR Testing Center” launched in
the NCGM Center Hospital grounds by commission from Shinjuku City

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13

Special Issue July 2021

Creation of a New Model for Recovery in Accommodation Facilities for
COVID-19 Mild or Asymptomatic Cases
Hidechika Akashi, Director, Department of Health Planning and Management, Bureau ofInternational Health Cooperation, NCGM
Toyomitsu Tamura, Director, Division of Public Relations and Communications, Department of
Human Resource Development, Bureau of International Health Cooperation, NCGM

Support for the setting up and management of accommodation facilities for
COVID-19 patients identified during quarantine
Contribution to the enhancement of Japan’s sustainable border control by helping on-site coordination
with the expertise of the Bureau of International Health Cooperation
The Japanese government issued and enacted “Cabinet Order for
Designating Novel Coronavirus Infection as a Type of Infectious
Disease Under Article 34 of the Quarantine Act” in February 2020.
Based on this cabinet order, the Japanese government has been
trying to strengthen border control by conducting interviews,
physical examinations, and testing of those who arrive in Japan
from specified countries, and by making novel coronavirus
carriers isolate, or detaining them for treatment accordingly.
Furthermore, based on “Handling of People with Positive Result
for COVID-19 PCR Test Conducted during Quarantine” issued
as an MHLW ministerial notice in April 2020, new arrivals whoare confirmed to be novel coronavirus carriers are required to betreated for a specified time period at accommodation facilities for
COVID-19 mild or asymptomatic cases.
Under these circumstances, MHLW requested the BIHC to support
the setting up and management of accommodation facilities
for PCR test-positive people. In response to this request, theBIHC provided support for setting up and managing COVID-19
patient accommodation facilities using two hotels in the Tokyo
metropolitan area.
(Toyomitsu Tamura)

Case 1Further improvement of the first COVID-19 patientaccommodation facility used as a model
To support the setting up and management of the first patientaccommodation facility, the BIHC dispatched a total of 302
doctors, nurses, technicians, and administrative staff during
the period from April 9 to September 28, 2020. Utilizing theirknowledge and experience from years of international healthcooperation, they helped to set up the facility, and provided
empathetic assistance to the foreign residents by understanding
their diverse cultural and religious backgrounds, thereby resolving
various problems occurring among them.
In the globally persisting COVID-19 pandemic, border control has
continued to be strengthened. Under such circumstances, the BIHC
also helped to establish sustainable, safe facility management using
private sectors instead of officers of MHLW and the quarantine
station. For example, facility residents used to be interviewed
by telephone twice a day in Japanese or English. The BIHC staff
prepared a healthcare check form using FORMS and introduced
FUJITSU applications, which had been used for quarantine support
activities for the cruise ship, Costa Atlantica, to reduce the burden

The staff also provided PPE-related training
to private non-healthcare workers tofacilitate sustainable facility management.
Doctors of the BIHC with nurses fromthe quarantine station created a poster
showing PPE donning and doffing
procedures. Using this poster, the staff
provided specific advice on the safe
donning and doffing of PPE.

The staff of the BIHC going to collectsamples from facility residents. Although it
was not easy to conduct clinical researchin a non-hospital environment, they
accomplished their mission using theirknowledge and experience from working
in developing countries.

32

Masataro Norizuki, Technical Officer, Division of Partnership
Development, Department of Global Network and Partnership,
Bureau of International Health Cooperation, NCGMof both facility residents and healthcare workers and thereby
increase efficiency in facility management. They continued to workon zoning, infection prevention, and instruction provision to private
workers to promote safe facility management.
As members of a research and development agency, the BIHC
staff also engaged in research activities within the patientaccommodation facility. They performed various different tests
simultaneously on facility residents, compared the results, andproposed optimal quarantine tests. Data from their research were
published in Global Health & Medicine, an academic journal in
English issued by NCGM.
(Masataro Norizuki)
Case 2
Support on the establishment of a new patientaccommodation facility for scale expansion
To support the setting up and management of the second patientaccommodation facility, the BIHC dispatched a total of 27 doctors,
nurses, and administrative staff during the period from September
14 to October 4, 2020. Based on the experience from the abovementioned support program for the setting up and management of
the first patient accommodation facility, they worked on the setting
up and management of the second one while providing advice
on coordination among the hotel personnel, quarantine officers
dispatched from various quarantine stations nationwide, public
officers, medical institution personnel, private contractors, security
companies, patient transporters, police officers, fire authorities,
and people from various other organizations. For example, thestaff members engaged in zoning within and outside the facility,
management of materials and equipment, and preparation ofvarious manuals. This patient accommodation facility was to be
operated by a private company with little knowledge in healthcare.
Therefore, it was one of our important missions to teach infection
prevention measures to all of the people concerned, including theTraining for correct donning and doffing of PPE was provided.

staff of the private company. In addition to providing training on
the donning and doffing of PPE, the BIHC staff prepared a manualof sample handling, and instructed the facility staff about this issue
with the help of quarantine officers.
For the support for management of this accommodation facility,
the patient information management system developed for the
first accommodation facility has been used to enhance system
unification. As shown above, the BIHC has provided support while
paying attention to the sustainability of facility management, evenafter the support had ended. This reflects our basic operation
policy for various projects in low- and middle-income countries. The
support on the setting up of patient accommodation facilities canbe seen as a good example of the on-site coordination capabilities.
（Toyomitsu Tamura）
Case 3
Response to COVID-19 in Okayama Prefecture:
Support for the management of a patientaccommodation facility and cluster intervention
The BIHC dispatches its staff members not only for overseas
projects, but also to Okayama Prefectural Office. In Okayama,
besides providing advice regarding the management ofaccommodation facilities
for COVID-19 mild or
asymptomatic cases, thestaff members helped
prefectural officers tocreate a frameworkfor securing a system
for COVID-19-related
healthcare provision andtaking anti-COVID-19
measures, and toestablish the Okayama
COVID-19 Cluster
Intervention Team (OCIT),
and provided lectures andinstructions regarding
At the award ceremony in Okayama Pref.
infection prevention in
many places throughout
the prefecture. A seriesof COVID-19-related activities made in Okayama were presented ina document issued by MHLW. In addition, due to the contribution
to the establishment of relevant systems in Okayama, the staff
member received an SDGs Award from Okayama University.
(Hidechika Akashi)

Checking flow lines of the accommodation facility with quarantine officers

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14

Special Issue July 2021

In Closing: Preparing for the Post- COVID-19 Era
Akira Harita, Director General, Bureau of Strategic Planning, NCGM

Despite the fact that all the countries in the world have been making a great effort to end the
COVID-19 pandemic for more than one year, future prospects still remain uncertain. Even if
this pandemic comes to an end, there is no end to the ongoing battle between humans andemerging/re-emerging infectious diseases. Just in the past two decades of this century, we
have witnessed numerous emerging/re-emerging diseases around the globe; SARS, H5N1
highly infectious avian influenza, the pandemic H1N1 swine flu, MERS, Ebola hemorrhagic
fever, Zika fever, and now COVID-19. These diseases have not only threatened our lives, buthave also caused social and economic turmoil.
Therefore, we must build back on healthcare and social systems effective enough to fightagainst the threats of future emerging/re-emerging diseases in the post-COVID-19 era. NCGM
is committed to playing a pivotal role in protecting human lives and society from emerging/re-emerging infectious diseases, based on an academic foundation in fields broadly ranging
from basic medical science to clinical and social medicine.

34

Tsuyoshi Nagabuchi on “NCGM Encouragement
Live Concert” held on the heliport of Center
Hospital of NCGM on October 3, 2020
Photo by courtesy of Office Ren Inc.

35

Feel the NCGM

Special Issue July 2021

Acknowledgements

We are going into the second year since NCGM has engaged in treatment andresearch of COVID-19. During the course, our nation has declared a state of
emergency four times and we have seen repeated surge of infections. Yet we see aray of hope with the start of vaccinations.
We would like to express our deepest gratitude to all who have made contributions
and supported us to this point.
Due to surge in COVID-19 cases, Center Hospital of NCGM is partially limiting
healthcare services, and either prohibiting or restricting visitors. Kohnodai Hospitalof NCGM is also implementing visiting restrictions. We thank all our patients andfamilies for understanding and cooperating with us.
In addition, we would also like to thank all our patients who have participated in
the clinical trial of convalescent plasma therapy for COVID-19.
NCGM will continue to work in unity to confront COVID-19 in order to save lives ofaffected patients and help them recover as soon as possible. We greatly appreciate
your continued support.
All Staff at NCGM

Planning/issuing

Bureau of Strategic Planning, National Center for Global Health and Medicine
1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655 Japan

TEL +81-3-3202-7181

https://www.ncgm.go.jp
Printed in Japan