Chapter 41
The Future of Infectious Disease Control
Field of expertise: Division of Infectious Diseases

Yuko Makino & Eiichi N. Kodama
Translated by Catherine Sachi Kikuchi

Summary
Disruption of lifelines (electricity and water), living in dense shelters, and interruption of information
networks due to widespread disasters such as the Great East Japan Earthquake are factors thatcause the spread of infectious diseases that would otherwise be controllable. Infectious diseases
themselves, such as COVID-19, are now being recognized as a type of disaster. It is important tobe prepared for disasters and infectious diseases, including through adequate predictions, training,and education.
Keywords: infectious disease, outbreak, training, education, network

Introduction
What measures should be taken to prevent serious outbreaks of infectious diseases inemergencies and disasters? What kind of preparations and attitudes are necessary in ordinary
times and during emergencies? We consider this question with reference to the Great East Japan
Earthquake.

1: Infectious Disease Problems Revealed by Disasters
Disasters and infectious diseases
The Great East Japan Earthquake caused unprecedented damage mainly in the coastal
areas of the Tohoku region due to the earthquake and huge tsunami. In fact, in Miyagi Prefecturealone, more than 320,000 disaster victims were forced to live together in evacuation centers at thepeak of the disaster (Miyagi Prefectural Government, 2015). Evacuation centers, where many
victims live together in a limited space, are prone to spread of infectious diseases. Since thecommunication infrastructure was also damaged, it was difficult to identify which infectious
diseases were occurring in the approximately 1,300 evacuation centers in the early stages of thedisaster. Delayed information is a major problem in infection control, where initial response iscrucial.

1The reality of disaster-related infectious diseases
Infectious diseases that occur during disasters vary depending on the type of disaster,
region, season, environment of the affected area, and phase of the disaster (Figure 41-1)(Japanese Society for Infection Prevention and Control, 2014). In the Great East Japan
Earthquake, immediately after the disaster, legionella infections from contaminated water causedby the tsunami, tetanus from trauma, seasonal influenza and norovirus infections from crowded
living situations in the evacuation centers were observed. It was difficult to maintain environmental
hygiene in the evacuation centers due to the lack of water for essentials like hand washing andflushing toilets. There was also an inadequate supply of physical resources such as disinfectants
and masks for infection control.

Figure 41-1. Infectious diseases and their onset times after a disaster1
Immediately after a disaster, influenza and norovirus increase, both which occur in trauma. Water
for hand-washing and drinking is essential to prevent gastrointestinal infections. We must also pay
attention to the fact that the time from infection to onset differs, depending on the disease.

2: Paradigm shift: New Measures are Necessary
Conventional support is not sufficient
Effective infection control requires a rapid understanding of the situation of infectious
disease outbreaks. However, at the time of the Great East Japan Earthquake, the system forgrasping the status of infectious disease outbreaks during disasters was not sufficiently
established. Furthermore, understanding the situation was extremely difficult due to the large
number of evacuation centers scattered over a wide area in the early stages of the disaster, the1

(Japanese Society for Infection Prevention and Control, 2014)2

shortage of human resources and supplies for surveying, and the lack of telephone, fax, and otherinformation networks. In the future, it will be important for local governments, medical institutions,specialized organizations, and universities to cooperate in order to build a support and cooperation
system for understanding and analyzing information.
New concerns
In the event of a large-scale disaster, a large number of medical personnel, local
government officials, and volunteers from various regions often enter and leave multiple
evacuation centers and support facilities in order to assist the affected areas. This means that
there is a possibility that pathogens may be brought to evacuation centers. Therefore, infection
control measures for support personnel and visitors are also necessary (Japanese Society for
Infection Prevention and Control, 2014; Kodama, 2019). We must also consider the possibility ofherpes zoster and tuberculosis, which are chronic or latent infections that manifest due to stressand fatigue caused by living in evacuation centers for a long period of time (Figure 41-2).

Figure 41-2. The source of infectious diseases is not always the devastated area2
Unlike infectious diseases such as influenza and norovirus that can be seen even in ordinary
times, most infections, including food poisoning, are brought in by support personnel.

3: A New Approach!
In a large-scale disaster, medical institutions and local governments in the devastated area
are also affected, resulting in a situation where support for victims can be delayed. In the wake of
the Great East Japan Earthquake, the Disaster Infection Control Team (DICT) was establishedmainly by the Japanese Society for Environmental Infectious Diseases. The DICT has establisheda support system of experts to prevent outbreaks of infectious diseases in evacuation centers andto respond to outbreaks of infectious diseases (Figure 41-3) (Japanese Society for Infection2(Japanese Society for Infection Prevention and Control, 2014)3

Prevention and Control, 2014). Risk assessments and educational materials for prevention ofinfection in evacuation centers have been prepared and are being used for rapid response todisasters. The Guide to Infection Control Management in Areas Affected by Large-Scale NaturalDisasters (Japanese Society for Infection Prevention and Control, 2014), compiled by the abovementioned society based on the experience of the Great East Japan Earthquake, describes
countermeasures against infectious diseases in times of disaster from the perspective of multiple
professions and organizations that experienced this disaster. In the future, we must continue tolearn from the past and consider infectious disease control measures that can manage various
disasters.

Figure 41-3. The activities of the Disaster Infection Control Team (DICT)3

4: Achievements and the future
Preparation during ordinary times
From the experience of the Great East Japan Earthquake, it has become possible toprovide human and material support for infectious disease response as well as information andawareness-raising materials at an early stage. On the other hand, infectious disease outbreaks
vary depending on the type of disaster and other factors, so it is important to practice making
assumptions and training during ordinary times (Kodama, 2019).
Effort during ordinary times
1. Infectious disease control education: It is important to provide education on hygiene andhealth management, including basic preventive measures such as hand washing and masks, sothat disaster victims can take preventive actions against infection. In fact, in July 2020, a torrential
rain disaster occurred during the novel coronavirus pandemic, but daily education on infectious
diseases was useful in preventing and stopping the spread of infection. 2. Vaccination: Vaccination
3(Japanese Society for Infection Prevention and Control, 2014)4

is necessary not only for local residents, but also for volunteers and local government employees
who provide support in times of disaster (Japanese Society for Infection Prevention and Control,2014). 3. Networks: In the event of a large-scale disaster, medical institutions and localgovernments will be affected at the same time, and the response to infectious diseases will bedelayed. It is important for local governments, medical institutions, universities, etc. to share
information on infectious diseases in the region and build a network. 4. Animals: It is also importantto pay attention to zoonotic diseases (infectious diseases common to both humans and animals)
during disasters. We must take measures against mosquitoes and other insects, avoid contact withrodents and other wild animals, and vaccinate pets since we can assume that they will evacuatewith their families.

Conclusion - from the author“Natural disasters will strike just when you forget about them”. Dr. Torahiko Terada, aprofessor at Tokyo Imperial University, spoke these words in the wake of the Great Kanto
Earthquake. In order to prepare for disasters, families, communities, workplaces, and otherorganizations should continue to make sufficient assumptions, as well as train, and educate
themselves. “Don’t make fun of the mundane tasks, do them properly” (abbreviated in Japanese toABC). This will protect us and those around us.

References
Japanese Society for Infection Prevention and Control. (2014). Guide to Infection Control
Management in the Areas Affected by Large-Scale Natural Disasters, Version 1. (In Japanese)
Version 2 published in 2021.
Kodama, E. (2019). Biosafety in disaster medicine. The Japanese Biological Safety Association,
9(1), 24-27.
Miyagi Prefectural Government. (2015). The Great East Japan Earthquake: A Record of Miyagi
Prefecture's Disaster Response in the First Year after the Disaster and a Review of the Response.
https://www.pref.miyagi.jp/site/kt-kiroku/kt-kensyou3.html (In Japanese)5