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Disponible en ligne surScienceDirect
www.sciencedirect.com

ORIGINAL ARTICLE

Lots of luck on thin ice from Tokyo to Paris:
Following the track of the preparedness andresults of Emergency Medical Services andDisaster Medical Response during 2020
Tokyo Olympic and Paralympic Games fromthe Perspective of Academic Consortium(AC2020) of Japan and Medical Advisory
Board of Tokyo Metropolitan Government
Suivi de la préparation et des résultats des services médicaux d’urgence et del’intervention médicale en cas de catastrophe pendant les Jeux Olympiques etparalympiques de Tokyo 2020 du point de vue du Consortium académique(AC2020) du Japon et du Conseil Consultatif Médical du gouvernement
métropolitain de Tokyo. Bonne chance pour cette traversée de Tokyo à Paris
sur une ﬁche couche de glace !
Naoto Morimura a,b,c,d,∗, Yasumitsu Mizobata a,
Manabu Sugita a, Satoshi Takeda a,b,
Yasuhiro Otomo a,c,d, Yoshihiro Yamaguchi c,d,
Tetsuya Sakamoto a,d, Masataka Inokuchi a,d,
Hiroyuki Yokota c,d, Hideharu Tanaka a,
Seizan Tanabe a, Tetsuro Kiyozumi b, Kiyoshi Matsuda a,
Chiaki Toida c, Takeshi Shimazu aa

The Joint Committee of the Academic Consortium on Emergency Medical Services andDisaster Medical Response Plan during the Tokyo Olympic and Paralympic Games in 2020
(AC2020), Tokyo, Japan∗ Corresponding author. Department of Emergency Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, 173-8606
Tokyo, Japan.
Adresse e-mail : molimula@r6.dion.ne.jp (N. Morimura).

https://doi.org/10.1016/j.jeurea.2022.11.003
2211-4238/© 2022 The Authors. Published by Elsevier Masson SAS. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

Pour citer cet article : N. Morimura, Y. Mizobata, M. Sugita et al., Lots of luck on thin ice from Tokyo to Paris: Following
the track of the preparedness and results of Emergency Medical Services and Disaster Medical Response during 2020 Tokyo
Olympic. . . , Journal Européen des Urgences et de Réanimation, https://doi.org/10.1016/j.jeurea.2022.11.003

Modele +ARTICLE IN PRESSJEUREA-422; No. of Pages 11

N. Morimura, Y. Mizobata, M. Sugita et al.
b

The Education and Training Working Group of AC2020, Tokyo, JapanThe Scientiﬁc Research Group of Ministry of Health, Labor and Welfare of Japan, Tokyo,
Japand
The Advisory Board of Emergency and Disaster Medical Response Planning of the 2020 Tokyo
Olympics and New Coronavirus Infection, Health and Welfare Bureau, Tokyo Metropolitan
Government, Tokyo, Japanc

Reçu le 25 octobre 2022 ; accepté le 14 novembre 2022

KEYWORDS
Olympics ;Paralympics ;Mass gatherings ;Emergency medical
services ;Public health care ;COVID-19 ;Disaster ;Mass casualty
incident

MOTS CLÉS
Jeux olympiques ;Paralympiques ;Rassemblement defoule ;
Services médicaux
d’urgence ;SAMU ;
Dispositif
prévisionnel desecours ;Santé publique ;COVID-19 ;Catastrophe ;Afﬂux de victimes

Summary
Introduction. — The 2020 Tokyo Olympic and Paralympic Games (2020 Tokyo Olympics) was heldin Japan during the pandemic of new coronavirus infection (COVID-19) in 2021.
Preparedness. — In 2016, the Academic Consortium consisting of 29 major medical associations(AC2020) was launched and undertook medical risk assessment, issuing statements, and disseminating manuals/guidelines, training materials through its website. Administratively, Tokyo
Organizing Committee of the Olympic and Paralympic Games (TOC) was responsible for preparations inside the venue, while Tokyo Metropolitan Government (TMG) was responsible forpreparations on the last mile and around the venue. In response to the AC2020 recommendation, the TOC and TMG has set up the subcommittee for reviewing emergency and disastermedical systems for the games. Finally, the 2020 Tokyo Olympics gave up accepting spectatorsfrom abroad and limited domestic spectators. The multi-organizational training was not systematically performed until just prior to the event due to the delay in deciding on the form of
this big event.
Results. — A total of 779,820 people participated during the entire period. The 316 patientswere seen at hospitals including 53 COVID- 19 cases, and the patient presentation rate (PPR)
was 2.4/1000. The COVID-19 cases in Japan increased as the games approached, and a major
wave peak of the epidemic was observed during the games.
Conclusion. — If MCI had occurred during the games, the current medical care system would
not have been able to cope with such situation. We were walking on thin ice, but fortunately,
we didn’t step out and drown in the water.
© 2022 Les Auteurs. Publié par Elsevier Masson SAS. Cet article est publié en Open Access sous
licence CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Résumé
Introduction. — Les Jeux Olympiques et Paralympiques de Tokyo 2020 (Jeux Olympiques deTokyo 2020) ont eu lieu au Japon pendant la pandémie COVID-19 en 2021.
Préparation. — En 2016, le Consortium Académique composé de 29 grandes associations médicales (AC2020) a été lancé et a entrepris une évaluation des risques médicaux, publié desmises aux points et diffusé des manuels/directives, du matériel de formation via son site Web.
Sur le plan administratif, le comité d’organisation des Jeux olympiques et paralympiques deTokyo (TOC) était responsable des préparatifs à l’intérieur du site, tandis que le gouvernement métropolitain de Tokyo (TMG) était responsable des préparatifs sur le dernier kilomètre
et autour du site. En réponse à la recommandation AC2020, le COT et le TMG ont mis en placele sous-comité chargé d’examiner les dispositifs prévisionnels de secours pour les urgences et
en cas de catastrophe pour les jeux. Enﬁn, les Jeux Olympiques de Tokyo 2020 ont renoncé à
recevoir des spectateurs étrangers et ont limité les spectateurs nationaux. La formation multiorganisationnelle n’a été systématiquement effectuée que juste avant l’événement en raison
du retard dans la décision sur la forme de ce grand événement.
Résultats. — Au total, 779 820 personnes ont participé pendant toute la période. Les 316
patients ont été vus dans les hôpitaux dont 53 cas de COVID-19, et le taux de présentation
des patients (PPR) était de 2,4/1000. Les cas de COVID-19 au Japon ont augmenté à l’approchedes jeux, et un pic de vague majeur de l’épidémie a été observé pendant les jeux.
Conclusion. — Si un afﬂux de victimes s’était produit pendant les jeux, le système de soins
médicaux actuel n’aurait pas été en mesure de faire face à une telle situation. Nous marchions
sur de la glace mince, mais heureusement, nous n’avons pas dérapé et ne nous sommes pas
noyés dans l’eau.
© 2022 Les Auteurs. Publié par Elsevier Masson SAS. Cet article est publié en Open Access sous
licence CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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Introduction

Box 1 : Medical risk and its cause related to the 2020
Tokyo Olympics.
Concentration of people in venue and surroundingarea• Impact on daily emergency medical system◦ Increase of number of medical telephone
consultations and ambulance calls◦ Increase of ambulance usage◦ Hospitals burden resulting from increase ofreferral to ED• Impact on disaster medical system◦ MCI due to increased population density in limitedareas◦ Earthquake directly under the capital city as an
assumed natural disaster
Weather condition related• Heatstroke• Lightning strike
Nationwide increase in tourists including visiting
foreigners• Epidemic of infectious disease• COVID-19• Impact on daily emergency medical system◦ Language, religion, insurance, repatriation
High international interest related• Multisite MCI caused by terrorism◦ Explosion, gunshot wound, special disaster
Health care workers related• Training of large number of medical staff andvolunteers
ED: emergency department; MCI: mass casualty
incident.

The Olympics and Paralympics are one of the largest mass
gathering events in the world. Mass gathering events aredeﬁned as ‘‘the concentration of people at a speciﬁc location for a speciﬁc purpose over a set period of time that havethe potential to strain the planning and response resourcesof the host country or community’’ by the World HealthOrganization (WHO) [1].
Mass gatherings also have the potential risk to escalate
the transmission of widespread infectious diseases.
The 2020 Tokyo Olympic and Paralympic Games (2020Tokyo Olympics) was held in Japan during the pandemic of
new coronavirus (SARSCoV-2) infection (COVID-19) [2] in thesummer of 2021.
In this article, the outline of the preparedness of emergency and disaster medical care system related to therunning of this big event, and the outcome of the medical
challenges in hosting the 2020 Tokyo Olympics are hereby
described from the perspective of the academic consortiumand the advisory board of emergency and disaster medical
response planning of the 2020 Tokyo Olympics and COVID19 in the health and welfare bureau of Tokyo metropolitan
government.

Preparedness
Establishment of AC2020
In April 2016, the ‘‘Academic Consortium on Emergency
Medical Service and Disaster Response Plan during the Tokyo
Olympic and Paralympic Games in 2020’’ (AC2020) was launched to provide academic support for the establishment ofan emergency and disaster medical system dedicated to the2020 Tokyo Olympics [3].
Twenty-nine various Japanese major medical associations
participated in the AC2020. The joint committee of AC2020,
consisting of members from each association, has been set
up as a department in charge of gathering knowledge fromeach specialty ﬁeld (Fig. 1), undertaking academic studies,issuing statements, and disseminating manuals/guidelines,
seminar information, lecture contents, and simulation training materials through its website. A lot of manuals andguidelines were released dealing with penetrating/explosive
injuries, cardiac arrest during sports, management of multiple burn cases and management of intensive care units andoperating rooms, infection control, and for nurses working
at mass gathering events, and so on (Table 1).
AC2020 aims to be a ‘‘platform’’ for the transmissionof information by experts, and a ‘‘portal’’ of information
source for citizens and those involved in planning. AC2020
put these contents together under the ‘‘The Mass Gathering
Medical Guidebook (in Japanese)’’ and uploading it to the
web in the spring of 2022. An English version is scheduled tobe released following this Japanese version.

Recommendations for the establishment of asystem based on organizing and presenting
the medical risks by the AC2020
The AC2020 has identiﬁed four major categories of risk basedon reports of past Olympic Games [4—9] (Box 1). The ﬁrst
is a temporary increase in the population of the host andsurrounding areas. This will place an additional burden on
the emergency medical system, which is under pressure ona daily basis [8,9]. An increase in workload for emergency
telephone counseling and the operation of ambulance dispatch is considered inevitable. In addition to the increase in
the number of emergency room visitors, there are concerns
about the possibility of delays in the start of basic treatment
caused by trafﬁc network disruption due to congestion anddelays between the arrival of ambulances and the arrival
on a hospital [7,10]. The increase in infectious diseases dueto the increased ﬂow of people from home and abroad has
also been cited as a risk from the outset. The second risk
is the weather condition of the event [6]. In the extremely
hot and humid environment, there is concern about increasein the occurrence of heat stroke not only at outdoor competitions, but also at large outdoor event sites called ‘‘live3

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N. Morimura, Y. Mizobata, M. Sugita et al.

Figure 1.

Organization chart of the AC2020.

Medical system preparation inside and outside
the venue

sites’’ and on route from the nearest train station to thecompetition site (the last mile), where large crowds are
expected. The third issue is the increase in the number offoreign visitors to Japan, which is expected to be nationwide. The workload related to language, religion, insurance,and repatriation will have a signiﬁcant impact on the daily
emergency medical care system. The fourth is the risk ofmass casualty incidents (MCI) caused by terrorism in light of
the recent international situation or by other events resulting from the increase in population density. It is necessary
to bear in mind the possibility of bombings, gunshot wounds,
and special disasters, of which there is little experience inJapan. Based on these issues, the AC2020 has identiﬁed thefollowing as important issues: ensuring a routine emergency
medical care system, establishing medical care system forlarge-scale events, and responding to unforeseen circumstances.

Administratively, Tokyo Organizing Committee of the Olympic and Paralympic Games (TOC) was responsible forpreparations inside the venue, while Tokyo Metropolitan
Government (TMG) was responsible for preparations on thelast mile leading to the venue, in penumbra, and around thevenue.
The TOC was in charge of developing a medical system
for athletes and spectators at the venues, as well as the athletes’ village, the Olympic family accommodation facilities,
and the media.

Medical service system at each venue
TOC has formulated a basic plan for the on-site medical system based on its experience in preparing for the FIFAWC and4

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Table 1

Released statements, guidelines, manuals from AC2020 through its website (excerpts).

No.

The organization in charge of
document preparation

Document
type1

AC2020 Joint CommitteeStatement

2

AC2020 Joint Committee

3

AC2020 Joint Committee

456AC2020 Joint Committee
Japanese Society of Intensive Care
Medicine
Japanese Society for Burn Injuries

7

AC2020 Joint Committee

8

AC2020 Joint Committee

9

The AED Foundation of Japan10

The Japanese MHLW research team11

AC2020 Joint Committee

12

AC2020 Joint Committee

13

Tokyo Medical Association

14

Japanese Association for The
Surgery of Trauma
Japanese Society for Aeromedical
Services15

16AC2020 Joint Committee

17

The Japanese Society of Intensive
Care Medicine
Japanese Society for Emergency
Medicine
Japanese Society for Emergency
Medicine
National Center for Global Healthand Medicine

18
19
20

Title of document

Uploaded date

Formation of AC2020 jointcommittee
Statement
Basic policy of emergency medical
service and disaster medical
response plan during Tokyo Olympic
2020
ReportReport from participatingorganizations
Statement
The kick-off symposium of AC2020
ReportSurvey of ICU capacity of eachhospital around each venue
Guideline
Survey on severe burn andguidebook of ﬁrst response on burnStatement
Proposal on necessity for
multi-agency coordination center
for medical and ﬁrst response
system at mass-gathering events
Statement
Proposal from the consortium
regarding preparation for
mass-gathering event based on aplan by Tokyo Metropolitan
Statement
Preventing sudden death during
Exercise
ReportReport of the Japanese MHLW
research teamStatement
Proposal for constructing medical
and ﬁrst responding system in
event-site during Tokyo Olympic
2020
Recommendation Consortium proposal of
requirements for medical and EMS
staffs, ver.1
Event-NewsWorkshop program on disaster
responses for Tokyo Olympic andParalympic Games by Tokyo
Medical Association
Guideline of treatment for trauma
Guideline
by gunshot and explosion
Overseas
Prehospital emergency medical
invited lecture
care at the 2020 Tokyo Olympics-Based on the experience ofLondon helicopter emergency
medical service response at the2012 London Olympics
Recommendation Consortium proposal of
requirements for medical and EMS
Staffs, ver.2
Guidance for disaster responses
Reportand preparedness in ICU
Guideline
Guideline of medical care forheatstroke
Guideline
Guideline of medical care points
for visiting foreigners
Report of symposium on medical
Reportpreparedness for Tokyo Olympic
Paralympic Games 2020

20 May, 2016

530 Sep, 2016

7 Nov, 2017
7 Nov, 201720 Apr, 201820 Apr, 201820 Apr, 201820 Apr, 201818 May, 201819 June, 201824 July, 2018

5 Sep, 2018

19 Sep, 2018

20 Sep, 201812 Oct, 201818 Oct, 2018

5 Nov, 201812 Dec, 201812 Dec, 201821 Dec, 2018

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Table 1

(Continued)

No.

The organization in charge of
document preparation

Document
type

Title of document

Uploaded date21

Guideline

Guideline for nurses on Tokyo
Olympic and Paralympic Games2020

19 Feb, 201922

The Japanese Association for
Emergency Nursing, The Japan
Academy of Critical Care Nursing,
The Japanese Society for
Emergency Medicine, The JapaneseSociety of Intensive Care Medicine,
The Japan Society for Infection
Prevention and Control, The
Japanese association of First aid
and Emergency Medicine
AC2020 Joint Committee

23

Japanese Orthopaedic Association

24

Japanese Association for Infectious
Diseases

25

Japanese Society for Burn Injuries
updated

26

Japanese Association for Acute
Medicine
Japanese Association for Acute
Medicine

27

28

Japanese Association for Acute
Medicine

29

AC2020 Joint Committee

30

Special Research in Health andLabor Sciences

31

Japanese Society ofAnesthesiologists

32

Japanese Society for Infection
Prevention and Control

Recommendation The curriculum and program forthe knowledge and skills training
necessary for medical staff during
the event have been started.
Questionnaire result about
correspondence at the time ofgenital injury
ManualResponse to Inbound Infectious
Diseases, For Tokyo 2020 Games:
Infectious Diseases Quick Reference
Report‘‘Survey on the current state of
medical care for severe burns,
Heisei 30th’’ supported by
Administrative Promotion for
Survey of the Ministry of Health,
Labor, and Welfare.
ReportCommittee visit report on heatstroke and hypothermiaStatement
The symposium session in‘‘Emergency and disaster medical
system for international mass
gatherings events’’
Report
The panel discussion in ‘‘Activities
and issues for the Academic
Consortium on Emergency Medical
Service and Disaster Medical
Response Plan during the Tokyo
Olympic and Paralympic Games in2020’’
Recommendation The medical staff training for theathletes in the venue has been
started by the program created by
the consortium
FOURTH GENERATION AGENTS:
Guideline
MEDICAL MANAGEMENT GUIDELINES(updated: January.18.2019) (inJapanese translation)
Guideline
Guideline of in-hospital response
for mass casualty incident: theﬁnal version
Instructional video in
Guideline
countermeasure for imported
infectious disease ‘‘To prevent an
outbreak: Infection control
measure we all can start and deal
with’’

6

19 June, 201929 July, 201929 July, 201923 Aug, 201912 Sep, 20197 Oct, 20197 Oct, 201924 Nov, 201916 Jan, 2020

3 Feb, 2020

3 Feb, 2020

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Table 1

(Continued)

No.

The organization in charge of
document preparation

Document
type

Title of document

Uploaded date33

AC2020 Joint CommitteeStatement

17 Mar, 2020

34

Japan Pediatric Society

Manual35

AC2020 Joint Committee

Guideline

Activities of response to COVID-19
by AC2020
ONLINE QQ: Guide for pediatric
medical emergency
Guideline for holding training
course of emergency/disastermedicine during the epidemic of
COVID-19

5 June, 2020
27 July, 2020

Tokyo Metropolitan Government response

the results of its hosting. The medical plan of FIFA World Cup
Games in 2002 learned a lot from the French medical plan ofFIFA 1998, and at that time the Scientiﬁc Research Group of
the Ministry of Health, Labor and Welfare of Japan provided
much of the medical advice [4].
Based on the previous guidelines, one medical ofﬁce forspectators was set up per 10,000 people per venue. For
the ﬁrst 10,000 people, two doctors and four nurses wereassigned. For each additional 10,000 people, one additional
doctor and two nurses were assigned. In the Field of Play
(FOP), a medical ofﬁce was set up for athletes and referees, and doctors, nurses, dentists, and physical therapists
were assigned according to the characteristics of the sport.
The Venue Medical Ofﬁcer (VMO) was in charge of medical
supervision of the entire Venue; mainly responsible for spectator care, and doctors and nurses were dispatched fromuniversity hospitals and core hospitals in the region, whichwere assigned to each venue. The Athlete Medical Supervisor(AMSV) was mainly responsible for athlete care, and sports
doctors afﬁliated with each athletic organization were in
charge of this. Depending on the sport, physicians and team
doctors from international athletic federations also participated (Fig. 2).
In addition, as in previous Games, a polyclinic was set
up in the athletes’ village. Doctors working at the polyclinics were mainly general practitioners and emergency
physicians, who were systematically dispatched from related societies and organizations at the request of the TOC.
Hospitals were designated in advance for athletes and VIPs.
If the injured or illness was not suitable for transportation
to a designated hospital, such as if the patient was in shock
requiring immediate medical attention, it was possible tochoose transportation to a regular tertiary emergency medical institution.
AC2020 presented the requirements for the skills andknowledge of medical staff working in the venue. In response, TOC asked AC2020 to help develop an education andtraining program for medical and volunteer staff. The program started in the fall of 2019 consisting 13 e-learningmaterials and practical training content for 4 items (CPR,
initial trauma care, ﬁrst aid, and disaster triage/radio
communication). After the event, a survey was conductedon the status of pre-training venue medical staff and volunteers. Of the 7,497 participating staff eligible for training,
94.1% had completed some form of face-to-face group or
remote training, or DVD on-demand self-training.

Below we report on the process of establishing the system
and its activities in Tokyo, where 24 of the 43 venues of the
Olympic games were located.

Establishment of subcommittees
In response to the recommendations from the AC2020 [11],the TMG has set up the subcommittee for reviewing emergency and disaster medical systems at large-scale events as a
medical advisory board dedicated to the 2020 Tokyo Olympics at the end of 2018. The initial aim was the following
issues:• the securing of daily emergency medical systems includingfor ‘‘penumbra’’, i.e., people affected by the event even
if they do not participate, such as local residents [8];• building a medical system for the 2020 Tokyo Olympics
ofﬁcials including athletes, domestic and foreign spectators, and a large number of domestic tourists and visiting
foreigners, and;• measurement against Mass Casualty Incidents caused byterrorism and natural disasters.
The subcommittee held regular monthly meetings fromJanuary 2019, assessed medical risks of ‘‘last mile’’ ofvenues, and formulated categorized medical support plans.

Risk identiﬁcation and response planning
At the beginning of assessment, heat stroke was considered as the greatest medical risk during the hot and humid
summer season in addition to MCI. We therefore quantitatively or qualitatively evaluated the degree of load that the
emergency medical care system in each of the regions centering on the Tokyo Olympics venues would face during thegames, and categorized the medical support according to
the degree of load. The following three indicators of load in
the region centered on each venue were established.
Daily medical supply capacity within each regional area:
total T-score (sum of T-scores calculated from the numberof doctors, number of nurses, total number of beds, andnumber of additional beds for emergency medical services
at each medical institution):
Based on data by tertiary and secondary emergency medical institutions in Tokyo, correlation analysis between suchitems was conducted to select the four items mentioned
above, and robust z-scores were calculated to standardize
the values for each item, where T-score is a conversion of7

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Figure 2.

Medical service system at each venue. Dr: doctor; Ns: nurse; IF: international federation; First aid: ﬁrst aid station.

the robust z-score. They are calculated by the following
equation:
Robust z-score = (x-␮1/2)/(MAD × 1.4826), ␮ = medianvalue, MAD (median absolute deviation) = median (|xi-˜x|),T-score = 50 + 10 × z-score
MCI response capacity within each region which is deﬁned the number of emergency center facilities capable oftransporting patients within 60 minutes of a disaster and the
median estimated time to arrive at the scene after requesting an ambulance (42 ambulances) for high urgency cases.
Assuming a uniform number of MCI patients at a single location of 300, and assuming that 14% (42) of these patientsrequire rapid medical transport due to high urgency, as inpast cases in Japan, the calculation is based on ambulancedata from the Tokyo Fire Department.
Demand-supply ratio of emergency medical services(which we named Risk-Resource Ratio: RRR) during mass
gathering:[[Number of patients per day daily accepted by medical
facilities within a 2-kilometer radius] + [emergency demand
added during mass gathering (projected crowds at each site
multiplied by injury and illness incidence rate*)] / total Tscore*The rate in Tokyo was calculated using the formula = number of patients seen in Tokyo per day [Sunday,
July 22, 2018] (number of patients coming alone + numberof ambulances brought in = 6,383) / Tokyo population[15,920,000 daytime residents].
The values of these indicators were then used to formulate a ﬂowchart for the typology of medical support foreach region centered on the venue (Types A, B, C, D, and E)(Fig. 3).

Command and control system
In line with the Consortium’s recommendations, a system
was created from the preparatory stage to ensure constant,real-time coordination between the Medical Coordination
Headquarters within the Main Operation Center, which islocated within the Organizing Committee, and the Medical
Section within the City Operation Center, which oversees theentire Tokyo Metropolitan Government.

Preparation of information andcommunication system
Hierarchy of information platforms was prepared and planned in advance to deﬁne who would share what and whenutilizing what information tools.

Stafﬁng
GPs from the Tokyo Metropolitan Medical Association weremainly in charge of the last mile, and a support system wasplanned, including the establishment of medical aid stations according to the aforementioned risk types. However,as there were almost no visitors in Tokyo in the end, only
medical aid stations were set up at some Type A venues.
Penumbra, therefore, went ahead with the current emergency medical care system.

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Figure 3. Type of medical support for each region centered on the venue. :required. :may be required. -:not applicable. MCI: masscasualty incident. MCI response; low if number of available hospitals ≤ 2 or on site to hospital transport time > 15 mins. Medical response
capacity; low if total T-score ≤ 152. RRR: Risk Resource Ratio: high if RRR ≥ 0.12, intermediate if RRR = 0.11, low if RRR ≤ 0.1. Each value isthe median for each indicator.

Infection control measures

Paralympic Committee (IPC)) decided to give up accepting
spectators from abroad in March 2021, in light of the domestic infection situation.
The ﬁve-party panel ﬁnally decided on July 8, two
weeks before the Games, to limit the number of domestic spectators. Of the 43 venues, 35 venues in Tokyo andthree neighboring prefectures that were under the COVID-19
emergency declaration or subject to priority measures, andthree venues out of Tokyo hosted the competition without
spectators, and four venues were to be ‘‘50% of capacity or
10,000 spectators, whichever is less,’’ and one venue was toadmit spectators as only children and students participatingin spectator programs in school partnership.

Following the decision on March 24, 2020, to postpone thegames by one year, an inter-organizational ‘‘Coordination
Meeting on COVID-19 Countermeasures at the Tokyo Olympics’’ was launched in September 2020, with the Cabinet
Secretariat as the secretariat. In order to thoroughly avoid
the introduction of COVID-19 into Japan through the participating athletes, ofﬁcials, and spectators, as well as its
spread both domestically and internationally, this meeting
discussed and adopted the ‘‘bubble method’’. This method
was an infection control method that limited the movement
and stay of athletes and related persons to a certain spacein order to avoid contact with the outside world as much as
possible. As it is called, a large bubble that envelopes anddivides the inside and the outside, thus restricting the placesof stay to accommodations, training grounds, and stadiums,
and separating the means of transportation from those ofgeneral public.
AC2020 prepared and provided the administration with amanual on how to deal with the sick on the last mile during
the epidemic period of infection, measures to be taken inﬁrst aid stations, and how to deal with medical ofﬁces in thecompetition venues [3].
The ﬁve-party conference (government, TMG, TOC,International Olympic Committee (IOC), and International

Results
Based on the data provided by TOC to AC2020 with thereview and approval of the Clinical Research Ethics andReview Committee of the Japanese Association for Acute
Medicine, the mass gathering size (for the entire period) was
779,820 (approximate value). The breakdown was 15,820
athletes, 43,000 convention ofﬁcials from abroad, 662,000
domestic convention ofﬁcials, and 59,000 spectators (olympic: 43,300, paralympic: 15,700). The number of injured and9Modele +JEUREA-422; No. of Pages 11

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Figure 4.

Trend of number of COVID-19 cases in Tokyo. Blue bidirectional arrows show the period of the 2020 Tokyo Olympics.

illness (during the competition period) was 1,856. Of these,
1,035 were spectators, ofﬁcials, and media, and 821 were
athletes*. The number of cases in the athletes’ village was
21438 (during the entire period).
The number of patients seen at hospitals (during entire
period) was 316 including 53 COVID-19 cases, of which 120
were transported by ambulance (during entire period), and80 were hospitalized (during entire period). There were 2
out-of-hospital cardiac arrests (during entire period), bothwith favorable neurological outcome. The patient presentation rate (PPR) was 29.0/1000 including the athletes’ village
cases and 2.4/1000 excluding the athletes’ village cases.
The transport to hospital rate (TTHR) was 0.4/1000.
Regarding the number of COVID-19 cases in Japan, thenumber of cases increased as the 2020 Tokyo Olympics
approached, and even though the increase ratio decreased
just before the games, a major wave peak of the epidemic
was observed during the games (Fig. 4).

Discussions
It was a big step forward that experts formed a consortiumand provided expert advice together as one team, not justonly in their individual areas. Command and control structure and communication between different organizations
are usually major challenges during events and disasters,
but based on the expert advices, we were able to overcome
them. The fact that we were able to create a frameworkthat encompassed both inside and outside the venue, andestablish such a public-academic framework, and that thevarious academic associations were able to work together todevelop statements and guideline/manuals, could be considered the true fruits of this big event.
The challenge is that there are too few temporary clerks
in the MOC. The future challenge will be the preparationof a proactive information sharing infrastructure with the
MOC, especially since participation in the COC is a historicalfact for Japan, but it is by no means functional and lacks
autonomy as a department.
Another issue is the inadequate multi-organizational training on each venue and receiving hospitals including the Fire
Department. The training was not systematically performed
until just prior to the event, and the site thought that theevent itself might not even take place, but in the end, sitespeciﬁc training and multi-organizational training could not
be implemented systematically.
The risk assessment method used in this study will enable
us to predict the urgency and number of casualties to betransported to medical facilities in the vicinity of each site,
and thus make more concrete preparations possible. At thesame time, the busyness of other medical institutions in
the vicinity will be known, which will be useful in advanceplanning for the entire region. In addition, the ﬂowchart
created in this study was thought to be simple and versatilewhen establishing a medical support system based on risk
assessment.
The drop in the increase ratio of COVID-19 cases in Japanjust prior to the Tokyo 2020 Games may be due to the effectof citizens’ disciplining restraint due to the rapid increasein the number of new positive cases. On the other hand, theincrease in the number of cases as the games approached10Modele +JEUREA-422; No. of Pages 11

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Journal Européen des Urgences et de Réanimation xxx (xxxx) xxx—xxx

may be due to a change in behavior caused by a sense of
excitement toward the Tokyo 2020 Games and baseless senseof security.
In summary, the direct impact of COVID-19 to Tokyo 2020
was not signiﬁcant. This is probably due to the fact thatthe event was held without spectators in principle. On theother hand, considering the indirect impact, the increasingrate continued to rise until just before Tokyo 2020. Thechange in people’s behavior need to be studied from various
aspects, including social and psychological standpoint. If amass gathering is to be held during an epidemic, it is important to take measures not only to the participants within thevenue, but also to thoroughly communicate the risks to all
citizens.
In these contexts, if MCI had occurred during the 2020
Tokyo Olympics, the current medical care delivery system
would not have been able to cope with such situation,
because we were actually very busy dealing with infectious
diseases, in addition of the lack of multi-professional training due to the delay in deciding on the form of this big
event.
We were actually lucky [12]. We were walking on thin ice,but fortunately, we didn’t step out and drown in the water.

Approval of the research protocol
N/A.

Informed consent
N/A.

Registry and the registration number ofthe study/trial
N/A.

Animal studies
N/A.

Acknowledgement
The authors would like to acknowledge the activities of thefollowing members of AC2020 and the Scientiﬁc ResearchGroup of Ministry of Health, Labor and Welfare (MHLW)
of Japan (Scientiﬁc Research Grant Number: H30-IRYOUSHITEI-005); Dr. Yuichi Koido, Dr. Akio Kimura, Dr. Kaneyuki
Kawamae, Dr. Shinichiro Suzaki, Dr. Kazuya Kiyota, Dr. Daizoh Saitoh, Dr. Tomohisa Shoko, Dr. Yoshiaki Inoue, Dr.
Atsushi Sakurai, Dr. Tetsu Okumura, Dr. Fumihiro Yamasawa,Dr. Tomoya Kinoshi, Dr. Koki Kaku, Dr. Nobuya Kitamura, Dr.
Tatsuya Hayakawa, Dr. Yasuhiro Kuroda, Dr. Yumiko Kuroki,
Dr. Junichi Sasaki, Dr. Jun Oda, Dr. Toru Kakuta, Dr. Satoru

Arai, Dr. Noriaki Sato, Dr. Hiroyuki Matsuura, Dr. Masahiro Nozawa, Dr. Toshio Osamura, Dr. Kazunori Yamashita,
Dr. Hiroshi Okudera, Dr. Akihiko Kawana, Dr. Tsugumichi
Koshinaga, Dr. Satoshi Hirano, Dr. Erisa Sugawara, Dr. Michihiro Kamata, Dr. Yasuhito Tajiri, Dr. Mototsugu Kohno, Dr.
Michiyasu Suzuki, Dr. Dr. Hiroyuki Dr. Nakase, Dr. Eiichi
Suehiro, Dr. Hiroaki Yamase, Dr. Hiroshi Otake, Dr. Hiroshi
Morisaki, Dr. Akiko Ozawa, Dr. Sho Takahashi, Dr. Kotaro
Otsuka, Dr. Kiyokazu Harikae, Dr. Kazuo Kishi, Dr. Hiroshi
Mizuno, Dr. Hideaki Nakajima, Dr. Hiroki Ueta, Dr. Masao
Nagayama, Dr. Migaku Kikuchi, and Dr. Tetsuo Yukioka. We
would also like to acknowledge the MHLW of Japan as thefunding agency.

Disclosure of interest
The authors declare that they have no competing interest.

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