1. Basic Policy

In regards to “Guideline for Securement of Medical Services, Quarantine and Request for Temporary Closure of Schools, Day-care Facilities” of May 22, 2009 published by the Ministry of Health, Labour and Welfare (MHLW), it is revised as follows with the view to the outbreak status to date both in Japan and abroad and so on.

(Outbreak Status Abroad)

The current novel influenza A (H1N1) is still spreading further, especially in the southern hemisphere where winter is coming from now. On June 12, 2009 (Japan time), the World Health Organization (WHO) announced that a global pandemic was underway and raised the level of influenza A (H1N1) pandemic alert to phase 6 according to the revised guideline of 2009, since sustained community level outbreaks in at least one other country in another WHO region had been recognized. Besides, WHO asked its member countries to stay on alert and also to respond flexibly depending on the status of each country not to cause social or economic confusion.

(Outbreak Status in Japan and Outlook for the Future)

As for the status of the virus infection in Japan, sporadic cases which originated with people having overseas travel history and outbreaks of group infection at schools have been reported in some regions. Moreover, there have been other sporadic cases in some prefectures. For those cases, investigation and health monitoring have been implemented to prevent infection spread.

However, looking at the trend of outbreak status abroad including countries in the southern hemisphere and the fact that international traffic is not restricted, allowing those infected with the virus to enter Japan, outbreaks will continue to occur in Japan. Furthermore, in light of some sporadic cases whose causes have not been identified, nationwide and large-scale increase in the number of patients could happen anytime towards autumn and winter.

It is reported that persons with underlying medical conditions tend to become severely ill as the characteristics of the current novel influenza A (H1N1). With increasing number of patients, serious cases are likely to increase among persons with underlying medical conditions, which we have to cope with.

(1) Response to patients and individuals who were in close contact with patients

[1] Patients

Patients (including suspected patients) should be stay at home and refrain from going out not to spread infection rather than being hospitalized under the direction of a doctor. In case of potential infection spread, the patient may be admitted to a hospital as necessary.

Individuals with underlying medical conditions* should be prophylactically administered antiviral drugs from the early stage of infection. Among them, high-risk patients will be given priority for having a PCR test and hospitalization as necessary. In order to contribute to doctors’ judgment, MHLW will provide medical workers with latest scientific findings as needed.

[2] Individuals who were in close contact with patients

Prefectural governments, etc. will request individuals who were in close contact with patients to contact the local health center if symptoms such as fever developed during a certain period of time, while explaining the importance of infection prevention behavior such as voluntary restraint from going out and asking for cooperation. In case more than one patients belonging to a group including schools are confirmed, proactive epidemiological surveillance should be implemented as needed to identify the close contacts.

If an individual with underlying medical conditions is strongly suspected of infection, antiviral drugs will be administrated as a prophylaxis at a doctor’s discretion. If an individual with underlying medical conditions among medical workers or initial response personnel is exposed to the virus, prophylactic administration of antiviral drugs will be implemented. If the possibility of infection is low, he/she may continue his/her duty.

The Fever Consultation Center offers telephone information service including referral to an appropriate medical institution to those with no idea of which medical institution they should visit, consultation service for patients staying at home, etc. Specific operations of the Fever Consultation Center will be determined by the prefectures, etc. depending on the information needed by the local residents.

As to the outpatient departments, not only the medical institutes currently providing medical care to patients with novel influenza A (H1/N1) infection, but as a rule every general medical institute should provide medical care in order to respond to increasing number of patients. On this occasion, the utmost attention should be paid for the medical institute to function as a fever clinic, such as separating the waiting area at the medical institute by patients with fever and other patients, or assigning separate consultation hours. In particular, full infection prevention measures should be taken so that individuals with underlying medical conditions may not be infected with the virus. Necessity of establishing an outpatient department outside the medical institution including in public facilities or outdoor tents will be considered by the prefectural government depending on the characteristics of the local community.

As a rule, patients are recommended to stay at home instead of hospitalization, however, serious patients will be hospitalized not only at designated medical institutes for infectious diseases but also at general medical institutes with inpatient facilities. In that case, the medical institute should utilize beds in consideration of averting in-hospital infection. The prefectural government should ensure hospital beds based on the situation of the local community.

In order to protect people considered to be at high-risk when infected with novel influenza A (H1/N1), prefectural government may determine medical institutes (e.g. dialysis facilities, cancer hospitals and maternity hospitals) where medical care is not provided for patients with fever as a rule.

(3) Schools and Day-care facilities, etc.

If an infected person is confirmed at schools, day-care facilities, etc., the prefectural government will request the officials of the relevant schools, day-care facilities, etc. for temporary closure as necessary in order to protect pupils/students of the relevant schools, day-care facilities, etc.

If it is considered to be essential for preventing the infection spread, the prefectural government may request temporary closure over broad area including schools, day-care facilities, etc. with no identified cases.

Universities shall be requested to contrive a management means, including closure, to slow down the infection spread.

3. Steady Implementation of Surveillance

(1) Early detection of Infection Spread

An outbreak of a group infection with novel influenza A (H1N1) should be detected as early as possible to avoid it developing into a rapid infection spread or a massive epidemic outbreak.

For this purpose, the public health center should not monitor all patients (including suspected patients), but focus on individuals who belong to groups, such as schools, where a large outbreak is possible if left as it is. In addition, subsequent patients in the identical group should also be monitored. This alteration should be implemented immediately after a smooth transition period.

The local institute of public health will perform confirmatory tests on the specimens from some of those suspected patients. If confirmed to be infected with novel influenza A (H1N1) virus, the doctor will report to the public health center.

Although public health centers have understood the status of suspension of attendance or temporary closure leading to an outbreak of a group infection, it should be done more quickly from now on.

The prefectural governments, etc. will report these results to the national government, and also implement necessary measures for infection prevention including responses to the patients, close contacts, etc.

(2) Monitoring of Aggravation and Viral Mutation

While assessing the number of serious patients admitted to hospital, viral change in property (i.e. pathogenicity, drug resistance, etc.) will be monitored at the local institutes of public health and the National Institute of Infectious Diseases, following submission of patient specimens from predetermined medical institutes for fixed point observation of pathogenicity.

If viral mutation is recognized, the result should be appropriately reflected to responses to the public health aspect, the medical care aspect and so forth.

(3) Accurate Understanding of the Outbreak Current of Novel Influenza A (H1N1) at Large

Based on the report to public health centers on the outbreak status of novel influenza A (H1N1) at predetermined medical institutes for fixed point observation, the outbreak current of novel influenza A (H1N1) at large will be accurately understood and then the information will be provided to medical workers and the public.

4. Quarantine

Taking into account the current situation of world-wide pandemic, the quarantine policy will be converted to as follows:

While a health card containing attention on novel influenza A (H1N1) virus infection will be distributed to people entering Japan, making calls for them in front of the quarantine booth, in order to familiarize them with paying attention to infection prevention as an individual, furthermore it will be disseminated to visit a medical institute if symptoms appear.

As for learning about individuals having symptoms, on-board quarantine will be continued depending on the situations of an advance notice, and request for cooperation for self-assessment of health conditions by enhancement of in-flight announcement, etc. will be also continued.

As a rule, individuals who are confirmed to having symptoms at the quarantine station will return home wearing a mask according to the symptoms and avoiding the public transport as much as possible, not having a PCR test for influenza A (H1N1) virus (it is not applicable if more than one person is confirmed in a group of the identical itinerary).

In case more than one person is confirmed from a group of the identical itinerary, a PCR test for influenza A (H1N1) virus will be conducted at the quarantine station for confirmation. If the result is positive, it will be informed to the person and a visit to a medical institute will be recommended. In this case, as to the other people of the identical itinerary, the local governments of their address will be provided with the information. The local governments will explain them well about the importance of infection prevention behavior such as self-restraint of going out to ask for cooperation, and the local governments also request them to report to the local health center if symptoms such as fever appear during a certain period of time.

5. In Preparation for Further Change

It is necessary to make preparation to respond to domestic large increase in the number of patients which is possible toward autumn and winter, and also to review appropriate and rapid response when the number of patients substantially increases actually.

Especially, to avoid such situation as patients cannot receive proper medical treatment, it is necessary to review and clarify specific measures including provision of inpatient treatment restricted to most severe cases.

As for surveillance, responses depending on situations will be implemented including continuation of pathogenicity surveillance for checking mutation in pathogenicity, drug resistance, etc., along with specializing in understanding of the outbreak current at predetermined medical institutes for fixed point observation instead of the approach to early detection of infection spread which will be aborted.

However, in case of viral mutation resulting in increase in pathogenicity or acquisition of drug resistance, this guideline will be reviewed.