Analysis

Japan's first wave of COVID-19 peaked in mid-April 2020 with 600 new cases daily. It then declined, but rose to a new peak of around 1,400 in mid-August before dropping again.

In late 2020, Suga announced measures to stimulate the economy (see JAPAN: Economy gains footing for future growth - February 17, 2021). The most publicised were subsidies to promote domestic tourism. This, plus seasonal travel at the year-end, led to a third wave, which peaked at 7,000 new cases daily in January, putting severe pressure on hospitals.

Emergency regulations were imposed on the Tokyo area on January 7 and later extended to all major urban areas. Most had been lifted by March 7, but they were extended in the Tokyo area until March 21.

The decline in new cases daily has levelled off at around 1,000 nationally and there are some signs of a slight increase. The R number stands at 1.23.

Strategy

Suga's announcement of the end of the emergency regulations included a new strategy:

• continued restrictions on opening hours for bars and restaurants;
• more monitoring of the spread of COVID-19, particularly new variants;
• reinforcing the hospital system to increase the number of beds for those with severe symptoms and facilities to host those with no or mild symptoms; and
• the vaccination programme.

Critics, including the Japan Medical Association and Tokyo Governor Yuriko Koike, worry that this will not prevent a fourth wave. Indeed, the governor of Osaka on March 29 argued that one has already begun.

Vaccination programme

Vaccinations began in mid-February with 10,000 volunteers, mostly with a medical background.

The next phase is to vaccinate all medical professionals, of whom there are an estimated 5 million.

From mid-to-late April the programme will expand to cover the entire elderly population by the end of June, a deadline that has already been pushed back.

A national roll-out will begin in mid-April, but some prefectures will only receive 1,000 doses at that point. There has been discussion about how to make vaccine supplies go further to ensure at least six doses per vial and even using shorter insulin needles to get seven. This latter is feasible because Japanese tend to have less subcutaneous fat than North Americans and Europeans.

Suppliers

Japan has secured rights to over 564 million doses from four non-Japanese producers.

Perceived vaccine hesitancy has made the government double down on insisting on clinical trials on Japanese nationals on Japanese territory.

At the moment only the Pfizer vaccine is licensed. Supplies are flown in from Belgium. Each planeload carries about 420,000 doses.

The Moderna and AstraZeneca vaccines are being considered for approval.

Japan has ordered 120 million doses of the AstraZeneca vaccine. Local pharmaceuticals firm Daiichi Sankyo and two smaller companies have already started preparing for distribution. They will be ready to supply as soon as approval is given, possibly in May, although worries about the vaccine in Europe and the United States may delay this. There are plans for production entirely in Japan by year-end, which will ease fears related to reliance on imported supplies.

Takeda Pharmaceutical Company will import 50 million doses of the Moderna vaccine, and is handling its approval, which is expected in the first half of 2021. The firm is also handling the approval and production of the Novavax vaccine, with plans to produce 250 million doses annually. Distribution is planned for late 2021.

Takeda also has an agreement with Johnson & Johnson that will use the facilities of Takeda's partner in Germany to manufacture the single-shot Jansen vaccine for a period of three months.

Domestic development

The government provided JPY11bn (USD100mn) in September to support work on a vaccine at Osaka University. Mitsubishi UFJ gave a further JPY250mn this month to support that work, but the vaccine is unlikely to be trialled by the end of this year.

The pharmaceuticals firm Shionogi received about JPY4bn from the government and began clinical trials of its recombinant protein vaccine in December, but it is unlikely to reach the market until 2022.

Daiichi Sankyo and KM Biologics started clinical trials in mid-March. Daiichi Sankyo is co-developing its vaccine with the University of Tokyo but does not expect an official launch until 2022 at the earliest. KM Biologics plans final clinical trials by year-end and an official launch sometime between April 2022 and March 2023.

Outlook

Suga and Kono have announced plans to secure enough vaccine for the whole nation by the end of June (see JAPAN: Taro Kono could be next prime minister - February 24, 2021). It is unclear whether 'securing' means possessing vaccines ready to distribute, or just having firm contracts for supply.

If AstraZeneca and/or Moderna are not approved soon, the entire programme will depend on imports from Europe -- 120 plane loads just to vaccinate the elderly population. This assumes that the EU will allow export.

There is some evidence of 'vaccine hesitancy'. So far Japanese have experienced side effects at a rate of 200 per million compared with 1-5 per million in the United States and United Kingdom. This may be due to different definitions of 'reaction' rather greater Japanese sensitivity, but the publicity recently given to concerns in Europe and the United States may boost resistance to vaccination. A recent survey suggested that 75% of over-65s would take a vaccine and 20% would refuse.

Mass vaccination starts will not begin to affect the number of new cases for months, and the new academic and business year begins on April 1, requiring domestic travel. People will gather for cherry blossom parties (albeit outside) and also be tempted to visit family and friends during the Golden Week holiday starting in late April. Some increase in transmission rates seems probable, and may develop into a fourth wave.