Author: David Sinclair

The number of coronavirus cases has been increasing in Japan over the past six weeks, but vaccination progress continues to be relatively slow. Just around one million people or 1% of the population have been vaccinated against COVID-19 in the country.

Close to one-third of the population in Japan is aged over 65 yet, as we have highlighted before, it is a country which has relatively low levels of uptake of existing adult vaccinations against diseases like influenza or pneumococcal disease.

ILC are currently working with Stripe Partners on a project which seeks to identify and develop solutions to address low uptake of adult vaccinations in Japan, with ethnographic fieldwork planned for later in the year. Earlier this month, we brought together a group of health experts with an interest in Japan to understand why uptake rates might be relatively low and what this might mean for the future.

So, what did they suggest?

Vaccination is just for kids

There is a perception among many people in Japan that vaccination is “something which you do in school”. So the concept of life-course vaccination just hasn’t found its place in policy or practice yet. Whilst there are mandatory and voluntary vaccinations for children, adult vaccination is relatively recent in the history of Japanese health policy.

Paper-based systems are a barrier to delivering national vaccination programmes effectively

The “paper-based system for health is a barrier” in terms of increasing uptake of adult vaccination. One participant pointed out that “one of the reasons for low compliance is that the vaccine schedule is too complicated and there are no electronic reminder systems”.

Japan has no national information infrastructure for adults. “Most people in Japan have access to smartphones and the internet, but we are behind places like South Korea and Taiwan in developing these systems”, one participant argued, There are plans for a location-based COVID-19 app but this has not been implemented yet.

There is also likely a significant disparity in access to these vaccinations between different municipalities and between rural and urban areas although there is limited data recorded to capture this. Better digital healthcare could help identify the nature of this challenge and target resources at areas where uptake is low.

Trust in Government is low

One participant highlighted that evidence from Edelman confirms that public trust in Government in Japan is very low. So it is difficult, even if Government had good public health systems, to develop trust in vaccination. However, trust in doctors is high and a key factor relating to uptake is “whether people have been told by their GP to have it”. While there are “willing doctors and health care professionals… they are inhibited by the fact that the Government is not supporting them”.

Cost is a barrier

“Money is a barrier to adult vaccination for some people”. “Vaccinations need higher co-payments compared to routine services”.

Our experts pointed out that vaccination is treated differently to other medical interventions in Japan. Whereas the Japanese medical system is very generous for acute services, “preventative health is not covered by public health insurance”. The subsidy levels for vaccination vary across municipalities which adds to the inequalities of access.

Some people find it difficult to find the time to go for a vaccination

One of our experts talked about the “time cost” of vaccination. In Japan, vaccination is only allowed under medical license so can’t therefore be administered in pharmacies or other community settings. In other words, current clinics may not be open at a convenient time for some adults. It is possible for nurses to deliver vaccinations, but doctors must prescribe and supervise. The Japanese Medical Association holds significant political power and doctors have not yet relinquished this power.

Government is cautious

The HPV vaccine litigation in Japan has led to significant caution about promoting vaccination through fear of legal action. As a result, information about vaccines, when provided, is couched in terms of risks and side effects above benefits. The “first line is vaccination is not mandatory, then there is a list of side effects then at the bottom – it is the benefits”. So that in itself is a big barrier to building trust in immunisation.

A concern about side effects. Safety is a bigger public worry than efficacy

There seems to be greater concern about side effects than efficacy among many people. In Japan there is a need for mandatory clinical trials on the local population even if safety and efficacy have been proven elsewhere.

There is a concern about “fake news” and one participant argued “there [were] some negative attitudes especially on social media about side effects.”

Our experts felt there was a need to design messaging that would target different groups and build trust. One person felt that building on “group dynamics in Japan” and delivering “shared briefing sessions” of “community based health promotion” may be a way forward.

Japanese locally-driven health works better for treatment than prevention

Historically-grown health structures have shaped the way health is distributed and organised.
The Japanese Public Health Centre was introduced after World War Two by the US occupational force. The centre was crucial in tackling poor hygiene and at that time provided free screening and vaccination. The Public Health Centre was the centre for health promotion in the community.

However, over the years the Japanese medical system gained additional status and the “free visit policy” emerged. The public were given wider choice and the Public Health Centre lost its monopoly to provide public health, limiting their role over time.

Whereas medical organisations have started taking preventative diseases more seriously, this has focussed mainly on non-communicable diseases rather than immunisation.

The “free visit policy” means that in Japan, GPs have no registration of patients so “everything is come and go”. Whilst this provides choice, it also means that there has been little focus on promoting public health by private doctors, as people only typically come into the health system as and when they need it.

It isn’t all bad news though.

Our experts felt that there were very positive signs about the future of preventive medicine and adult vaccination.

Perhaps there isn’t really vaccine hesitancy in adults in Japan

Our experts argued strongly that despite a popular perception, vaccine hesitancy among adults is overplayed. They felt that people understood effectiveness and are eager to have vaccines. The only issues are accessibility, availability and cost.

One doctor stated that “vaccination is widely accepted by older people. Most of the older patients in my clinic accept it and believe it is important. Older people are very positive about attending vaccination clinics. In November, my patients often say “it’s flu vaccination season, where is my vaccine”.

In terms of the COVID-19 vaccination, the fact that there will be no charge will help with uptake. It was felt that “the big issue is supply and logistics”. One of our participants quoted a survey which suggests that 95% of Japanese aged over 65 wanted to have a COVID-19 vaccine.

COVID-19 vaccination information about side effects may be reducing hesitancy

One expert pointed out that whilst “there is some negative feeling [toward] vaccination, this is changing due to COVID. We have seen from other countries that there are few side effects and tiny numbers of anaphylactic incidents. This is actually raising confidence.”

The broadcasting company is providing daily information about side effects with an aim to increase confidence. The Government is campaigning strongly on safety (“this is a first”…“the first time Government took very active action to prove vaccination safety”).

Government has also piloted a COVID-19 vaccine in medical staff in national hospitals and has been collecting data on side effects. 70% of medical staff agreed to make a diary to record and report on side effects.

Japan does have strong systems for some forms of preventative care

“There is a good tradition of screening in relation to TB, NCDs and cancer”. Building on this could help increase uptake of adult vaccinations.

So, what happens next?

Whilst COVID-19 cases are increasing, they remain relatively low compared to Europe and North and South America. Deaths remain very low compared to many other countries across the world.

Japan is expecting significant COVID-19 vaccine supply between May and June and it will be interesting to observe whether Japan can encourage its older population to take up their right to a vaccine.

And the long term question is whether the experience of the COVID-19 vaccination programme will lead to a longer term increase in uptake of other adult vaccines such as influenza and pneumococcal disease.