Observed Case-Fatality Ratio
Credit Johns Hopkins Coronavirus Resource Center
#18,452
Officially, somewhere over 7 million people have died from SARS-CoV-2 globally since December 2019, but the real number has been estimated to be 2 or 3 times higher (see The Lancet Estimating excess mortality due to the COVID-19 pandemic).
Numbers provided many countries are highly suspect (see EID Journal: Estimate of COVID-19 Deaths, China, Dec 2022–Feb 2023), and over the past 2-3 years 90% of countries simply stopped reporting COVID hospitalizations or deaths to the WHO.
But even with the limitations of data we know that some countries saw far lower mortality rates from COVID than others. Among highly populated nations with reasonably accurate (when graded on the curve) reporting of deaths, the United States and Canada saw 5 times more deaths per capita than Japan (see JHU Chart above).
This was achieved despite Japan's significantly older demographics, and the fact that Japan never invoked mandatory lockdowns during the pandemic.
A couple of obvious reasons include:
- Even before COVID (see 2019's HK CDW: Surgical Masks For Respiratory Protection), the wearing of surgical masks by the public in Asia during cold and flu season was ubiquitous, and was strongly encouraged by public health officials, while mask wearing was discouraged in the early days of the pandemic in the United States.
- Additionally, the uptake of the COVID vaccine was much greater in Japan than here in the United States.
But today we've a preprint (not yet peer reviewed) which - using a series of surveys conducted between 2021-2023 - finds a number of other factors that may have contributed to Japan's relative success in controlling the pandemic.
While many countries opted for harsh, and prolonged, lockdowns and school closures, Japan followed a far less restrictive path; encouraging mask wearing, reduction of social contacts, and avoiding the `3 Cs'; places that are closed, crowded and entail close contact.
Unlike here in the United States, where the CDC's Guidelines on How Fully Vaccinated People Can Visit Safely with Others, quickly reduced social distancing requirements in certain settings, in Japan vaccinated individuals continued to practice social distancing.
While many countries were eager to abandon masks and resume `normal' social contact, Japan's population exercised far more cautious behaviors - continuing to wear masks and restrict social contacts - well into 2023.
I've only posted the link, Abstract, and an excerpt below. Follow the link to read it in its entirety. I'll have a postscript after the break.
Tomoka Nakamura, ProfileRyo Kinoshita, Akira Endo, Katherine E. Atkins, Hitoshi Oshitani, Yoko Ibuka, ProfileMotoi Suzuki, Koya Ariyoshi, Kathleen M. O’Reilly
doi: https://doi.org/10.1101/2025.04.17.25326019
Abstract
Despite implementing no lockdowns and having a large elderly population, Japan had a low mortality rate due to COVID-19 compared to Europe and North America. The extent to which policies impacted person-to-person contact remains unclear. In this study, we examined changes in contact patterns and their association with behaviors and governmental recommendations in Japan during the pandemic.
Ten social contact surveys were conducted between 2021 and 2023 reaching over 1500 participants per survey in Osaka and Fukuoka prefectures where governmental recommendations were first implemented due to high COVID-19 incidence. Their contact patterns were assessed through their demographic characteristics, COVID-19 vaccination status, and individual disease mitigation measures. Generalized linear models were used to identify factors associated with increased contacts.
The mean number of contacts during the pandemic declined by at least 49.8% (8.2 weekday contacts and 6.0 weekend contacts per individual, adjusted by age and sex) compared to a study conducted prior to 2020. Weekdays, occupation, larger household sizes, and mask wearing were associated with a higher number of contacts. The frequency and duration of contacts were negatively associated with the issuance of COVID-19 governmental measures, yet the relative change in contacts was not as prominent as pre- and post-lockdown situations in the United Kingdom.
There was a gradual increase in contacts with time and less strict public health recommendations. Yet, contacts that did not increase with uptake of COVID-19 vaccination and continuous mask wearing depict cautious behavior across the survey population during the pandemic and into 2023. These results are in contrast with European countries where contacts largely increased among vaccinated individuals compared to the non-vaccinated. Social contacts are country and context specific, highlighting the need for data collection across different communities.
(SNIP)
We conducted repeated surveys in Japan to understand how the population modified its behavior and contact patterns during the pandemic. Our results showed that daily contacts dropped by approximately 50% during the pandemic, rebounding only slowly after the government recommendations were relaxed.
People proceeded with caution as they wore masks longer if they had more contacts and consistently wore masks until 2023, even after a full year since the last governmental recommendation was lifted.
The frequency of contacts did not increase after individuals received the COVID-19 vaccine which is in contrast with European countries where the opposite trend was reported. Our findings provide evidence on the importance of reduced contacts, careful behavior, and high vaccination coverage that potentially limited disease transmission and mortality in Japan.
Since COVID is unlikely to be the last pandemic threat we'll face, it is important to analyze what worked, and what didn't during the last pandemic. Clearly, 1 million-plus U.S. deaths was far from optimal.
Japan's > 5 fold reduction in mortality despite a significantly older population - without resorting to draconian lockdowns or extended school closures - is certainly impressive.
And even though the COVID `pandemic' is over, research continues to show the more times you are infected with COVID, the more likely you are to experience `long Covid', or other sequalae (see CIDRAP COVID-19 reinfection ups risk of long COVID, new data show).
Both of which would seem to favor a less onerous, and more sustainable, approach.
Whether we can find the political - and societal - will to adopt something like this `Japanese model' the next time a severe pandemic threatens remains to be seen. The current anti-vaccine climate, and a distain for wearing masks and social distancing, makes it difficult.
But at least we are under no illusions of the cost of doing it the `old way'.