Health preparedness plan for dengue detection during the 2020 summer Olympic and Paralympic games in Tokyo

Naoki Yanagisawa; Koji Wada; John D Spengler; Ramon Sanchez-Pina

doi:10.1371/journal.pntd.0006755

. 2018 Sep 20;12(9):e0006755. doi: 10.1371/journal.pntd.0006755

Health preparedness plan for dengue detection during the 2020 summer Olympic and Paralympic games in Tokyo

Naoki Yanagisawa ^1,^*, Koji Wada ², John D Spengler ¹, Ramon Sanchez-Pina ¹

Editor: Kiyoshi Kita³

PMCID: PMC6147396 PMID: 30235211

Abstract

Background

Participants in mass gathering events are at risk of acquiring imported and locally endemic infectious diseases. The 2014 dengue outbreak in Tokyo gathered attention since it was the first time in 70 years for Japan to experience an autochthonous transmission. Preparation for emerging infectious threats is essential even in places where these outbreaks have been largely unknown. The aim of this study is to identify strategies for early detection and prevention of dengue infection during the 2020 summer Olympics and Paralympics in Tokyo.

Methodology/Principal findings

We modified and adapted the failure mode and effect analysis (FMEA) methodology, generally used in industrial manufacturing, to examine the current controls for dengue detection and assessment. Information on existing controls were obtained from publicly available resources. Our analysis revealed that the national infectious disease control system to detect dengue in Japan is robust. However, in the case of large assemblies of international visitors for special events when the spread of communicable and vector-borne diseases increases, there are three main gaps that could be reinforced. First, cyclical training or a certification program on tropical disease management is warranted for physicians, especially those working in non-infectious disease-designated hospitals or clinics. Second, multi-language communication methods need to be strengthened especially in the health and hospitality sector. Third, owners of accommodations should consider incorporating a formal tropical disease-training program for their staff members and have a contingency plan for infectious disease-suspected travelers.

Conclusions/Significance

Our findings may facilitate physicians and public health officials where new controls would be beneficial for the 2020 summer Olympics and Paralympics. The FMEA framework has the potential to be applied to other infectious diseases, not just dengue.

Author summary

Dengue is a mosquito-borne disease that is most prevalent among the emerging arboviruses. Most patients recover from dengue without complications, but a small portion of cases may progress to severe dengue which carries a high mortality rate if left untreated. In 2014, a dengue outbreak unexpectedly occurred in Tokyo, which was the first time in 70 years for Japan to experience an autochthonous transmission. Thus, preparation for dengue and other emerging infectious threats is essential even in places where these outbreaks have been largely unknown. Tokyo will be hosting the Olympic and Paralympic games in 2020, and interventions are warranted to mitigate the risks. We modified and adapted the failure mode effect analysis (FMEA) methodology to test the vulnerability and resiliency of the current controls. Although the FMEA methodology is generally used in industrial manufacturing, it has the potential to be utilized for health preparedness for other infectious diseases as well. Our analysis identifies three strategies to reinforce early detection of dengue infection and prevent further transmission during the Olympic and Paralympic Games.

Introduction

Participants and spectators of international sporting events such as the Olympics, are at risk of acquiring imported and locally endemic infectious diseases [1, 2]. Host countries need to be well prepared to address these challenges, since infectious disease outbreaks can occur with little warning. The risk of an outbreak occurring, even in areas where a disease has been previously unknown, is increasing due to globalization. The International Air Travel Association reported that there were 3.8 billion air travelers in 2016 but expects the number to nearly double to 7.2 billion passengers in 2035 [3]. Globalization has certainly provided a great opportunity for traveling, culture exchange, and trade but on the other hand, it has enabled a person carrying an infectious pathogen to go almost anywhere in the world within days. Development of the transportation network expedites the rate at which a pathogen spreads and poses a major threat to the international community [4]. It is notable, however, that despite the ever-increasing and unpredictable shocks of health pandemics, the tourism industry continues to grow, accounting for 10.2% of the global gross domestic product in 2016 [5].

Respiratory infections and gastrointestinal illnesses have always been a major concern at international sporting mass gatherings [6]. Examples of these outbreaks include influenza at the 2002 Winter Olympics in Salt Lake City [7], norovirus gastroenteritis at the 2006 FIFA World Cup in Germany [8], and measles at the 2010 Winter Olympics in Vancouver [9]. Recently, a norovirus outbreak was confirmed at the 2018 Winter Olympics in PyeongChang [10]. However, vector-borne disease, namely Zika virus, gathered worldwide attention at the 2016 Olympics in Rio de Janeiro [11, 12]. The outbreak raised considerable debate internationally about whether postponing and/or relocating the games should be considered, due to the risk of infection of athletes and visitors and potential acceleration of the spread of Zika virus worldwide [13–16]. The World Health Organization declared that there was no public health justification for postponing or cancelling the 2016 Olympic Games, and no laboratory-confirmed cases of Zika virus were subsequently reported among participants [17, 18].

The 2020 summer Olympic and Paralympic games in Tokyo

Tokyo will be hosting the next Olympic and Paralympic games during the summer season in 2020 (Tokyo 2020) [19]. Although Tokyo is located in a temperate climate zone, vector-borne disease will continue to be a major concern, as it was with the previous games. It was unexpected that a dengue outbreak occurred in the summer of 2014, which was the first time in 70 years for Japan to experience an autochthonous transmission [20]. This outbreak implies that Tokyo possess a suitable ecoclimatic condition, has a population that is immunologically naïve to the virus, with a high probability of introduction of the virus by travelers, and the existence of the Aedes mosquito, which is the competent vector. Furthermore, the activity of the Aedes mosquito and the number of imported dengue cases will peak during the same time period as Tokyo 2020 [21]. Although A. aegypti does not exist in Japan, A. albopictus is found in Tokyo and seems to be extending its habitat further north, where climate change may play an important role [22].

Prior to this dengue outbreak, which resulted in more than 160 laboratory-confirmed cases, there have been 50 to 200 official reported dengue cases annually, all of which have been imported [21]. Similar to the global trend, the number of tourists who visited Japan increased 4.6-fold, from 5.2 to 24.0 million people [23], from 2003 to 2016. Many factors contribute to risk of dengue importation, such as number and origin of the tourists, epidemiology of dengue in their countries of origin, and seasonal synchrony. In this regard, Japan may be at increased risk for dengue importation since the country is promoting more tourists, aiming for 40 million people by 2020, from all over the world.

Health effects of dengue

Dengue is the most prevalent among the emerging arboviruses. Recent studies have demonstrated that 58.4 to 96 million clinically significant cases occur annually, with the number of cases more than doubling every decade between 1990 and 2013 [24, 25]. Clinical characteristics of dengue include sudden high-grade fever, headache, vomiting, myalgia and arthralgia, typically occurring in what is called the febrile stage. These symptoms typically develop between 4 and 7 days after the bite of an infected mosquito. This phase lasts for 3 to 7 days, after which most patients recover without complications. However, among the infected, up to 5% may progress to severe dengue, an illness characterized by plasma leakage leading to hypovolemic shock, hemorrhage, and potentially death [26]. The mortality rate of severe dengue is 20% if left untreated, but it could be reduced to less than 1% with appropriate clinical management [27]. While dengue could result in severe consequences, it is notable that most dengue infections are asymptomatic or mild—only about 1 in 4 infections is symptomatic—and result in complete recovery [28]. However, people with asymptomatic dengue infections may be more infectious to mosquitoes than people with dengue symptoms [29]. This implies that an asymptomatic infected individual can be the source of virus for mosquitos as well.

Health preparedness plan and failure mode and effects analysis (FMEA)

Preparation for emerging infectious threats is essential even in places like Japan where these outbreaks have been largely unknown. Considering the nature of infectious disease, it is virtually impossible to prevent any pathogen from entering a country just by enhancing border control. A pragmatic approach is to have a preparedness plan so that health professionals along with others knows how to recognize symptoms and how to respond. In this context, failure mode and effects analysis (FMEA) is a framework that is suitable to test the vulnerability and resiliency of the current preparedness plans and to strengthen these current plans in order to forestall failures [30].

FMEA is a procedure for the analysis of potential failure modes within a system in order to classify and quantify risks by their occurrence, severity and detection controls already in place. The original FMEA methodology was developed by the U.S. Military during World War II for the assessment of failures and subsequent risks [31]. Although the process and the parameters continue to evolve to conform with new applications, the FMEA basic framework is retained and used around the world 70 years after the end of World War II. After the U.S. Military developed FMEA, it was adopted by the National Aeronautics and Space Agency, and then by various large U.S. manufacturing companies. General Motors and Boeing Aircraft use FMEA methodology to assess their manufacturing processes. When some of the models of Toyota Motors experienced a sudden unintended acceleration and catastrophic accidents, the company incorporated FMEA in a significant way to assess the risks and prevent accidents.

FMEA became well-known because it is a risk prevention tool instead of a corrective measurement to diminish risk when designing new products, industrial processes, customer service applications, and infrastructure of the environment and health systems. The methodology of FMEA is appealing, because the analysis is prospective rather than retrospective, enabling us to not rely on the analysis of errors after they have occurred. FMEA has been implemented mainly in the engineering industry and is more recently gaining momentum in healthcare [32–34]. However, to the best of our knowledge, the FMEA framework has not been applied to health preparedness plans for infectious diseases. The aim of this study is to search the gaps in the current controls which could be reinforced for dengue detection and assessment during Tokyo 2020 using the FMEA methodology.

Methods

Application of FMEA

In the application of FMEA, a process map of the operation is created, including all of the activities and understanding how the process steps are related. Second, every operation or activity in the process will be analyzed in order to understand its potential failure modes and the effects of these failures. Third, the controls for each failure mode will are described, and the severity (S), occurrence (O) and detection (D) of each failure mode under current process controls is assessed. We have developed a novel criterion for each of the components (S1 Table, S2 Table, S3 Table). The numbers are multiplied to calculate the Risk Priority Number (RPN) for every failure mode (RPN = S x O x D; range, 1 to 1000). The criteria to take action varies, but the most accepted notions to take action after the RPNs are calculated are as follows: 1. Create a corrective action for every failure mode that has a 9 or a 10 in any of its S, O, or D numbers or RPN number higher than 150; 2. Decide if a corrective action is necessary for failure modes with RPNs between 80 and 150. Implement a corrective action if the cost of the corrective control is low or moderate. 3. Apply a corrective control when the RPN is lower than 80 if the corrective action is easy, inexpensive and quick to implement. 4. The “safe” range is for failure modes with RPNs within the range of 1 to 40. Lastly, after the corrective actions have been implemented in the design/process, the new RPN should be checked to confirm the improvements (risk reduction of failure mode). A countries’ health systems or infrastructure and the situation of the disease in which may occur should be taken into consideration upon evaluation. The most relevant number should be chosen if there is no exact match.

In our analysis, we focused specifically on processes necessary for detection and assessment of dengue cases. Since Japan is currently not endemic for dengue, physicians may not be prepared or even aware that a dengue patient could show up in their own hospital. In order to promptly activate a public health response, such as enhancing the surveillance system or vector control activities in areas where persons became infected, accurate and timely reporting of the disease will be essential. Therefore, we divided the process into three components: 1. detection of the disease, 2. assessment of the disease, 3. patient communication. Detection of the diseases focuses mainly on the role the travelers themselves and the community, whereas assessment of the disease focuses on the role of the physicians in the hospitals and/or clinics. For the purpose of our study, we did not include other interventions for prevention or mitigating disease spread for analysis such as vector control strategies, disease/vector surveillance, and community education. The authors of the manuscript are experts in the field of clinical infectious diseases, public health, disaster preparedness, and environmental health.

Data collection

All data were obtained from publicly available resources. The majority of the data regarding the current controls came from the websites of the Japan National Tourism Organization (JNTO), The Ministry of Health, Labour and Welfare (MHLW) of Japan, the National Institute of Infectious Diseases (NIID) of Japan, and The Japanese Association for Infectious Diseases (JAID). Collecting ground-level firsthand information was not conducted, although there were a few direct conversations with individuals of their personal experiences.

Results

We identified a total of 20 failure modes which are summarized in Tables 1–3. There were 8 failure modes for detection of disease, 6 for assessment of disease, and 6 for patient communication. Failure modes related to Olympic-related facilities (No. 6 and No. 20) were not evaluated since there was no publicly available information for current controls.