Details of a Researcher - Nomura, Shuhei

Papers - Nomura, Shuhei

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The Unseen Aftermath: Associations Between the COVID-19 Pandemic and Shifts in Mortality Trends in Japan

Hasan Jamil, Shuhei Nomura, Stuart Gilmour

International Journal of Environmental Research and Public Health 22 ( 1 ) 74 2025.01

Accepted, ISSN 16617827

The COVID-19 pandemic disrupted healthcare systems globally, potentially altering mortality trends for non-COVID-19 diseases, particularly in aging populations like Japan’s. Assessing these impacts is essential for responsive healthcare planning. We analyzed Japanese vital registration mortality records from January 2018 to December 2021 for adults aged 25 and older, excluding COVID-19-related deaths. Data were stratified by sex and ICD-10 cause-of-death chapters. Poisson regression models assessed changes in mortality rates and trends, incorporating pandemic-related variables and interactions between time, age group, and the pandemic term. Among the 4,920,942 deaths analyzed, 2,456,750 occurred during the pandemic years. Significant sex-specific changes in mortality trends were observed. Women experienced increases in mortality rates and trends for endocrine, nutritional, and metabolic diseases; skin and subcutaneous tissue diseases; circulatory diseases; and genitourinary diseases, reversing some pre-pandemic declines. Men showed increases in mortality trends for endocrine, nutritional, and metabolic diseases and genitourinary diseases but no significant changes for skin or circulatory diseases. These findings indicate that the pandemic differentially affected mortality trends between sexes, with women experiencing broader increases across multiple disease categories. The COVID-19 pandemic was associated with significant changes in mortality trends for certain non-COVID-19 diseases in Japan, with notable sex differences. Increased mortality among women across multiple disease categories highlights the pandemic’s indirect health impacts and underscores the need for sex-specific healthcare strategies in the post-pandemic era.

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Cost-Benefit Analysis of Pre-Entry Tuberculosis Screening Policy: Nepalese and Japanese Perspectives

Y Iwaki, T Hayashi, S Nomura, S Shimamura, R Gauchan, MC Huang

2025

Trading-Off Privacy and Willingness to Share Personal Health Information: A Survey of Municipal Employees in Fukuoka City, Japan

Shuhei Nomura, Yasumasa Segawa, Cyrus Ghaznavi, Takanori Fujita, Keiko Maruyama-Sakurai, Manae Uchibori, Akifumi Eguchi, Masaharu Ishigaki, Kazuto Fujiwara, Masayuki Kido, Hiroaki Miyata, Takanori Yamashita, Naoki Nakashima

Health (Scientific Research Publishing, Inc.) 16 ( 12 ) 1315 - 1331 2024.12

Lead author, Corresponding author, Accepted, ISSN 1949-4998

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Lifestyle differences in the metabolic comorbidity score of adult population from South Asian countries: a cross-sectional study

Sabera Sultana, Shuhei Nomura, Chris Fook Sheng, Masahiro Hashizume

AJPM Focus (Elsevier BV) 3 ( 6 ) 100273 - 100273 2024.12

Accepted, ISSN 2773-0654

Introduction: Metabolic comorbidities are involved in the development and progression of noncommunicable diseases. There is convincing evidence that lifestyles are important contributors to metabolic comorbidities. This study measured the metabolic comorbidity score of South Asian adults and identified its relationship with lifestyles. Methods: The authors studied 5 South Asian countries, including Afghanistan, Bangladesh, Bhutan, Nepal, and Sri Lanka, using the World Health Organization's STEPwise approach to noncommunicable disease risk factor surveillance data between 2014 and 2019. This was a nationally representative and cross-sectional survey on participants aged 15–69 years. The sample size was 27,616. The outcome was metabolic comorbidity score, calculated on the basis of total cholesterol, fasting plasma glucose, blood pressure, and abdominal obesity. Total metabolic comorbidity score of each participant varied between 0 and 8. It was then divided into 3 ranges: the lowest range (total metabolic comorbidity score <3), medium range (total metabolic comorbidity score ≥3 and ≤5), and the highest range (total metabolic comorbidity score ≥6). On the basis of the outcome of nonparametric receiver operating characteristics analysis, the medium and the highest ranges together were considered as higher metabolic comorbidity score. The lowest range was considered as lower metabolic comorbidity score. The higher metabolic comorbidity score was coded as 1, and the lower metabolic comorbidity score was coded as 0. Thus, the outcome variable, metabolic comorbidity score, became a binary variable. Exposures included physical inactivity (<150 minutes of medium-to-vigorous physical activity/week), high daily sedentary time (≥9 hours/day), use of tobacco (present or past smoking or daily use of smokeless tobacco products), and consumption of alcohol (at least once per month in the last 1 year). Binomial logistic regression model produced the OR with corresponding 95% CIs. Results: The prevalence of higher metabolic comorbidity score was 34% among South Asian adults, 25% among the male respondents, and 41% among the female respondents. Participants who were physically inactive (OR=1.26; 95% CI= 1.17, 1.36), had high sedentary time (OR=1.24; 95% CI=1.11, 1.33), and consumed alcohol (OR=1.40; 95% CI=1.23, 1.53) showed higher metabolic comorbidity score than participants who were physically active, had low sedentary time, and did not consume alcohol respectively. However, the authors found an inverse association (OR=0.75; 95% CI=0.71, 0.81) between the use of tobacco and metabolic comorbidity score. Conclusions: One third of South Asian adults had higher metabolic comorbidity score. Physical inactivity, daily sedentary hours, and minimal alcohol consumption were associated with higher metabolic comorbidity score.

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Indirect and direct effects of nighttime light on COVID-19 mortality using satellite image mapping approach

Daisuke Yoneoka, Akifumi Eguchi, Shuhei Nomura, Takayuki Kawashima, Yuta Tanoue, Masahiro Hashizume, Motoi Suzuki

Scientific reports 14 ( 1 ) 25063 - 25063 2024.12

ISSN 2045-2322

The COVID-19 pandemic has highlighted the importance of understanding environmental factors in disease transmission. This study aims to explore the spatial association between nighttime light (NTL) from satellite imagery and COVID-19 mortality. It particularly examines how NTL serves as a pragmatic proxy to estimate human interaction in illuminated nocturnal area, thereby impacting viral transmission dynamics to neighboring areas, which is defined as spillover effect. Analyzing 43,199 COVID-19 deaths from national mortality data during January 2020 and October 2022, satellite-derived NTL data, and various environmental and socio-demographic covariates, we employed the Spatial Durbin Error Model to estimate the direct and indirect effect of NTL on COVID-19 mortality. Higher NTL was initially directly linked to increased COVID-19 mortality but this association diminished over time. The spillover effect also changed: during the early 3rd wave (December 2020 - February 2021), a unit (nanoWatts/sr/cm2) increase in NTL led to a 7.9% increase in neighboring area mortality (p = 0.013). In contrast, in the later 7th wave (July - September 2022), dominated by Omicron, a unit increase in NTL resulted in an 8.9% decrease in mortality in neighboring areas (p = 0.029). The shift from a positive to a negative spillover effect indicates a change in infection dynamics during the pandemic. The study provided a novel approach to assess nighttime human activity and its influence on disease transmission, offering insights for public health strategies utilizing satellite imagery, particularly when direct data collection is impractical while the collection from space is readily available.

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Global, regional, and national stillbirths at 20 weeks' gestation or longer in 204 countries and territories, 1990–2021: findings from the Global Burden of Disease Study 2021

GBD 2021 Global Stillbirths Collaborators

The Lancet (Elsevier BV) 404 ( 10466 ) 1955 - 1988 2024.11

Accepted, ISSN 01406736

Background: Stillbirth is a devastating and often avoidable adverse pregnancy outcome. Monitoring stillbirth levels and trends—in a comprehensive manner that leaves no one uncounted—is imperative for continuing progress in pregnancy loss reduction. This analysis, completed as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021, methodically accounted for different stillbirth definitions with the aim of comprehensively estimating all stillbirths at 20 weeks or longer for 204 countries and territories from 1990 to 2021. Methods: We extracted data on stillbirths from 11 412 sources across 185 of 204 countries and territories, including 234 surveys, 231 published studies, 1633 vital statistics reports, and 10 585 unique location-year combinations from vital registration systems. Our final dataset comprised 11 different definitions, which were adjusted to match two gestational age thresholds: 20 weeks or longer (reference) and 28 weeks or longer (for comparisons). We modelled the ratio of stillbirth rate to neonatal mortality rate with spatiotemporal Gaussian process regression for each location and year, and then used final GBD 2021 assessments of fertility and all-cause neonatal mortality to calculate total stillbirths. Secondary analyses evaluated the number of stillbirths missed with the more restrictive gestational age definition, trends in stillbirths as a function of Socio-demographic Index, and progress in reducing stillbirths relative to neonatal deaths. Findings: In 2021, the global stillbirth rate was 23·0 (95% uncertainty interval [UI] 19·7–27·2) per 1000 births (stillbirths plus livebirths) at 20 weeks' gestation or longer, compared to 16·1 (13·9–19·0) per 1000 births at 28 weeks' gestation or longer. The global neonatal mortality rate in 2021 was 17·1 (14·8–19·9) per 1000 livebirths, corresponding to 2·19 million (1·90–2·55) neonatal deaths. The estimated number of stillbirths occurring at 20 weeks' gestation or longer decreased from 5·08 million (95% UI 4·07–6·35) in 1990 to 3·04 million (2·61–3·62) in 2021, corresponding to a 39·8% (31·8–48·0) reduction, which lagged behind a global improvement in neonatal deaths of 45·6% (36·3–53·1) for the same period (down from 4·03 million [3·86–4·22] neonatal deaths in 1990). Stillbirths in south Asia and sub-Saharan Africa comprised 77·4% (2·35 million of 3·04 million) of the global total, an increase from 60·3% (3·07 million of 5·08 million) in 1990. In 2021, 0·926 million (0·792–1·10) stillbirths, corresponding to 30·5% of the global total (3·04 million), occurred between 20 weeks' gestation and 28 weeks' gestation, with substantial variation at the country level. Interpretation: Despite the gradual global decline in stillbirths between 1990 and 2021, the overall number of stillbirths remains substantially high. Counting all stillbirths is paramount to progress, as nearly a third—close to 1 million in total—are left uncounted at the 28 weeks or longer threshold. Our findings draw attention to the differential progress in reducing stillbirths, with a high burden concentrated in countries with low development status. Scarce data availability and poor data quality constrain our capacity to precisely account for stillbirths in many locations. Addressing inequities in universal maternal health coverage, strengthening the quality of maternal health care, and improving the robustness of data systems are urgently needed to reduce the global burden of stillbirths. Funding: Bill & Melinda Gates Foundation.

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Changes in Healthcare Utilization in Japan in the Aftermath of the COVID-19 Pandemic: A Time Series Analysis of Japanese National Data Through November 2023

Yuta Tanoue, Alton Cao, Masahide Koda, Nahoko Harada, Cyrus Ghaznavi, Shuhei Nomura

Healthcare 12 ( 22 ) 2307 2024.11

Accepted, ISSN 2227-9032

Introduction: The COVID-19 pandemic precipitated substantial disruptions in healthcare utilization globally. In Japan, reduced healthcare utilization during the pandemic’s early phases had been documented previously. However, few studies have investigated the impact of the pandemic’s later stages (2022–2023) on healthcare utilization rates, particularly in the Japanese context. Methods: We employed a quasi-Poisson regression model, adapted from the FluMOMO framework, to analyze temporal trends in Japanese healthcare utilization throughout the pandemic until November 2023. We estimated inpatient and outpatient volumes and hospital length of stay by bed type (general and psychiatric). Results: In general hospital beds, inpatient volumes remained significantly below pre-pandemic levels for every month until November 2023, with a reduction of 7.8 percent in 2023 compared to pre-pandemic levels. Psychiatric inpatient volumes, which had been declining before the pandemic, continued this downward trend, with the average occupancy rate decreasing by approximately 5.3% to 81.3% in 2023 compared to pre-pandemic levels. Significantly reduced outpatient volumes for both general and psychiatric care, in addition to prolonged lengths of hospital stay for psychiatric beds, were observed sporadically for several months in 2022 and 2023, persisting beyond the cessation of state of emergency and quasi-state of emergency declarations. Conclusion: The COVID-19 pandemic fundamentally altered healthcare utilization patterns in Japan. We observed a sustained reduction in general and psychiatric inpatient volumes relative to pre-pandemic baselines nationwide. The prolonged impact on healthcare utilization patterns, persisting beyond emergency measures, warrants continued monitoring of service delivery.

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Changes in mortality during the COVID-19 pandemic in Japan: descriptive analysis of national health statistics up to 2022

Hirokazu Tanaka, Shuhei Nomura, Kota Katanoda

Journal of Epidemiology (Japan Epidemiological Association) 2024.10

Accepted, ISSN 0917-5040

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Determinants of sodium intake knowledge and attitude: a cross-national analysis of socio-economic and health factors

Santosh Kumar Rauniyar, Yuta Tanoue, Cyrus Ghaznavi, Hitomi Hayabuchi, Toshihide Nishimura, Yukari Takemi, Shuhei Nomura

Public Health Nutrition 27 ( 1 ) e216 2024.10

Accepted, ISSN 13689800

Objective: The aim of this study is to conduct a comparative analysis across nations to: (1) identify the determinants influencing knowledge and attitudes related to sodium (Na) intake and (2) to analyse the association between knowledge and attitudes related to Na intake. Design: We utilised a secondary data from a cross-sectional study that was conducted across seven nations. Structural equation modelling (SEM) was utilised to assess the impact of socio-economic and health-related predictors on knowledge and attitudes pertaining to Na intake and further to investigate the relationship between knowledge and attitude. Setting: Indonesia, Brazil, Thailand, Japan, France, the UK and the USA. Participants: 7090 participants aged 15 years and above were included in the study. Results: SEM analysis showed a strong association between knowledge about Na intake and related attitude across all countries, particularly in the UK (2.65, 95 % CI 1.48-3.82), France (2.62, 1.45-3.79) and the USA (1.97, 1.21-2.73). In Brazil, Japan and France, individuals or family members having certain health conditions such as raised blood pressure, heart diseases, strokes or other diseases exhibited a positive attitude towards reducing Na intake. Conversely, socio-economic factors like education and income demonstrated the complexity of influences on knowledge and attitudes about Na intake. Conclusion: The study underscores the need for tailored public health interventions to reduce excessive Na consumption, considering the diverse cultural, social and economic factors. It highlights the complex determinants of knowledge and attitudes towards Na intake, calling for further research in varied populations.

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Analysis of factors associated with public attitudes towards salt reduction: a multicountry cross-sectional survey

Yuta Tanoue, Santosh Kumar Rauniyar, Manae Uchibori, Cyrus Ghaznavi, Hana Tomoi, Mami Ueta, Prapichaya Prommas, Alton Cao, Daisuke Yoneoka, Takayuki Kawashima, Akifumi Eguchi, Shuhei Nomura

BMJ Open 14 ( 10 ) e086467 2024.10

Accepted, ISSN 2044-6055

<jats:sec><jats:title>Objective</jats:title><jats:p>This paper provides an in-depth examination of public attitudes towards salt reduction across seven culturally diverse countries: the USA, the UK, France, Japan, Indonesia, Thailand, and Brazil.</jats:p></jats:sec><jats:sec><jats:title>Design</jats:title><jats:p>Cross-sectional regression analysis with questionnaire data.</jats:p></jats:sec><jats:sec><jats:title>Setting</jats:title><jats:p>An analysis of questionnaire study in seven countries.</jats:p></jats:sec><jats:sec><jats:title>Participants</jats:title><jats:p>The study’s questionnaire collected responses from 7090 participants across seven countries with the mean age of respondents being 46.06 years (SD 16.96). The gender distribution encompassed 3473 men (49.12%), 3582 women (50.66%), 24 non-binary individuals (0.34%) and 11 who identified as ‘other’ (0.16%).</jats:p></jats:sec><jats:sec><jats:title>Primary and secondary outcome measures</jats:title><jats:p>Attitudes toward sodium reduction were measured on a seven-point Likert scale.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>Regression analysis revealed significant associations between attitudes towards sodium reduction and various factors across countries. Gender was a significant factor in France, with women showing less awareness than men (coefficient −0.123, 95% CI −0.237 to −0.008). Age was a significant factor in Japan and Thailand, with older generations exhibiting stronger awareness. Occupation was a significant factor in France (grocery, 0.678, 0.229 to 1.127) and Japan (food service, 0.792, 0.300 to 1.283). In France (0.090, 0.033 to 0.146) and Brazil (0.092, 0.040 to 0.144), attitudes towards reducing sugar intake were positively associated with sodium reduction attitudes. Government interventions showed varying impacts, with positive associations in Thailand (0.004, 0.001 to 0.008) and negative associations in France (−0.003 –0.005 to −0.000).</jats:p></jats:sec><jats:sec><jats:title>Conclusion</jats:title><jats:p>Our study reveals a complex array of factors shaping attitudes towards sodium reduction across seven countries. These findings support the need for nuanced, country-specific approaches in formulating sodium reduction strategies. Future research should validate these findings, explore further determinants and understand how attitudes translate into dietary behaviours.</jats:p></jats:sec>

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Strengthening Public Health System Resilience to Disasters in Türkiye: Insights from a Scorecard Methodology

Ismail Tayfur, Perihan Şimşek, Abdülkadir Gunduz, Mayumi Kako, Shuhei Nomura, Benjamin Ryan

International Journal of Disaster Risk Reduction (Elsevier BV) 113 104869 - 104869 2024.10

Accepted, ISSN 22124209

Background: Türkiye is a country that faces many disasters, especially earthquakes and floods, which have serious short- and long-term consequences for public health. The importance of disaster risk reduction activities in building resilience before a disaster strikes is increasingly recognized. Furthermore, resilience assessment is considered to be the starting point for these activities. However, there is a substantial gap in the scientific evidence on systematic assessments of the resilience of the public health system and also a serious lack of activities to strengthen the system against disasters in Türkiye. Aim: Using a Scorecard methodology, the study aimed to systematically assess the resilience of the public health system in Türkiye by examining key indicators related to disaster risk management and preparedness, and subsequently to recommend priority actions. A systematic assessment of resilience can provide the scientific evidence needed to identify weaknesses in the system. Furthermore, identifying priority actions based on this evidence allows progress to be made towards strengthening the system. Methods: This mixed-methods study was conducted in two separate regions of Türkiye with the highest earthquake (Esenler/Istanbul) and flood risk (Ortahisar/Trabzon). Based on the Scorecard methodology, two-stage workshops (online and face-to-face) were held. During the online stage, qualitative data were collected by interviewing participants about their evaluation of the situation in the counties regarding the Scorecard indicators, and quantitative data were collected through scoring. In the face-to-face stage, strategies were developed to improve the resilience of the public health system. Quantitative data were expressed with numbers and percentages, and thematic analysis was utilized for qualitative data analysis. Results: The lowest scoring indicators were as follows (Esenler and Ortahisar, respectively): addressing mental health needs associated with disasters (2.17 ± 1.29; 2.27 ± 1.16), resilience of key healthcare facilities (2.22 ± 0.55; 2.91 ± 1.08), and protection and identification of ecosystem services (2.39 ± 1.04; 2.13 ± 1.49). In this study, participants recommended increasing the resilience of the public health infrastructure and improving human resources and ecosystem services to ensure the resilience of the public health system. Conclusions: The study found that the weakest areas in terms of public health system resilience were the seismic safety and infrastructure of health facilities, the capacity of disaster-related mental health services, and disaster-related ecosystem services. To improve the resilience of public health systems, it is essential to strengthen these areas of weakness and ensure collaboration between all stakeholders in the system. The identification of weaknesses in the study has guided the determination of priority actions to build a baseline of resilience. In addition, the results of the study have highlighted priority areas for investment to improve disaster response and the overall health of the population in the context of disasters.

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Forecasting the effects of smoking prevalence scenarios on years of life lost and life expectancy from 2022 to 2050: a systematic analysis for the Global Burden of Disease Study 2021

GBD 2021 Tobacco Forecasting Collaborators

The Lancet Public Health (Elsevier BV) 9 ( 10 ) e729 - e744 2024.10

Accepted, ISSN 2468-2667

Background: Smoking is the leading behavioural risk factor for mortality globally, accounting for more than 175 million deaths and nearly 4·30 billion years of life lost (YLLs) from 1990 to 2021. The pace of decline in smoking prevalence has slowed in recent years for many countries, and although strategies have recently been proposed to achieve tobacco-free generations, none have been implemented to date. Assessing what could happen if current trends in smoking prevalence persist, and what could happen if additional smoking prevalence reductions occur, is important for communicating the effect of potential smoking policies. Methods: In this analysis, we use the Institute for Health Metrics and Evaluation's Future Health Scenarios platform to forecast the effects of three smoking prevalence scenarios on all-cause and cause-specific YLLs and life expectancy at birth until 2050. YLLs were computed for each scenario using the Global Burden of Disease Study 2021 reference life table and forecasts of cause-specific mortality under each scenario. The reference scenario forecasts what could occur if past smoking prevalence and other risk factor trends continue, the Tobacco Smoking Elimination as of 2023 (Elimination-2023) scenario quantifies the maximum potential future health benefits from assuming zero percent smoking prevalence from 2023 onwards, whereas the Tobacco Smoking Elimination by 2050 (Elimination-2050) scenario provides estimates for countries considering policies to steadily reduce smoking prevalence to 5%. Together, these scenarios underscore the magnitude of health benefits that could be reached by 2050 if countries take decisive action to eliminate smoking. The 95% uncertainty interval (UI) of estimates is based on the 2·5th and 97·5th percentile of draws that were carried through the multistage computational framework. Findings: Global age-standardised smoking prevalence was estimated to be 28·5% (95% UI 27·9–29·1) among males and 5·96% (5·76–6·21) among females in 2022. In the reference scenario, smoking prevalence declined by 25·9% (25·2–26·6) among males, and 30·0% (26·1–32·1) among females from 2022 to 2050. Under this scenario, we forecast a cumulative 29·3 billion (95% UI 26·8–32·4) overall YLLs among males and 22·2 billion (20·1–24·6) YLLs among females over this period. Life expectancy at birth under this scenario would increase from 73·6 years (95% UI 72·8–74·4) in 2022 to 78·3 years (75·9–80·3) in 2050. Under our Elimination-2023 scenario, we forecast 2·04 billion (95% UI 1·90–2·21) fewer cumulative YLLs by 2050 compared with the reference scenario, and life expectancy at birth would increase to 77·6 years (95% UI 75·1–79·6) among males and 81·0 years (78·5–83·1) among females. Under our Elimination-2050 scenario, we forecast 735 million (675–808) and 141 million (131–154) cumulative YLLs would be avoided among males and females, respectively. Life expectancy in 2050 would increase to 77·1 years (95% UI 74·6–79·0) among males and 80·8 years (78·3–82·9) among females. Interpretation: Existing tobacco policies must be maintained if smoking prevalence is to continue to decline as forecast by the reference scenario. In addition, substantial smoking-attributable burden can be avoided by accelerating the pace of smoking elimination. Implementation of new tobacco control policies are crucial in avoiding additional smoking-attributable burden in the coming decades and to ensure that the gains won over the past three decades are not lost. Funding: Bloomberg Philanthropies and the Bill & Melinda Gates Foundation.

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Global, regional, and national burden of stroke and its risk factors, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

GBD 2021 Stroke Risk Factor Collaborators

The Lancet Neurology (Elsevier BV) 23 ( 10 ) 973 - 1003 2024.10

Accepted, ISSN 14744422

Background: Up-to-date estimates of stroke burden and attributable risks and their trends at global, regional, and national levels are essential for evidence-based health care, prevention, and resource allocation planning. We aimed to provide such estimates for the period 1990–2021. Methods: We estimated incidence, prevalence, death, and disability-adjusted life-year (DALY) counts and age-standardised rates per 100 000 people per year for overall stroke, ischaemic stroke, intracerebral haemorrhage, and subarachnoid haemorrhage, for 204 countries and territories from 1990 to 2021. We also calculated burden of stroke attributable to 23 risk factors and six risk clusters (air pollution, tobacco smoking, behavioural, dietary, environmental, and metabolic risks) at the global and regional levels (21 GBD regions and Socio-demographic Index [SDI] quintiles), using the standard GBD methodology. 95% uncertainty intervals (UIs) for each individual future estimate were derived from the 2·5th and 97·5th percentiles of distributions generated from propagating 500 draws through the multistage computational pipeline. Findings: In 2021, stroke was the third most common GBD level 3 cause of death (7·3 million [95% UI 6·6–7·8] deaths; 10·7% [9·8–11·3] of all deaths) after ischaemic heart disease and COVID-19, and the fourth most common cause of DALYs (160·5 million [147·8–171·6] DALYs; 5·6% [5·0–6·1] of all DALYs). In 2021, there were 93·8 million (89·0–99·3) prevalent and 11·9 million (10·7–13·2) incident strokes. We found disparities in stroke burden and risk factors by GBD region, country or territory, and SDI, as well as a stagnation in the reduction of incidence from 2015 onwards, and even some increases in the stroke incidence, death, prevalence, and DALY rates in southeast Asia, east Asia, and Oceania, countries with lower SDI, and people younger than 70 years. Globally, ischaemic stroke constituted 65·3% (62·4–67·7), intracerebral haemorrhage constituted 28·8% (28·3–28·8), and subarachnoid haemorrhage constituted 5·8% (5·7–6·0) of incident strokes. There were substantial increases in DALYs attributable to high BMI (88·2% [53·4–117·7]), high ambient temperature (72·4% [51·1 to 179·5]), high fasting plasma glucose (32·1% [26·7–38·1]), diet high in sugar-sweetened beverages (23·4% [12·7–35·7]), low physical activity (11·3% [1·8–34·9]), high systolic blood pressure (6·7% [2·5–11·6]), lead exposure (6·5% [4·5–11·2]), and diet low in omega-6 polyunsaturated fatty acids (5·3% [0·5–10·5]). Interpretation: Stroke burden has increased from 1990 to 2021, and the contribution of several risk factors has also increased. Effective, accessible, and affordable measures to improve stroke surveillance, prevention (with the emphasis on blood pressure, lifestyle, and environmental factors), acute care, and rehabilitation need to be urgently implemented across all countries to reduce stroke burden. Funding: Bill & Melinda Gates Foundation.

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Progress and scenario-based projections of health service availability and coverage towards UHC in the post-conflict and post-pandemic Iraq: a Bayesian hierarchical regression approach

Hiroko Taniguchi, Md Mizanur Rahman, Ashraf Hussain, Shuhei Nomura, Ganan Devanathan, Masahiro Hashizume

BMJ Open (BMJ) 14 ( 9 ) e080492 - e080492 2024.09

Accepted, ISSN 2044-6055

Background

Two decades have passed since the beginning of the Iraq War in 2003. Iraq has long suffered from conflicts and instability, where the people have limited access to healthcare. The coronavirus disease (COVID-19) pandemic brought additional disruption to health service provision.

Objectives

At the midpoint towards universal health coverage (UHC) in 2030, this study aims to gain a better understanding of the trends of UHC progress in Iraq in the context of the conflicts and the COVID-19 pandemic and to indicate possible pragmatic options.

Design

This study employed Bayesian hierarchical regression models to estimate trends and projections of health service availability and coverage indicators up to 2030. Furthermore, for health service coverage, four scenarios were defined based on the availability of health services, and projections were made for each scenario up to 2030.

Setting

Our approach used the yearly data from the Ministry of Health and four nationally representative household surveys between 2000 and 2020. We evaluated the subnational-level progress in three health service availability indicators and 13 health service coverage indicators in 18 governorates in Iraq from 2000 to 2030.

Results

The findings from 2000 to 2020 revealed a lack of progress in the indicators of health facility and inpatient bed, and pronounced detrimental effects from major conflicts and the pandemic on all measured health service coverage indicators. Despite these setbacks, several health service coverage indicators demonstrated resilience and elasticity in their recovery. The projected trends for 2021 to 2030 indicated limited alternations in the health service availability. By 2030, five health service coverage indicators will achieve the designated 80% targets. A scenario-based analysis predicts improved coverage of antenatal care, and child immunisation and treatment if health service availability is bolstered to globally recommended standards. Under this scenario, several governorates—Anbar, Baghdad, Nainawa, Qadissiyah, Salahaddin, Thiqar and Wasit—presented improved health service coverage in more indicators.

Conclusion

Strengthened health service availability has the potential to significantly improve fragile health service coverage indicators and in more vulnerable governorates.

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Factors associated with lifetime use of commercial sex work services among Japanese men aged 20–49: findings from a quasi-representative national survey, 2022

Cyrus Ghaznavi, Peter Ueda, Shuhei Nomura, Masahiro Ishikane, Shunsuke Uno, Haruka Sakamoto

Sexually Transmitted Infections (BMJ) 100 ( 6 ) 371 - 380 2024.08

Accepted, ISSN 13684973

Objectives

Approximately half of Japanese men aged 20–49 years have purchased sexual services, but data concerning the use of commercial sex work (CSW) in Japan remain scarce.

Methods

We used online survey data from the National Inventory of Japanese Sexual Behavior conducted in 2022 (N=4000 Japanese men aged 20–49 years). We calculated the median number of paid sexual partners over the lifetime. We performed logistic regression analysis to determine the sociodemographic, anthropometric and attitudinal factors associated with any lifetime CSW use among men in Japan.

Results

The median number of paid sexual partners reported among men who had ever used CSW was 6 (IQR 3–17) across the lifetime; the corresponding value for those who had ever used CSW in the past year was 2 (IQR 1–4) over the last 12 months. In general, those reporting lifetime use of CSW were significantly more likely than their CSW-naïve counterparts to be older, be married, be heterosexual or bisexual, have higher income and have higher education. Those reporting higher self-rated attractiveness, high or low satisfaction with their sex lives, a desire to increase their frequency of sex and considering sex to be an important aspect of their lives were also found to have a higher likelihood of having used CSW.

Conclusions

High rates of CSW use in Japan likely reflect ease of access, low stigma with respect to use of sexual services and the diversity in the type of services offered. High-income, employed older men have more financial resources at their disposal to purchase services, which can be cost-prohibitive for part-time or unemployed young men with low incomes. These findings will serve as a launchpad for public health efforts directed at promoting safe sexual practices and improved sexually transmitted infection screening rates among users of CSW in Japan.

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Factors influencing parental COVID-19 vaccination willingness for children in Japan

Mami Ueta, Alton Cao, Michio Murakami, Hana Tomoi, Stuart Gilmour, Keiko Maruyama-Sakurai, Yoshihiro Takayama, Yoshitake Takebayashi, Masahiro Hashizume, Rauniyar Santosh Kumar, Hiroyuki Kunishima, Wataru Naito, Tetsuo Yasutaka, Satoshi Kaneko, Hiroaki Miyata, Shuhei Nomura

Vaccine: X (Elsevier BV) 19 100528 - 100528 2024.08

Accepted, ISSN 2590-1362

Objectives: This study aims to investigate the factors influencing parental willingness in COVID-19 vaccination for children in Japan in light of the introduction of pediatric vaccines. Methods: An online survey was conducted in February 2022, coinciding with the imminent start of pediatric COVID-19 vaccinations in Japan. It assessed attitudes toward vaccine uptake and included questions about health-related attributes, psychological considerations, and sources of COVID-19 information. Data from 2,419 respondents who had children under the age of 12 were analyzed using multinomial logistic regression to identify factors associated with parental willingness towards COVID-19 vaccination for children. The outcomes were “agree” (in favor of vaccination), “not sure” (undecided), with “disagree” (against vaccination) as the reference category. Results: Among participants supportive of vaccination (“agree” compared to the “disagree” reference), salient determinants included: gender (Men in reference to women: odds ratio [OR] 1.54; 95 % confidence interval [CI] 1.11–2.15), highest educational level (Junior College/Vocational in reference to under high school: OR 0.61; 95 % CI 0.40–0.93, Bachelor's /Master's/Doctoral degree in reference to under high school: OR 0.59; 95 % CI 0.42–0.84), perception of benefits of COVID-19 vaccination (Significant in reference to Insignificant: OR 2.04; 95 % CI 1.26–3.28), perception of risks of COVID-19 vaccination (Significant in reference to Insignificant: OR 0.28; 95 % CI 0.19–0.42, Neutral in reference to Insignificant: OR 0.48; 95 % CI 0.33–0.71), the number of referenced information sources utilized for COVID-19 was associated with attitudes towards children's vaccination (OR 1.02; 95 % CI 1.00–1.04). Conclusion: The study highlights the multifaceted factors influencing parents’ COVID-19 vaccination attitudes for their children, encompassing socioeconomic, health, psychological, and informational aspects. Factors like cautious information gathering, vaccine concerns and diverse referenced information sources impact willingness. To facilitate informed decision-making, essential measures include government risk communication, widespread vaccine information dissemination, and enhancing parents’ health information accessibility and evaluation skills are important.

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Trust in governments, public health institutions, and other information sources as determinants of COVID-19 vaccine uptake behavior in Japan

Alton Cao, Mami Ueta, Manae Uchibori, Michio Murakami, Hiroyuki Kunishima, Rauniyar Santosh Kumar, Prapichaya Prommas, Hana Tomoi, Stuart Gilmour, Haruka Sakamoto, Masahiro Hashizume, Wataru Naito, Tetsuo Yasutaka, Keiko Maruyama-Sakurai, Hiroaki Miyata, Shuhei Nomura

Vaccine (Elsevier BV) 42 ( 17 ) 3684 - 3692 2024.06

Accepted, ISSN 0264410X

Objectives: Trust in governments and public institutions as a determinant of public health outcomes has gained increased attention since the COVID-19 pandemic. Provided historically low confidence in vaccines in Japan, investigating the role of trust in information sources and actual COVID-19 vaccination uptake behavior will be invaluable for future vaccine promotion policymaking. Therefore, the objective of this study was to elucidate the determinants of COVID-19 vaccination uptake and evaluate the relationship between trust in different information sources and COVID-19 vaccination behavior in Japan. Methods: For this study, we leveraged a longitudinal series of web-based surveys of 19,174 individuals in Japan conducted between 2021 and 2022 which asked questions regarding a wide range of sociodemographic and psychographic characteristics related to the COVID-19 pandemic. Determinant analysis for vaccination (at least one dose of a COVID-19 vaccine) was conducted via multiple logistic regression, and odds ratios (OR) with 95% confidence intervals (CI) were estimated. Results: After adjustment for sociodemographic determinants of vaccine uptake, aggregate trust in the systems and institutions of vaccine approval (OR: 1.42, 95% CI: 1.30–1.56), and trust in information about the COVID-19 pandemic coming from government sources (OR: 1.27, 95% CI: 1.12–1.44) were found to be consistently powerful predictors of COVID-19 vaccination. Trust in media sources including traditional media (OR: 1.21, 95% CI: 1.07–1.36), and the internet (OR: 0.77, 95% CI: 0.66–0.89) had significant and opposing effects. Conclusions: Our findings support the broader hypothesis that trust in governments and public health institutions remains a powerful determinant for COVID-19 vaccine uptake in Japan. We also found that vaccination decision-making is a multifactorial process that includes the synthesis of trust in public institutions and media, and its interaction with psychosocial determinants such as prosociality and health literacy. We hope to apply this study's findings towards future vaccine programs for contagious diseases.

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Comparing the risks of environmental carcinogenic chemicals in Japan using the loss of happy life expectancy indicator

Michio Murakami, Kyoko Ono, Yoshitake Takebayashi, Masaharu Tsubokura, Shuhei Nomura

Environmental Research (Elsevier BV) 251 118637 - 118637 2024.06

Accepted, ISSN 00139351

In this study, we aimed to use the loss of happy life expectancy (LHpLE), an indicator that enables risk assessment considering wellbeing, to compare the risks of environmental carcinogenic chemicals in Japan. First, we surveyed Japanese people to determine their emotional happiness by age and sex and evaluated whether cancer incidence reduced emotional happiness. Questionnaires were administered to a general population panel and a panel of patients with cancer in 2022, recruiting a predetermined number of responses of 5000 and 850, respectively. Second, using the survey data, LHpLE was calculated for radon, arsenic, and fine particulate matter (aerodynamic diameter <2.5 μm; PM2.5) and compared to psychological distress, considering increased mortality and decreased emotional happiness due to these risks. We discovered no significant decrease in emotional happiness due to cancer incidence and no significant associations between emotional happiness and cancer type, history, or stage. LHpLE was calculated to be 6.4 × 10−3 years for radon, 2.6 × 10−3 years for arsenic, 1.1 × 10−2 years (2012 exposure) and 8.6 × 10−4 years (2020 exposure) for PM2.5, and 9.7 × 10−1 years for psychological distress. The fraction of losses caused by these carcinogenic chemicals to HpLE exceeded 10−5, suggesting that risk reduction for these chemicals is important in environmental policies. The LHpLE indicator allows for comparing different types of risks, such as environmental chemicals and psychological distress. This is the first study to compare chemical risks using the LHpLE indicator.

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The importance of methodological vigilance: Reevaluating suicide trends in Japan post‐2022

Masahide Koda, Nahoko Harada, Shuhei Nomura

Psychiatry and Clinical Neurosciences Reports (Wiley) 3 ( 2 ) 2024.06

Last author, Accepted, ISSN 2769-2558

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Active and passive smoking and breast cancer in Japan: a pooled analysis of nine population-based cohort studies

Wada K., Nagata C., Utada M., Sakata R., Kimura T., Tamakoshi A., Sugawara Y., Tsuji I., Sato R., Sawada N., Tsugane S., Oze I., Ito H., Kitamura T., Koyanagi Y.N., Lin Y., Matsuo K., Abe S.K., Inoue M., Tanaka S., Kimura T., Sugawara Y., Mizoue T., Nomura S., Takimoto H., Tanaka K., Charvat H., Hidaka A., Hirabayashi M., Iwasaki M., Kitamura Y., Mori N., Muto M., Naito M., Nakayama T., Nishino Y., Sadakane A., Saito E., Sasazuki S., Shimazu T., Shimizu H., Sugiyama K., Suzuki H., Tsubono Y., Wakai K., Yamagiwa Y., Yamaji T.

International Journal of Epidemiology 53 ( 3 ) 2024.06

ISSN 03005771

Background: Epidemiological studies have shown inconsistent results regarding the link between smoking and breast cancer risk, despite the biological plausibility of a positive association. Methods: Participants were 166 611 women from nine prospective cohort studies in Japan which launched in 1984-1994 and followed for 8-22 years. Information on smoking and secondhand smoke was obtained through self-administered baseline questionnaires. Breast cancer was defined as code C50 according to the International Classification of Diseases for Oncology, 3rd Edition or the International Classification of Diseases, 10th Revision. After adjusting for several potential confounders, relative risks for breast cancer were calculated in the individual studies according to the current or previous status of active and passive smoking using Cox regression, followed by a summary estimate of hazard ratios using random-effects meta-analyses. Results: Of the 60 441 participants who reported being premenopausal and 106 170 who reported being postmenopausal at baseline, 897 and 1168 developed breast cancer during follow-up, respectively. Compared with never smokers, current smokers had a higher risk of developing breast cancer before the age of 50 years. In addition, ever smokers who started smoking at 30 years of age or younger, or who started smoking before first childbirth, had a higher risk of developing breast cancer before the age of 50 years. No association between adulthood or childhood exposure to secondhand smoke and breast cancer was observed. Conclusion: Smoking may increase the risk of premenopausal breast cancer, and smoking earlier in life might be especially harmful. The impact of secondhand smoke needs further investigation.

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Characterizing Healthy Dietary Practices in Japan: Insights from a 2024 Nationwide Survey and Cluster Analysis

Shuhei Nomura, Akifumi Eguchi, Keiko Maruyama-Sakurai, Ruka Higashino, Daisuke Yoneoka, Takayuki Kawashima, Yuta Tanoue, Yumi Kawamura, Rauniyar Santosh Kumar, Takanori Fujita, Hiroaki Miyata

Nutrients (MDPI AG) 16 ( 10 ) 1412 - 1412 2024.05

Accepted

The increasing burden of lifestyle-related diseases highlights the need to address unhealthy dietary habits. This study aims to explore the latest dietary patterns in Japan following the COVID-19 pandemic, focusing on trends in health-promoting food choices. A web-based survey was conducted among 27,154 Japanese adults, selected via quota sampling to mirror national demographics. The study evaluated dietary diversity, measured through the Dietary Variety Score (Outcome 1), and the prioritization of nutritional and health considerations in food selection, assessed via a Likert scale (Outcome 2). Uniform Manifold Approximation and Projection (UMAP) and Ordering Points To Identify the Clustering Structure (OPTICS) algorithms were used to delineate patterns in health-centric food selections. OPTICS clustering revealed four distinct clusters for each outcome. Cluster 3, with a diverse diet, comprised older, predominantly female individuals with higher well-being and lower social isolation compared to Cluster 4, which lacked distinct dietary patterns. Cluster 3 also engaged more in snacking, treat foods, home cooking, and frozen meals. Similarly, a divide emerged between those prioritizing dietary considerations (Cluster C) and those indifferent to such aspects (Cluster D). The findings underscore the need for holistic post-COVID-19 public health initiatives addressing socioeconomic and cultural barriers to healthier dietary practices.

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Excess suicides in Japan: a three-year post-pandemic assessment of gender and age disparities

Haruka Sakamoto, Masahide Koda, Akifumi Eguchi, Kaori Endo, Takahiro Arai, Nahoko Harada, Takashi Nishio, Shuhei Nomura

Psychiatry Research (Elsevier BV) 334 115806 - 115806 2024.04

Accepted, ISSN 01651781

This study offers an in-depth analysis of Japan's suicide trends three years after the COVID-19 outbreak. Using data from the National Police Agency (January 2010-May 2023), we examined suicide rates across genders and age groups. Employing the quasi-Poisson regression, we predicted monthly death counts. Findings indicate a steady rise in female suicides from April 2020 to January 2023. Notably, male cohorts aged 50–59 and over 80 in 2022 displayed heightened death rates. While these trends may reflect the impacts of the pandemic, it is essential to consider other factors, including socio-economic changes, to fully understand the context of Japan's suicide patterns.

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Prioritizing Strategies for Building the Resilience of Public Health Systems to Disasters Across Multiple Communities and Countries

Benjamin J. Ryan, Mayumi Kako, Shelby Garner, Rok Fink, Ismail Tayfur, Jonathan Abrahams, Sanjaya Bhatia, Adriana Campelo, Matthew Fendt, Alicia Fontenot, Nahuel Arenas Garcia, Tim Hatch, Ryoma Kayano, LaShonda Malrey-Horne, Makiko MacDermot, Md Moshiur Rahman, Chaverle Noel, Shuhei Nomura, Jeremy P. Novak, Maria Opazo, Kendell Oliver, Luciana Peters, Sohel Rahman, Perihan Şimşek, Andrew Stricklin, Raymond Swienton, Bryan W. Brooks

International Journal of Disaster Risk Science (Springer Science and Business Media LLC) 15 ( 1 ) 1 - 17 2024.02

Accepted, ISSN 20950055

Abstract

The COVID-19 pandemic highlighted the urgent need to strengthen public health systems. In response, the United Nations Disaster Risk Reduction (UNDRR) Public Health System Resilience Scorecard (Scorecard) was applied in workshops across multiple countries. The aim of our research was to explore the workshop findings to develop priority strategies for strengthening public health system resilience. We conducted a workshop from 14 to 16 March 2023, at the UNDRR Global Education and Training Institute in Incheon, Republic of Korea. A sequential modified Delphi method was utilized to develop a set of prioritized resilience strategies. These were drawn from 70 strategies identified from 13 distinct workshops in eight countries. After two surveys, 23 strategies were finalized. Ten received ratings of “High” or “Very High” from 89% of participants. These related to the inclusion of public health risks in emergency plans, integrating multidisciplinary teams into public health, enabling local transport mechanisms, and improving the ability to manage an influx of patients. The Scorecard provides an adaptable framework to identify and prioritize strategies for strengthening public health system resilience. By leveraging this methodology, our study demonstrated how resilience strategies could inform disaster risk reduction funding, policies, and actions.

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Factors associated with barriers to healthcare access among ever-married women of reproductive age in Bangladesh: Analysis from the 2017–2018 Bangladesh Demographic and Health Survey

Hitomi Hinata, Kaung Suu Lwin, Akifumi Eguchi, Cyrus Ghaznavi, Masahiro Hashizume, Shuhei Nomura

PLOS ONE (Public Library of Science (PLoS)) 19 ( 1 January ) e0289324 - e0289324 2024.01

Accepted, ISSN 1932-6203

Background

Globally, women experience healthcare inequalities, which may contribute to excessive mortality rates at various stages of their lives. Though Bangladesh has achieved excellent progress in providing healthcare, the country still has some critical challenges that need immediate attention. The objective of this study is to examine the association between social determinants and barriers to accessing healthcare among ever-married women aged 15–49 in Bangladesh.

Methods

The study was conducted among 20,127 women aged 15–49, using data from the 2017–2018 Bangladesh Demographic and Health Survey. Four barriers to healthcare were considered: whether women face problems with permission, obtaining money, distance, and companionship. The multivariable logistic regression analysis was used, with a broad array of independent variables (such as age, and educational level) to identify the determinants of barriers to healthcare access. The associations were expressed as adjusted odds ratios (AOR) with a 95% confidence interval (CI).

Results

More than two-thirds (66.3%) of women reported having at least one perceived barrier to accessing healthcare. Women with a higher level of education (AOR = 0.49, 95% CI: 0.41–0.57), owning a mobile telephone (AOR = 0.78, 95% CI: 0.73–0.84), and those in the richest wealth quintile (AOR = 0.45, 95% CI: 0.38–0.52) had lower odds of having barriers to accessing healthcare. In addition, widowed (AOR = 1.53, 95% CI: 1.26–1.84), divorced (AOR = 1.91, 95% CI:1.47–2.48), or separated (AOR = 1.98, 95% CI: 1.46–2.69) women had higher odds of having a money barrier to accessing healthcare, than married women.

Conclusions

This study shows that individual-, household-, and community-level factors are associated with barriers to healthcare accessibility. To improve the state of women’s health in Bangladesh, it is vital to consider these socio-economic factors and implement fundamental measures, such as supporting the national health policy, empowering women’s socio-economic situation, and spreading the flexible way of healthcare access.

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Impact of the COVID-19 pandemic on cancer death locations in Japan: an analysis of excess mortality through February 2023

S Nomura, M Nishio, SK Abe, A Eguchi, M Inoue, M Suzuki, M Hashizume

Journal of Epidemiology 34 (7), 349-355 (Japan Epidemiological Association) 34 ( 7 ) 349 - 355 2024

Accepted, ISSN 09175040

Background: The novel coronavirus disease 2019 (COVID-19) pandemic has significantly impacted end-of-life decisions for cancer patients in Japan, with disparities existing between preferred and actual care settings. Our study investigates the potential shifts in cancer death locations during the pandemic and if there were excess cancer deaths. Methods: Utilizing national mortality data from the Ministry of Health, Labour and Welfare from January 2012 to February 2023, we identified cancer deaths using International Classification of Disease, 10th revision codes. We assessed death locations, including medical institutions, nursing facilities, and homes. The Farrington algorithm was employed to estimate expected death counts, and the differences between observed and expected counts were denoted as excess deaths. Results: From January 2018 to February 2023, there was consistently increase in the weekly observed cancer deaths. The presence of a definitive excess during the pandemic period remains uncertain. The percentage of deaths in medical institutions declined from 83.3% to 70.1%, while home deaths increased from 12.1% to 22.9%. Between April 2020 and February 2023, deaths in medical institutions frequently fell below the 95% prediction lower limit. Home deaths consistently exceeded the 95% prediction upper limit, with significant excess deaths reported annually. Conclusion: Our study found a shift in cancer death locations from medical institutions to homes in Japan during the COVID-19 pandemic. Our study did not confirm an overall increase in cancer deaths during this period. As with global trends, the profound shift from hospitals to homes in Japan calls for a comprehensive exploration to grasp the pandemic’s multifaceted impact on end-of-life cancer care decisions.

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Health Information Seeking on the Internet Among Patients With and Without Cancer in a Region Affected by the 2011 Fukushima Triple Disaster: Cross-Sectional Study

Yudai Kaneda, Akihiko Ozaki, Michio Murakami, Toyoaki Sawano, Shuhei Nomura, Divya Bhandari, Hiroaki Saito, Masaharu Tsubokura, Kazue Yamaoka, Yoshinori Nakata, Manabu Tsukada, Hiromichi Ohira

JMIR Cancer 10 e49897 2024

Accepted

Background: Health information seeking via the internet among patients with cancer in disaster-affected areas is underresearched. Objective: This study aims not only to assess the extent and means of web-based health information seeking among patients with cancer living in the disaster-affected area of the 2011 Fukushima triple disaster but also to compare these patterns with those without cancer, identifying distinct and shared factors influencing their web-based health information behaviors. Methods: We surveyed 404 patients (263 with and 141 without cancer) from the surgery department outpatient office at Minamisoma Municipal General Hospital, from October 2016 to January 2017. The survey included self-administered questions on internet and digital device use. Descriptive analyses were performed to examine the use patterns of digital devices and the internet and their impact on health information seeking across different age groups of patients with and without cancer. Multivariable logistic regression was used to examine factors associated with web-based health information seeking, stratifying by cancer diagnosis. Results: The proportion of participants who sought health information on the internet was comparable between patients with cancer and patients without cancer (19% vs 17.4%; P=.71). Digital device use varied significantly with age, with peak smartphone use occurring among the youngest cohorts for both groups. Multivariable logistic regression revealed that patients with cancer using smartphones or tablets daily were significantly more likely to gather web-based health information (odds ratio [OR] for smartphones 3.73, 95% CI 1.58-8.80; OR for tablets 5.08, 95% CI 1.27-20.35). Trust in institutional websites also significantly influenced web-based health information gathering among patients with cancer (OR 2.87, 95% CI 1.13-7.25). Conversely, among patients without cancer, unemployment was associated with a lower likelihood of seeking web-based health information (OR 0.26, 95% CI 0.08-0.85), whereas trust in both institutional and personal websites significantly increased this likelihood (OR for institutional websites 6.76, 95% CI 2.19-20.88; OR for personal websites 6.97, 95% CI 1.49-32.58). Conclusions: This study reveals that a small proportion of both patients with cancer and patients without cancer engage in health information seeking via the internet, influenced by age, digital device use, and trust in institutional websites. Given the growing prevalence of digital literacy, strategies to enhance accessible and reliable web-based health information should be developed, particularly for patients with cancer in postdisaster settings. Future efforts should focus on tailored health communication strategies that address the unique needs of these populations.

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Changes in Place of Death Among Patients With Dementia During the COVID-19 Pandemic in Japan: A Time-series Analysis

Nahoko Harada, Masahide Koda, Akifumi Eguchi, Masahiro Hashizume, Motoi Suzuki, Shuhei Nomura

Journal of Epidemiology 34 ( 10 ) 493 - 497 2024

ISSN 09175040

Background: A key measure of the effectiveness of end-of-life care is the place of death. The coronavirus disease 2019 (COVID-19) pandemic affected end-of-life care and the circumstances of patients with dementia. Methods: This observational, retrospective cohort study used Japanese national data to examine the numbers and locations of reported deaths among patients with dementia older than 65 years during the COVID-19 pandemic. Locations were grouped as medical institutions, nursing facilities, homes, or all settings. The quasi-Poisson regression model known as the Farrington algorithm was employed. Results: Between December 30, 2019, and January 29, 2023, 279,703 patients who died of causes related to dementia were reported in Japan. A decline was seen in early 2020, followed by increased numbers of deaths in homes, medical facilities, and nursing homes beginning in October 2020, December 2020, and March 2021, respectively. In 2021, the percentage of excess deaths at home peaked at 35.2%, while in 2022, those in medical facilities and nursing homes peaked at 18.8% and 16.6%, respectively. In 2022, the percentage of excess deaths in nursing homes exceeded that of other locations. Conclusion: The results suggest a change in the preferred place of death, along with pandemic-related visitation restrictions among healthcare facilities. Excess deaths also suggest strained medical resources and limited access to care. Methodological limitations include data from a limited period (2017 onwards) and post-2020 data used to estimate data after 2021, albeit with weighting. Considering these findings, physicians should reconfirm preferred places of death among older patients with dementia.

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A comprehensive assessment of deworming coverage among pregnant women in low- and middle-income countries, 2000–30

Miho Sassa, Daisuke Yoneoka, Chris Fook Sheng Ng, Alton Quan Cao, Ganan Devanathan, Masahiro Hashizume, Shuhei Nomura

Journal of Global Health (International Society of Global Health) 14 04002 2024

Accepted, ISSN 20472978

Background Intestinal parasitic infections pose a significant global public health issue, particularly among pregnant women, who are generally more susceptible due to their elevated need for iron and nutrients. Deworming stands as a secure and efficacious public health intervention. The World Health Organization (WHO) set a target for the national deworming coverage rate among pregnant women at 75% by 2030. Nonetheless, the existing body of evidence on deworming among pregnant women in low- and middle-income countries (LMICs) remains limited. Methods Based on Demographic Health Survey (DHS) data from 56 LMICs (n = 924 277) between 2000 and 2022, we used Bayesian hierarchical models to estimate trends of deworming coverage up to 2030 and to analyse determinant factors of deworming. Results We found that, despite progress in deworming coverage estimates for most countries, only 11 (<20%) are on track to achieve the WHO target coverage at the national level. Inequality gaps were projected to increase in most LMICs. A multilevel model showed that increased numbers of antenatal care, access to safe water, and a higher wealth index were associated with higher odds of deworming. Conclusions The progress on deworming coverage and inequality in many countries remains insufficient for achieving the WHO target by 2030. Additional investments in the health sector towards the expansion of deworming programmes, along with integration with existing health services, are urgently required, as is the introduction of effective policies and strengthening programmes within the context of the ‘Leave No One Behind’ agenda.

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Robust estimation of the incubation period and the time of exposure using <i>γ</i> -divergence

Daisuke Yoneoka, Takayuki Kawashima, Yuta Tanoue, Shuhei Nomura, Akifumi Eguchi

Journal of Applied Statistics 1 - 19 2024

Accepted, ISSN 02664763

Estimating the exposure time to single infectious pathogens and the associated incubation period, based on symptom onset data, is crucial for identifying infection sources and implementing public health interventions. However, data from rapid surveillance systems designed for early outbreak warning often come with outliers originated from individuals who were not directly exposed to the initial source of infection (i.e. tertiary and subsequent infection cases), making the estimation of exposure time challenging. To address this issue, this study uses a three-parameter lognormal distribution and proposes a new γ-divergence-based robust approach for estimating the parameter corresponding to exposure time with a tailored optimization procedure using the majorization-minimization algorithm, which ensures the monotonic decreasing property of the objective function. Comprehensive numerical experiments and real data analyses suggest that our method is superior to conventional methods in terms of bias, mean squared error, and coverage probability of 95% confidence intervals.

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Complex Landscape of Vaccine Hesitancy in Japan: A Public Health Challenge

S Nomura, M Ueta, A Cao, H Tomoi

2024

Factors associated with barriers to healthcare access among ever-married women of reproductive age in Bangladesh: Analysis from the 2017–2018 Bangladesh Demographic and Health …

H Hinata, KS Lwin, A Eguchi, C Ghaznavi, M Hashizume, S Nomura

Plos one 19 (1), e0289324 2024

The importance of methodological vigilance: Reevaluating suicide trends in Japan post-2022

M Koda, N Harada, S Nomura

Psychiatry and Clinical Neurosciences Reports 3 (2), e214 2024

Substrate, liquid crystal antenna and high-frequency device

S Nomura, K Ono

US Patent App. 18/771,189 2024

Progress and scenario-based projections of health service availability and coverage towards UHC in the post-conflict and post-pandemic Iraq: a Bayesian hierarchical regression …

H Taniguchi, MM Rahman, A Hussain, S Nomura, G Devanathan, ...

BMJ open 14 (9), e080492 2024

Mapping the Research Landscape of Disaster-Related Deaths and Health Effects in Japan: A Scoping Review

N Harada, M Koda, S Nomura, K Fujimoto, A TOMOTAKI

OSF 2024

Laminated member

S Ogawa, S Nomura, N Nakazawa

US Patent 11,958,269 2024

Laminated member

S Ogawa, N Nakazawa, S Nomura

US Patent 11,964,450 2024

Global incidence, prevalence, years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries in …

AJ Ferrari, DF Santomauro, A Aali, YH Abate, C Abbafati, H Abbastabar, ...

The Lancet 403 (10440), 2133-2161 2024

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the …

M Naghavi, KL Ong, A Aali, HS Ababneh, YH Abate, C Abbafati, ...

The Lancet 403 (10440), 2100-2132 2024

Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease …

M Brauer, GA Roth, AY Aravkin, P Zheng, KH Abate, YH Abate, C Abbafati, ...

The Lancet 403 (10440), 2162-2203 2024

Global age-sex-specific mortality, life expectancy, and population estimates in 204 countries and territories and 811 subnational locations, 1950–2021, and the impact of the …

AE Schumacher, HH Kyu, A Aali, C Abbafati, J Abbas, ...

The Lancet 403 (10440), 1989-2056 2024

Glass substrate for high-frequency device and circuit board for high-frequency device

K Ono, S Nomura, N Kidera, N Takeshita

US Patent App. 18/734,875 2024

Forecasting the effects of smoking prevalence scenarios on years of life lost and life expectancy from 2022 to 2050: a systematic analysis for the Global Burden of Disease …

D Bryazka, MB Reitsma, YH Abate, AHA Abd Al Magied, A Abdelkader, ...

The Lancet Public Health 9 (10), e729-e744 2024

Global Burden of Cardiovascular Diseases and Risks, 1990-2022

Global Burden of Cardiovascular Diseases and Risks Collaborators

Journal of the American College of Cardiology (Elsevier BV) 82 ( 25 ) 2350 - 2473 2023.12

Accepted, ISSN 07351097

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Early Outcomes of Changes to Collection of Suicide Data in Japan

Nahoko Harada, Masahide Koda, Shuhei Nomura

JAMA Network Open (American Medical Association (AMA)) 6 ( 12 ) e2347543 - e2347543 2023.12

Accepted, ISSN 2574-3805

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Modelling of salt intake reduction by incorporation of umami substances into Japanese foods: a cross-sectional study.

Shiori Tanaka, Daisuke Yoneoka, Aya Ishizuka, Megumi Adachi, Hitomi Hayabuchi, Toshihide Nishimura, Yukari Takemi, Hisayuki Uneyama, Haruyo Nakamura, Kaung Suu Lwin, Kenji Shibuya, Shuhei Nomura

BMC public health (Springer Science and Business Media {LLC}) 23 ( 1 ) 516 - 516 2023.12

Accepted, ISSN 1471-2458

BACKGROUND: Evidence has demonstrated that excess sodium intake is associated with development of several non-communicable diseases. The main source of sodium is salt. Therefore, reducing salt intake in foods is an important global public health effort to achieve sodium reduction and improve health. This study aimed to model salt intake reduction with 'umami' substances among Japanese adults. The umami substances considered in this study include glutamate or monosodium glutamates (MSG), calcium diglutamate (CDG), inosinate, and guanylate. METHODS: A total of 21,805 participants aged 57.8 years on average from the National Health and Nutrition Survey was used in the analysis. First, we employed a multivariable linear regression approach with overall salt intake (g/day) as a dependent variable, adjusting for food items and other covariates to estimate the contribution of salt intake from each food item that was selected through an extensive literature review. Assuming the participants already consume low-sodium products, we considered three scenarios in which salt intake could be reduced with the additional umami substances up to 30%, 60% and 100%. We estimated the total amount of population-level salt reduction for each scenario by age and gender. Under the 100% scenario, the Japan's achievement rates against the national and global salt intake reduction goals were also calculated. RESULTS: Without compromising the taste, the 100% or universal incorporation of umami substances into food items reduced the salt intake of Japanese adults by 12.8-22.3% at the population-level average, which is equivalent to 1.27-2.22 g of salt reduction. The universal incorporation of umami substances into food items changed daily mean salt intake of the total population from 9.95 g to 7.73 g: 10.83 g to 8.40 g for men and 9.21 g to 7.17 g for women, respectively. This study suggested that approximately 60% of Japanese adults could achieve the national dietary goal of 8 g/day, while only 7.6% would meet the global recommendation of 5.0 g/day. CONCLUSIONS: Our study provides essential information on the potential salt reduction with umami substances. The universal incorporation of umami substances into food items would enable the Japanese to achieve the national dietary goal. However, the reduced salt intake level still falls short of the global dietary recommendation.

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Response to antiviral therapy for chronic hepatitis C and risk of hepatocellular carcinoma occurrence in Japan: a systematic review and meta-analysis of observational studies

Yamagiwa Y., Tanaka K., Matsuo K., Wada K., Lin Y., Sugawara Y., Mizoue T., Sawada N., Takimoto H., Ito H., Kitamura T., Sakata R., Kimura T., Tanaka S., Inoue M., Abe S.K., Nomura S.

Scientific Reports 13 ( 1 ) 2023.12

In Japan, hepatocellular carcinoma (HCC) is a leading cause of cancer mortality and hepatitis C virus infection is a major cause of HCC. We conducted a systematic review and meta-analysis of published studies evaluating patient response to antiviral therapy for chronic hepatitis C on the risk of HCC occurrence in Japan. Articles were searched using terms determined a priori through PubMed, screened by title and abstract, and selected by full-text assessment according to criteria determined a priori, including HCC occurrence in response to interferon (IFN)-based or IFN-free therapy, Japanese study, and 2 or more years of follow-up. We excluded studies on HCC recurrence. We calculated the pooled estimate of the crude incidence rate ratio with data from the selected studies using the person-years method with Poisson regression model and pooled estimate of the hazard ratio adjusted for potential confounders reported by the studies using a random effects model. A total of 26 studies were identified, all of which examined only IFN-based therapy as a result of the selection process. The pooled estimate (95% confidence interval [CI]) of 25 studies was 0.37 (0.33–0.43) for sustained virologic response (SVR) and 1.70 (1.61–1.80) for non-SVR for the HCC incidence rate per 100 person-years, and 0.22 (0.19–0.26) for the incidence rate ratio (SVR vs. non-SVR). The pooled estimate of the hazard ratio (95% CI) of HCC incidence adjusted for potential confounders of 8 studies was 0.25 (0.19–0.34). SVR to interferon therapy for chronic hepatitis C reduces the risk of HCC occurrence.

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Understanding factors related to healthcare avoidance for menstrual disorders and menopausal symptoms: a cross-sectional study among women in Japan

Manae Uchibori, Akifumi Eguchi, Cyrus Ghaznavi, Yuta Tanoue, Mami Ueta, Miho Sassa, Shu Suzuki, Sayaka Honda, Yukiko Kawata, Miho Iida, Haruka Sakamoto, Shuhei Nomura

Preventive Medicine Reports (Elsevier BV) 36 102467 - 102467 2023.12

ISSN 2211-3355

This study explored the factors associated with healthcare avoidance behavior for menstrual disorders and menopausal symptoms among women in Japan. Using data from a nationally representative cross-sectional online survey conducted in September 2022, responses from 4,950 women aged 25–59 were analyzed. This study applied binomial logistic regression models specifically to participants who reported having ever felt the need to seek healthcare assistance due to health issues related to menstruation and menopause. We computed adjusted odds ratios for key sociodemographic traits, work environment factors, health literacy, menstrual and menopausal symptoms, and attitudes and understanding regarding women's health, associated with healthcare avoidance behavior in the past 12 months. As a sensitivity analysis, a regression was performed limited to those who are working. The results showed that 50.6% of respondents recognized the need for healthcare support for menstrual or menopausal health issues, but 22.8% exhibited healthcare avoidance in the past year. Younger and high-income individuals showed higher avoidance rates. Those with diagnosed gynecological conditions and those perceiving menstrual pain as something to endure also displayed increased avoidance tendencies. Women experiencing significant health effects beyond work and those lacking understanding of the purpose of health check-ups were more prone to healthcare avoidance. Our results underscore the importance of implementing strategically tailored health education initiatives, and re-examining societal attitudes concerning women's health, in order to cultivate enhanced healthcare-seeking behaviors among women.

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Estimation of the time of exposure based on interval and censored data using the <i>ε</i>‐accelerated EM algorithm

Daisuke Yoneoka, Takayuki Kawashima, Yuta Tanoue, Shuhei Nomura, Akifumi Eguchi

Statistics in Medicine (Wiley) 42 ( 25 ) 4542 - 4555 2023.11

Accepted, ISSN 02776715

Accurately estimating the timing of pathogen exposure plays a crucial role in outbreak control for emerging infectious diseases, including the source identification, contact tracing, and vaccine research and development. However, since surveillance activities often collect data retrospectively after symptoms have appeared, obtaining accurate data on the timing of disease onset is difficult in practice and can involve “coarse” observations, such as interval or censored data. To address this challenge, we propose a novel likelihood function, tailored to coarsely observed data in rapid outbreak surveillance, along with an optimization method based on an ‐accelerated EM algorithm for faster convergence to find maximum likelihood estimates (MLEs). The covariance matrix of MLEs is also discussed using a nonparametric bootstrap approach. In terms of bias and mean‐squared error, the performance of our proposed method is evaluated through extensive numerical experiments, as well as its application to a series of epidemiological surveillance focused on cases of mass food poisoning. The experiments show that our method exhibits less bias than conventional methods, providing greater efficiency across all scenarios.

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Strategies for Strengthening the Resilience of Public Health Systems for Pandemics, Disasters, and Other Emergencies

Benjamin Ryan, Mayumi Kako, Rok Fink, Perihan Şimşek, Paul Barach, Jose Acosta, Sanjaya Bhatia, Mark Brickhouse, Matthew Fendt, Alicia Fontenot, Nahuel Arenas Garcia, Shelby Garner, Abdülkadir Gunduz, D. Mike, Hardin Jr, Tim Hatch, LaShonda Malrey-Horne, Makiko MacDermot, Ryoma Kayano, Joshua McKone, Chaverle Noel, Shuhei Nomura, Jeremy Novak, Andrew Stricklin, Raymond Swienton, Ismail Tayfur, Bryan Brooks

Disaster Medicine and Public Health Preparedness 17 ( 5 ) e479 2023.09

Accepted, ISSN 19357893

Objective: The aim of this study was to identify and prioritize strategies for strengthening public health system resilience for pandemics, disasters, and other emergencies using a scorecard approach. Methods: The United Nations Public Health System Resilience Scorecard (Scorecard) was applied across 5 workshops in Slovenia, Turkey, and the United States of America. The workshops focused on participants reviewing and discussing 23 questions/indicators. A Likert type scale was used for scoring with zero being the lowest and 5 the highest. The workshop scores were analyzed and discussed by participants to prioritize areas of need and develop resilience strategies. Data from all workshops were aggregated, analyzed, and interpreted to develop priorities representative of participating locations. Results: Eight themes emerged representing the need for better integration of public health and disaster management systems. These include: assessing community disease burden; embedding long-term recovery groups in emergency systems; exploring mental health care needs; examining ecosystem risks; evaluating reserve funds; identifying what crisis communication strategies worked well; providing non-medical services; and reviewing resilience of existing facilities, alternate care sites, and institutions. Conclusions: The Scorecard is an effective tool for establishing baseline resilience and prioritizing actions. The strategies identified reflect areas in most need for investment to improve public health system resilience.

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Body mass index and esophageal and gastric cancer: A pooled analysis of 10 population-based cohort studies in Japan

Koyanagi Y.N., Matsuo K., Ito H., Wang C., Tamakoshi A., Sugawara Y., Tsuji I., Ono A., Tsugane S., Sawada N., Wada K., Nagata C., Takeuchi T., Kitamura T., Utada M., Sakata R., Mizoue T., Abe S.K., Inoue M., Kimura T., Sugawara Y., Nomura S., Takimoto H., Oze I., Lin Y., Hidaka A., Hirabayashi M., Iwasaki M., Kitamura Y., Mori N., Muto M., Naito M., Nakayama T., Nishino Y., Sadakane A., Saito E., Sasazuki S., Shimazu T., Shimizu H., Sugiyama K., Suzuki H., Tamakoshi A., Tanaka K., Tanaka S., Tsubono Y., Wakai K., Yamagiwa Y., Yamaji T.

Cancer Science 114 ( 7 ) 2961 - 2972 2023.07

ISSN 13479032

The effect of body mass index (BMI) on esophageal and gastric carcinogenesis might be heterogeneous, depending on subtype or subsite. However, findings from prospective evaluations of BMI associated with these cancers among Asian populations have been inconsistent and limited, especially for esophageal adenocarcinoma and gastric cardia cancer. We performed a pooled analysis of 10 population-based cohort studies to examine this association in 394,247 Japanese individuals. We used Cox proportional hazards regression to estimate study-specific hazard ratios (HRs) and 95% confidence intervals (CIs), then pooled these estimates to calculate summary HRs with a random effects model. During 5,750,107 person-years of follow-up, 1569 esophageal cancer (1038 squamous cell carcinoma and 86 adenocarcinoma) and 11,095 gastric (728 cardia and 5620 noncardia) cancer incident cases were identified. An inverse association was observed between BMI and esophageal squamous cell carcinoma (HR per 5-kg/m2 increase 0.57, 95% CI 0.50–0.65), whereas a positive association was seen in gastric cardia cancer (HR 1.15, 95% CI 1.00–1.32). A nonsignificant and significant positive association for overweight or obese (BMI ≥25 kg/m2) relative to BMI <25 kg/m2 was observed with esophageal adenocarcinoma (HR 1.32, 95% CI 0.80–2.17) and gastric cardia cancer (HR 1.24, 95% CI 1.05–1.46), respectively. No clear association with BMI was found for gastric noncardia cancer. This prospective study—the largest in an Asian country—provides a comprehensive quantitative estimate of the association of BMI with upper gastrointestinal cancer and confirms the subtype- or subsite-specific carcinogenic impact of BMI in a Japanese population.

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Estimating global changes in routine childhood vaccination coverage during the COVID-19 pandemic, 2020–2021

C Ghaznavi, A Eguchi, KS Lwin, D Yoneoka, Y Tanoue, SK Rauniyar, ...

Vaccine 41 (28), 4151-4157 (Elsevier BV) 41 ( 28 ) 4151 - 4157 2023.06

Accepted, ISSN 0264410X

Objectives: The COVID-19 pandemic has disrupted the distribution of routine immunizations globally. Multi-country studies assessing a wide spectrum of vaccines and their coverage rates are needed to determine global performance in achieving vaccination goals. Methods: Global vaccine coverage data for 16 antigens were obtained from WHO/UNICEF Estimates of National Immunization Coverage. Tobit regression was performed for all country-antigen pairs for which data were continuously available between 2015–2020 or 2015–2021 to predict vaccine coverage in 2020/2021. Vaccines for which multi-dose data were available were assessed to determine whether vaccine coverage for subsequent doses were lower than that of first doses. Results: Vaccine coverage was significantly lower-than-predicted for 13/16 antigens in 2020 and all assessed antigens in 2021. Lower-than-predicted vaccine coverage was typically observed in South America, Africa, Eastern Europe, and Southeast Asia. There was a statistically significant coverage drop for subsequent doses of the diphtheria-tetanus-pertussis, pneumococcus, and rotavirus vaccines compared to first doses in 2020 and 2021. Conclusion: The COVID-19 pandemic exerted larger disruptions to routine vaccination services in 2021 than in 2020. Global efforts will be needed to recoup vaccine coverage losses sustained during the pandemic and broaden vaccine access in areas where coverage was previously inadequate.

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Projection of morbidity and mortality due to breast cancer between 2020 and 2050 across 42 low- and middle-income countries

Santosh Kumar Rauniyar, Masahiro Hashizume, Daisuke Yoneoka, Shuhei Nomura

Heliyon (Elsevier BV) 9 ( 6 ) e16427 - e16427 2023.06

Accepted, ISSN 24058440

Objective: Aim of the study is to predict trends in morbidity and mortality due to breast cancer in 42 LMICs between 2020 and 2050. Design: and Setting: National level cross-sectional breast cancer related data between 1990 and 2019 were used. Recurrent Neural Network, Long-Short-Term Memory (RNN-LSTM) model was employed to forecast the trend in breast cancer burden. Main outcomes and measures: Age standardized breast cancer incidence, mortality, and disability adjusted life years (DALYs) rates. Results: By 2050, the age standardized breast cancer incidence rate is expected to increase in 38 LMICs with highest incidence rate in Namibia; 127.0 (78.0–176.0) followed by Nigeria 71.1 (53.9–88.3) and Papua New Guinea 70.6 (88.7–74.6). Similarly, the age standardized breast cancer mortality and DALYs rates in 2050 are expected to increase in 33 and 35 LMICs respectively. The highest mortality and DALYs rates in 2050 are expected to be 64.7 (42.6–86.7) in Namibia and 1543.6 (1463.1–1624.1) in Pakistan. The estimated annual percentage change (EAPC) is expected to increase uniformly in all the countries during the same period. Due to considerable variation in exposure risk, such as high plasma glucose level, high body mass index (BMI) and socio-demographic index (SDI), high regional disparity in burden of breast cancer is expected among the countries. Conclusion: and Relevance: Breast cancer burden is expected to increase in most of the LMICs with high regional disparity by 2050. Our study's finding focuses on LMICs with high breast cancer burden that require tailored strategies and effective action plans to ensure prevention from catastrophic consequences in the future. Minimizing the exposure to behavioral and metabolic risk factors such as high plasma glucose, high BMI, along with tackling the issue of low fertility rate would be important in managing breast cancer burden in LMICs.

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Changes in cerebrovascular disease–related deaths and their location during the COVID-19 pandemic in Japan

S Nomura, A Eguchi, C Ghaznavi, L Yamasaki, SK Rauniyar, Y Tanoue, ...

Public Health 218, 176-179 (Elsevier BV) 218 ( 218 ) 176 - 179 2023.05

Accepted, ISSN 00333506

Objective: The COVID-19 pandemic placed an enormous strain on healthcare systems and raised concerns for delays in the management of patients with acute cerebrovascular events. In this study, we investigated cerebrovascular excess deaths in Japan. Study design: Vital mortality statistics from January 2012 to May 2022 were obtained from the Japanese Ministry of Health, Labour and Welfare. Methods: Using quasi-Poisson regression models, we estimated the expected weekly number of cerebrovascular deaths in Japan from January 2020 through May 2022 by place of death. Estimates were calculated for deaths in all locations, as well as for deaths in hospitals, in geriatric health service facilities, and at home. The age subgroups of ≥75 and <75 years were also considered. Weeks with a statistically significant excess of cerebrovascular deaths were determined when the weekly number of observed deaths exceeded the upper bound of 97.5% prediction interval. Results: Excess deaths were noted in June 2021 and became more pronounced from February 2022 onward. The trend was notable among those aged ≥75 years and for those who died in hospitals. With respect to the location of deaths, the excess was significant in geriatric health services facilities from April 2020 to June 2021, whereas no evidence of excess hospital deaths was observed during the same period. Conclusions: Beginning in the late 2021, excess cerebrovascular deaths coincided with the spread of the Omicron variant and may be associated with increased healthcare burden. In 2020, COVID-19 altered the geography of cerebrovascular deaths, with fewer people dying in hospitals and more dying in geriatric health service facilities and at home.

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Promote global solidarity to advance health-system resilience: proposals for the G7 meetings in Japan

Hiroshima Global Health Task Force (in alphabetical order: Keishi Abe, Sarah Krull Abe, Takanori Fujita, Yoshiaki Gu, Masahiro Hashizume, Chieko Ikeda, Masaki Inaba, Kazuaki Jindai, Naoki Kondo, Osamu Kunii, Makiko Matsuo, Hiroki Nakatani, Yoshitaka Nishino, Shuhei Nomura, Haruka Sakamoto, Hideaki Shiroyama, Tomoko Suzuki, Ayako Takemi, Kayo Takuma)

The Lancet (Elsevier {BV}) 401 ( 10385 ) 1319 - 1321 2023.04

Accepted, ISSN 0140-6736

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Recent changes in the reporting of STIs in Japan during the COVID-19 pandemic.

Cyrus Ghaznavi, Yuta Tanoue, Takayuki Kawashima, Akifumi Eguchi, Daisuke Yoneoka, Haruka Sakamoto, Peter Ueda, Masahiro Ishikane, Naokatsu Ando, Yusuke Miyazato, Shuhei Nomura

Sexually transmitted infections 99 ( 2 ) 124 - 127 2023.03

Accepted, ISSN 13684973

OBJECTIVES: The COVID-19 pandemic has had variable effects on the rates of STIs reported across the globe. This study sought to assess how the number of STI reports changed during the pandemic in Japan. METHODS: We used national infectious disease surveillance data from the National Institute of Infectious Diseases (Tokyo, Japan) for the period between January 2013 and December 2021. We compared reported rates of chlamydia, gonorrhoea, condyloma acuminata and genital herpes, as well as total notifications for HIV/AIDS and syphilis during the pandemic versus previous years in Japan. We used a quasi-Poisson regression to determine whether any given week or month between January 2018 and December 2021 had a significant excess or deficit of STIs. Notification values above or below the 95% upper and lower prediction thresholds were considered as statistically significant. The start of the pandemic was defined as January 2020. RESULTS: Chlamydia generally remained within predicted range during the pandemic period. Reporting of gonorrhoea was significantly higher than expected throughout early-to-mid 2021 but otherwise generally remained within predicted range prior to 2021. Condyloma, herpes and HIV/AIDS reporting were transiently significantly lower than expected throughout the pandemic period, but no significant periods of higher-than-expected reporting were detected. Syphilis showed widespread evidence of significantly lower-than-predicted reporting throughout 2020 but eventually reversed, showing significantly higher-than-predicted reporting in mid-to-late 2021. CONCLUSIONS: The COVID-19 pandemic was associated with variable changes in the reporting of STIs in Japan. Higher-than-predicted reporting was more likely to be observed in the later phases of the pandemic. These changes may have been attributable to pandemic-related changes in sexual behaviour and decreased STI clinic attendance and testing, but further research on the long-term impact of the pandemic on STIs is necessary.

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The impact of social isolation from COVID-19-related public health measures on cognitive function and mental health among older adults: A systematic review and meta-analysis

Prapichaya Prommas, Kaung Suu Lwin, Yi Chi Chen, Misa Hyakutake, Cyrus Ghaznavi, Haruka Sakamoto, Hiroaki Miyata, Shuhei Nomura

Ageing Research Reviews (Elsevier {BV}) 85 101839 - 101839 2023.03

Accepted, ISSN 15681637

We aimed to estimate the impact of social isolation on cognitive function and mental health among older adults during the two-year-and-a-half COVID-19 period. Pubmed Central, Medline, CINAHL Plus and PsychINFO were searched between March 1, 2020, and September 30, 2022. We included all studies that assessed proportions of older adults with the mean or the median with a minimum age above 60 reporting worsening cognitive function and mental health. Thirty-two studies from 18 countries met the eligibility criteria for meta-analyses. We found that the proportions of older adults with dementia who experienced worsening cognitive impairment and exacerbation or new onset of behavioral and psychological symptoms of dementia (BPSD) were approximately twice larger than that of older adults with HC experiencing SCD and worsening mental health. Stage of dementia, care options, and severity of mobility restriction measures did not yield significant differences in the number of older adults with dementia reporting worsening cognitive impairment and BPSD, while the length of isolation did for BPSD but not cognitive impairment. Our study highlights the impact of social isolation on cognitive function and mental health among older adults. Public health strategies should prioritize efforts to promote healthy lifestyles and proactive assessments.

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Salt intake reduction using umami substance-incorporated food: a secondary analysis of NHANES 2017-2018 data

Shuhei Nomura, Shiori Tanaka, Akifumi Eguchi, Takayuki Kawashima, Haruyo Nakamura, Kaung Suu Lwin, Lisa Yamasaki, Daisuke Yoneoka, Yuta Tanoe, Megumi Adachi, Hitomi Hayabuchi, Shosei Koganemaru, Toshihide Nishimura, Byron Sigel, Hisayuki Uneyama, Kenji Shibuya

Public Health Nutrition (Cambridge University Press (CUP)) 26 ( 2 ) 488 - 495 2023.02

Accepted, ISSN 13689800

Abstract

Objective:

Excessive salt intake raises blood pressure and increases the risk of non-communicable diseases (NCDs), such as cardiovascular disease, chronic kidney disease, and stomach cancer. Reducing the sodium content of food is an important public health measure to control the NCDs. This study quantifies the amount of salt reduced by using umami substances, i.e., glutamate, inosinate, and guanylate, for adults in the United States (US).

Design:

The secondary data analysis was performed using data of the US nationally representative cross-sectional dietary survey, the National Health and Nutrition Examination Survey (NHANES) 2017-2018. Per capita daily salt intake corresponding to the NHANES food groups was calculated in the four hypothetical scenarios of 0%, 30%, 60%, and 90% market share of low-sodium foods in the country. The salt reduction rates by using umami substances were estimated based on the previous study results.

Setting:

The United States

Participants:

4,139 individuals aged 20 years and older in the US

Results:

Replacing salt with umami substances could help the US adults reduce salt intake by 7.31–13.53% (7.50–13.61% for women; 7.18–13.53% for men), which is equivalent to 0.61–1.13g/day (0.54–0.98g/day for women; 0.69–1.30g/day for men) without compromising the taste. Approximately, 21.21–26.04% of the US adults could keep their salt intake below 5 g/day, the World Health Organization’s recommendation in the scenario where there is no low-sodium product on the market.

Conclusions:

This study provides essential information that the use of umami substances as a substitute for salt may help reduce the US adults’ salt intake.

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Reducing salt intake with umami: A secondary analysis of data in the UK National Diet and Nutrition Survey

Haruyo Nakamura, Takayuki Kawashima, Lisa Yamasaki, Kaung Suu Lwin, Akifumi Eguchi, Hitomi Hayabuchi, Yuta Tanoe, Shiori Tanaka, Daisuke Yoneoka, Cyrus Ghaznavi, Hisayuki Uneyama, Kenji Shibuya, Shuhei Nomura

Food Science & Nutrition (Wiley) 11 ( 2 ) 872 - 882 2023.02

ISSN 2048-7177

Reducing sodium content in foods is an important public health measure to reduce salt intake and decrease the incidence of noncommunicable diseases, such as cardiovascular disease and chronic kidney disease. This study quantified the amount of salt intake that could potentially be reduced by using umami substances, including glutamate, inosinate, and guanylate, without compromising taste, for adults in the United Kingdom (UK). We used data comprised of 1834 adults aged 20 years and over from the National Diet and Nutrition Survey (NDNS RP) 2016/2017–2018/2019. Four hypothetical scenarios in which the market share of low-sodium foods accounts for 0%, 30%, 60%, or 90% of consumed products were considered in the analyses. Per capita daily salt intake corresponding to the NDNS RP food groups was calculated for each scenario, and the salt intake was aggregated by gender and age groups. Replacing salt with umami substances could help UK adults reduce daily salt intake by 9.09%–18.59% (9.21%–18.43% for women; 8.83%–19.43% for men), which is equivalent to 0.45–0.92 g/day of salt reduction (0.41–0.82 g/day for women; 0.50–1.10 g/day for men). The use of umami substances may serve as one method for the UK government to encourage salt intake reduction, particularly in the context of food product reformulation, as 80% of salt consumed in the country comes from processed foods. Empirical studies with sensory evaluation should be conducted to confirm consumer tolerance. The food industry should also be engaged in conversations regarding the addition of umami to food products in the United Kingdom.

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Annual prevalence of non-communicable diseases and identification of vulnerable populations following the Fukushima disaster and COVID-19 pandemic

Michio Murakami, Shuhei Nomura

International Journal of Disaster Risk Reduction 84 103471 2023.01

Accepted, ISSN 22124209

Disasters, pandemics, and their response measures can have secondary effects on the physical and psychological health of affected populations. Using health insurance receipt data from 2009 to 2020, we assessed changes in the prevalence of major non-communicable diseases (NCDs), including hypertension, hyperlipidemia, diabetes, and mental disorders, among affected populations before and after the Fukushima disaster and coronavirus disease (COVID-19) outbreak in Japan. Furthermore, age and sex groups with the largest increases in prevalence after these events were identified. The participants of this study were employees of large companies and their dependent family members who were insured by health insurance societies (HIS). The dataset was provided by JMDC Inc. The annual age-adjusted prevalence of each disease belonging to the HIS scheme was used to calculate the ratio of disease prevalence before and after the events. After the Fukushima disaster, hypertension, hyperlipidemia, and diabetes generally increased over a 9-year period in Fukushima Prefecture. The increase in the prevalence rate of these three NCDs and mental disorders was the highest among females aged 40–74 years compared to males and the other age groups. The prevalence of all four diseases increased after the COVID-19 outbreak in Japan, with a marked increase in males aged 0–39 years. Changes in prevalence ratios of NCDs after the COVID-19 outbreak among the areas affected by the Fukushima disaster were lower than in the whole of Japan. It is important to provide tailor-made public health support among populations in accordance with the type of disasters and pandemic.

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Effect of the COVID-19 pandemic and state of emergency declarations on the relative incidence of legionellosis and invasive pneumococcal disease in Japan.

Cyrus Ghaznavi, Masahiro Ishikane, Daisuke Yoneoka, Yuta Tanoue, Takayuki Kawashima, Akifumi Eguchi, Shuhei Nomura

Journal of Infection and Chemotherapy (Elsevier BV) 29 ( 1 ) 90 - 94 2023.01

Accepted, ISSN 1341321X

INTRODUCTION: During the COVID-19 pandemic, the incidence of many droplet-transmitted infections decreased due to increased mask-wearing and social distancing. Contrastingly, there has been concern that COVID-19 countermeasures, such as lockdowns, may increase legionellosis incidence via water stagnation. During the pandemic in Japan, four state of emergency declarations were imposed between 2020-2021, which makes it particularly suitable to test this hypothesis. METHODS: We use country-level surveillance data from the National Institute of Infectious Diseases to track the relative incidence of legionellosis compared to invasive pneumococcal disease (IPD) during the COVID-19 pandemic in Japan, with a focus on the periods just after state of emergency declarations were lifted. RESULTS: The absolute number of legionellosis and IPD cases decreased in 2020 and 2021 compared to previous years. The average relative incidence of legionellosis as well as the variance of the relative incidence significantly increased during the pandemic compared to previous years. There were no increases in the relative incidence of legionellosis during the periods immediately following emergency declaration liftings, but the relative incidence did increase considerably during the first two states of emergency. CONCLUSIONS: COVID-19 countermeasures appear more effective at decreasing the incidence of human-to-human transmitted infections, such as IPD, compared to environmentally-transmitted infections, such as legionellosis. Though no evidence was found to suggest that legionellosis cases increased after state of emergency declarations, public health efforts should continue to emphasize the importance of routine sanitation and water system maintenance to prevent water stagnation and Legionellaspp. contamination.

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Insights from the COVID-19 pandemic: trends in development assistance committee countries’ aid allocation, 2011–2021

Shuhei Nomura, Cyrus Ghaznavi, Kazuki Shimizu, Alton Cao, Miho Sassa, Manae Uchibori, Rauniyar Santosh Kumar, Lisa Yamasaki, Hana Tomoi, Haruka Sakamoto

Global Health Action 16 ( 1 ) 2258707 2023

Accepted

Background: Official Development Assistance (ODA) significantly aids sustainable development in low- and middle-income countries (LMICs). However, the COVID-19 pandemic has impacted aid allocation, posing challenges for attaining the Sustainable Development Goals (SDGs). Objective: This study explores and underscores the profound implications of shifts in ODA allocation by Development Assistance Committee (DAC) member countries, resulting from the COVID-19 pandemic, offering a unique perspective on the evolving landscape of international aid. Methods: Drawing from the gross ODA disbursement data for LMICs by DAC member countries from 2011 to 2021, a linear regression analysis assessed the changes in ODA amount, ODA-to-gross national income (GNI) ratio, sectoral aid allocation, and the balance between bilateral and multilateral aid, primarily focusing on the differences pre- and post-COVID-19. For non-specialised multilateral agencies’ core funding, the OECD’s methodology for calculating imputed multilateral ODA was employed to estimate ODA flows. Results: The study found an increasing trend in the total ODA provided by DAC member countries from 2011 to 2021. However, the average ODA/GNI ratio showed a slight but significant decrease before the pandemic, followed by an increase after the COVID-19 pandemic. The health sector received the highest percentage of aid after the pandemic, with a marked increase in both bilateral and multilateral aid. However, other sectors such as humanitarian aid, water and sanitation, and energy experienced a significant decrease in sectoral aid share. Conclusions: Emerging from this analysis is a strong recommendation for DAC members to re-evaluate aid objectives and escalate their financial commitments to reinforce SDGs and sustainable development efforts. While the rise in health aid is essential, other sectors also require equal focus to offset the ramifications of the COVID-19 pandemic. Understanding the intricacies of aid allocation can improve aid efficacy, culminating in greater, transformative results for recipient countries.

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Public transportation network scan for rapid surveillance

Y Tanoue, D Yoneoka, T Kawashima, S Uryu, S Nomura, A Eguchi, ...

Biostatistics & Epidemiology 7 (1), e2069458 (Informa UK Limited) 7 ( 1 ) 1 - 15 2023

Accepted, ISSN 24709360

As people move around using public transportation networks, such as train and airplanes, it is expected that emerging infectious diseases will spread on the network. The scan statistics approach has been frequently applied to identify high-risk locations, and the results are widely used for making a clinical decisions in a timely manner. However, they are not optimally designed for modeling the spread and might not effectively work under the emergency situation where computational time is essentially important. We propose a new scan statistics approach for the public transportation network, called PTNS (Public Transportation Network Scan). PTNS utilizes the available network structure to construct potential candidates of clusters, and thus it can work well especially in situations where public transportation is the main medium of the infection spread. Further, it is designed for rapid surveillance. Lastly, PTNS is generalized to detect space-time clusters by customizing the iteration for potential clusters creation. Using the simulation data generated with a real railway network, we showed that, PTNS outperformed the conventional methods, including Circular- and Flex-scan approaches in terms of the detection performance, while the computational time is feasible.

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Estimation of the time of exposure based on interval and censored data using the ε‐accelerated EM algorithm

D Yoneoka, T Kawashima, Y Tanoue, S Nomura, A Eguchi

Statistics in Medicine 42 (25), 4542-4555 2023

Age-Related Differences in Side Walls of Maxillary First Molar Pulp Cavities in Japanese Using Micro-Computed Tomography

S Nomura, S Matsunaga, M Yamada, N Kasahara, S Abe, M Furusawa

Journal of Hard Tissue Biology 32 (3), 191-196 2023

Comparing the risks of diabetes, psychological distress, and radiation-induced cancer exposure after the Fukushima disaster using the loss of happy life expectancy

M Murakami, A Ozaki, K Ono, S Nomura, Y Takebayashi, M Tsubokura

medRxiv, 2023.05. 01.23289327 2023

Body mass index and esophageal and gastric cancer: A pooled analysis of 10 population‐based cohort studies in Japan

YN Koyanagi, K Matsuo, H Ito, C Wang, A Tamakoshi, Y Sugawara, I Tsuji, ...

Cancer Science 114 (7), 2961-2972 2023

The Efficacy of an mHealth App in Facilitating Weight Loss Among Japanese Fitness Center Members: Regression Analysis Study

Akifumi Eguchi, Yumi Kawamura, Takayuki Kawashima, Cyrus Ghaznavi, Keiko Ishimura, Shun Kohsaka, Satoru Matsuo, Shinichiro Mizuno, Yuki Sasaki, Arata Takahashi, Yuta Tanoue, Daisuke Yoneoka, Hiroaki Miyata, Shuhei Nomura

JMIR Formative Research (JMIR Publications Inc.) 7 ( 1 ) e48435 - e48435 2023

ISSN 2561-326X

Background

Self-tracking smartphone apps have emerged as promising tools to encourage healthy behaviors. In this longitudinal study, we used gym use data from members of a major fitness club that operates gyms throughout Japan from January 2014 to December 2019.

Objective

Our objective was to assess the extent to which a health and fitness self-tracking mobile app introduced to gym members on January 1, 2018, contributed to their weight loss. The app allows users to input information regarding diet, sleep, weight, and gym exercise so that they can receive personalized feedback from an artificial intelligence chatbot to improve their health behaviors.

Methods

We used linear regression to quantify the association between app use and weight loss. The primary outcome of the study was the weight loss achieved by each gym user, which was calculated as the difference between their initial and final weights in kilograms, as recorded in the app. Individuals who did not attend the gym or failed to use the mobile app at least twice during the study period were excluded from the analysis. The model accounted for age, gender, distance between the gym and the member’s residence, average weekly number of times a member used the gym, user’s gym membership length in weeks, average weekly number of times a member input information into the app, and the number of weeks that the app was used at least once.

Results

Data from 26,589 participants were analyzed. Statistically significant associations were detected between weight loss and 2 metrics related to app use: the average weekly frequency of use and the total number of weeks in which the app was used at least once. One input per week was found to be associated with a loss of 62.1 (95% CI 53.8-70.5) g, and 1 week of app use was associated with 21.7 (95% CI 20.5-22.9) g of weight loss from the day of the first input to that of the final input to the app. Furthermore, the average number of times that a member used the gym weekly was also shown to be statistically significantly associated with weight loss: 1 use per week was associated with 255.5 (95% CI 228.5-282.6) g of weight loss.

Conclusions

This empirical study demonstrated a significant association between weight loss among gym members and not only the frequency of weekly gym use but also the use of a health and fitness self-tracking app. However, further work is needed to examine the mechanisms through which mobile apps affect health behaviors and to identify the specific app features that are most effective in promoting weight loss.

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Glass substrate and laminated substrate

Y Hanawa, S Sawamura, S Nomura, K Ono, N Takeshita, K Hanashima

US Patent 11,715,673 2023

Salt intake reduction using umami substance-incorporated food: a secondary analysis of NHANES 2017–2018 data

S Nomura, S Tanaka, A Eguchi, T Kawashima, H Nakamura, KS Lwin, ...

Public Health Nutrition 26 (2), 488-495 2023

Perceptions and responses to COVID-19 through wastewater surveillance information and online search behavior: A randomized controlled trial

M Murakami, S Nomura, H Ando, M Kitajima

medRxiv, 2023.10. 20.23297297 118 2023

ISSN 22124209

An influence of wastewater surveillance during infectious disease outbreak on public perception and behavior remains unclear. Here, we used a randomized controlled trial to analyze the influence of wastewater surveillance-based information on “understanding of,” “interest in,” “relief regarding,” “preventive behavioral intention against,” and “subsequent online search behavior related to” COVID-19. Valid responses were obtained from 1000 individuals in both control and intervention groups from Yahoo! JAPAN crowdsourcing users aged ≥18 years in Japan. This survey was conducted from August 4 to August 7, 2023, just before the common Japanese tradition of returning to hometowns. The questionnaire not only collected personal attributes but also gauged responses to COVID-19 information. This information highlighted the early detection capabilities and representativeness of wastewater surveillance compared with sentinel surveillance at medical institutions. At one-week post-survey, we obtained the survey participants’ online search history for key words such as “bullet train,” “highway,” “airplane,” and “wastewater.” Wastewater surveillance-based information did not notably elevate “understanding” or “specific intentions” regarding COVID-19, such as wearing masks and receiving vaccination. However, it significantly increased “interest in,” “relief concerning the infection status,” and “general preventive behavioral intentions.” Heightened “interest” and “general preventive intentions” did not depend on prior interest or behavior. However, those who previously engaged in preventive behavior or who were less interested in COVID-19 exhibited more “relief” after exposure to wastewater surveillance-based information. Furthermore, this information could slightly influence online searches, such as highways. In conclusion, information from wastewater surveillance effectively shapes individual perceptions of and responses to infections.

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High Sodium Intake and its Public Health Impacts: Perspectives from the Global Burden of Disease Study and the Global Nutrition Report

S NOMURA

イルシー (Web), 23-34 2023

Glass substrate, semiconductor device, and display device

S Nomura, K Ono

US Patent 11,554,983 2023

Glass substrate, semiconductor device, and display device

S Nomura, K Ono

US Patent App. 18/054,667 2023

Glass substrate, liquid crystal antenna and high-frequency device

S Nomura, K Ono

US Patent App. 18/157,213 2023

Glass substrate, liquid crystal antenna and high-frequency device

S Nomura, K Ono

US Patent 11,594,811 2023

Glass substrate for high-frequency device and circuit board for high-frequency device

K Ono, S Nomura, N Kidera, N Takeshita

US Patent 11,708,294 2023

Distributed lag interrupted time series model for unclear intervention timing: effect of a statement of emergency during COVID-19 pandemic.

Daisuke Yoneoka, Takayuki Kawashima, Yuta Tanoue, Shuhei Nomura, Akifumi Eguchi

BMC medical research methodology (Springer Science and Business Media {LLC}) 22 ( 1 ) 202 - 202 2022.12

ISSN 1471-2288

BACKGROUND: Interrupted time series (ITS) analysis has become a popular design to evaluate the effects of health interventions. However, the most common formulation for ITS, the linear segmented regression, is not always adequate, especially when the timing of the intervention is unclear. In this study, we propose a new model to overcome this limitation. METHODS: We propose a new ITS model, ARIMAITS-DL, that combines (1) the Autoregressive Integrated Moving Average (ARIMA) model and (2) distributed lag functional terms. The ARIMA technique allows us to model autocorrelation, which is frequently observed in time series data, and the decaying cumulative effect of the intervention. By contrast, the distributed lag functional terms represent the idea that the intervention effect does not start at a fixed time point but is distributed over a certain interval (thus, the intervention timing seems unclear). We discuss how to select the distribution of the effect, the model construction process, diagnosing the model fitting, and interpreting the results. Further, our model is implemented as an example of a statement of emergency (SoE) during the coronavirus disease 2019 pandemic in Japan. RESULTS: We illustrate the ARIMAITS-DL model with some practical distributed lag terms to examine the effect of the SoE on human mobility in Japan. We confirm that the SoE was successful in reducing the movement of people (15.0-16.0% reduction in Tokyo), at least between February 20 and May 19, 2020. We also provide the R code for other researchers to easily replicate our method. CONCLUSIONS: Our model, ARIMAITS-DL, is a useful tool as it can account for the unclear intervention timing and distributed lag effect with autocorrelation and allows for flexible modeling of different types of impacts such as uniformly or normally distributed impact over time.

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Green tea and coffee consumption and risk of kidney cancer in Japanese adults

Yichi Chen, Sarah K. Abe, Manami Inoue, Taiki Yamaji, Motoki Iwasaki, Shuhei Nomura, Masahiro Hashizume, Shoichiro Tsugane, Norie Sawada, N. Sawada, S. Tsugane, M. Iwasaki, M. Inoue, T. Yamaji, R. Katagiri, Y. Miyamoto, H. Ihira, S. K. Abe, S. Tanaka, T. moriya, T. Minamizono, Y. Shirai, H. Kuniyoshi, T. Yoshimi, H. Sonoda, T. Tagami, T. Ando, T. Kimura, Y. Kokubo, K. Yamagishi, T. Mizoue, K. Nakamura, R. Takachi, J. Ishihara, H. Iso, T. Kitamura, I. Saito, N. Yasuda, M. Mimura, K. Sakata, M. Noda, A. Goto, H. Yatsuya, M. Mimura, T. Hanaoka, A. Hidaka, S. Sasazuki, H. Charvat, T. Shimazu, S. Budhathoki, M. Muto, T. Imatoh, J. Ogata, S. Baba, T. Mannami, A. Okayama, K. Miyakawa, F. Saito, A. Koizumi, Y. Sano, I. Hashimoto, T. Ikuta, Y. Tanaba, H. Sato, Y. Roppongi, T. Takashima, H. Suzuki, T. Sugie, Y. Miyajima, N. Suzuki, S. Nagasawa, Y. Furusugi, N. Nagai, Y. Ito, S. Komatsu, H. Sanada, Y. Hatayama, F. Kobayashi, H. Uchino, Y. Shirai, T. Kondo, R. Sasaki, Y. Watanabe, Y. Miyagawa, Y. Kobayashi, M. Machida, K. Kobayashi, M. Tsukada, Y. Kishimoto, E. Takara, T. Fukuyama, M. Kinjo, M. Irei, H. Sakiyama, H. Sakiyama, K. Imoto, H. Yazawa, T. Seo, A. Seiko, F. Ito, F. Shoji, R. Saito, A. Murata, K. Minato, K. Motegi, T. Fujieda, S. Yamato, K. Matsui, T. Abe, M. Katagiri, M. Suzuki, M. Doi, A. Terao, Y. Ishikawa, H. Sueta, H. Doi, M. Urata, N. Okamoto, F. Ide, H. Goto, R. Fujita, Y. Sou, H. Sakiyama, N. Onga, H. Takaesu, M. Uehara, T. Nakasone, M. Yamakawa, Y. Miyasato, F. Horii, I. Asano, H. Yamaguchi, K. Aoki, S. Maruyama, M. Ichii, M. Takano, Y. Tsubono, K. Suzuki, Y. Honda, S. Sakurai, N. Tsuchiya, M. Kabuto, M. Yamaguchi, Y. Matsumura, S. Sasaki, S. Watanabe, M. Akabane, T. Kadowaki, Y. Takashima, Y. Yoshida, S. Matsushima, S. Natsukawa, H. Sugimura, S. Tominaga, M. Iida, W. Ajiki, A. Ioka, S. Sato, M. Konishi, K. Okada, T. Sobue, Y. Kawaguchi, N. Hamajima, S. Akiba, T. Isobe, Y. Sato, T. Sobue, H. Shimizu, S. Kono, T. Sobue, E. Maruyama

Scientific Reports (Springer Science and Business Media LLC) 12 ( 1 ) 20274 - 20274 2022.12

Accepted

Abstract

The study aimed to evaluate the association between green tea and coffee consumption and the risk of kidney cancer using data from a large prospective cohort study in Japan (the Japan Public Health Center-based Prospective Study: JPHC Study). A total of 102,463 participants aged 40–69 were followed during 1,916,421 person-years (mean follow-up period, 19 years). A total of 286 cases of kidney cancer (199 in men, 87 in women) were identified. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (95% CIs) while adjusting for potential confounders. No statistically significant association between green tea intake and kidney cancer risk was found in the total population. Among women who consumed more than five cups of green tea per day, a statistically significant decreased risk was shown with a HR of 0.45 (95% CI: 0.23–0.89), compared to women who rarely consumed green tea. For coffee consumption, the association of kidney cancer risk was not statistically significant. This large prospective cohort study indicated green tea intake may be inversely associated with kidney cancer risk in Japanese adults, particularly in Japanese women.

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Preventive Behaviors and Information Sources during COVID-19 Pandemic: A Cross-Sectional Study in Japan.

Manae Uchibori, Cyrus Ghaznavi, Michio Murakami, Akifumi Eguchi, Hiroyuki Kunishima, Satoshi Kaneko, Keiko Maruyama-Sakurai, Hiroaki Miyata, Shuhei Nomura

International journal of environmental research and public health 19 ( 21 ) 14511 2022.11

Accepted, ISSN 16617827

BACKGROUND: individual preventive behaviors are one of the key measures needed to prevent the spread of COVID-19. This study sought to identify the factors associated with the adoption of COVID-19 preventive measures, focusing specifically on information sources. METHODS: we conducted a nationally representative cross-sectional survey of 30,053 Japanese adults in February 2021. The survey asked about socioeconomic, health-related, and psychological characteristics, attitudes toward immunization, and the use of information sources regarding COVID-19. We have constructed multivariable logistic regression to estimate the factors associated with the adoption of three preventive measures: 3Cs avoidance, hand hygiene and respiratory hygiene. RESULTS: socioeconomic variables, psychological variables, and the use of information sources are significantly associated with the adoption of preventive measures. The more information sources one uses, the more likely one is to adopt preventive measures. Trust in healthcare professionals is positively associated with adopting preventive measures. On the other hand, negative correlations between trust in social media and preventive behaviors were observed. CONCLUSIONS: encouraging access to multiple information sources, utilizing communication channels, and modifying messaging according to target groups are essential to promote COVID-19 preventive measures.

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Estimated Global Proportions of Individuals With Persistent Fatigue, Cognitive, and Respiratory Symptom Clusters Following Symptomatic COVID-19 in 2020 and 2021

Sarah Wulf Hanson, Cristiana Abbafati, Joachim G. Aerts, Ziyad Al-Aly, Charlie Ashbaugh, Tala Ballouz, Oleg Blyuss, Polina Bobkova, Gouke Bonsel, Svetlana Borzakova, Danilo Buonsenso, Denis Butnaru, Austin Carter, Helen Chu, Cristina De Rose, Mohamed Mustafa Diab, Emil Ekbom, Maha El Tantawi, Victor Fomin, Robert Frithiof, Aysylu Gamirova, Petr V. Glybochko, Juanita A. Haagsma, Shaghayegh Haghjooy Javanmard, Erin B. Hamilton, Gabrielle Harris, Majanka H. Heijenbrok-Kal, Raimund Helbok, Merel E. Hellemons, David Hillus, Susanne M. Huijts, Michael Hultström, Waasila Jassat, Florian Kurth, Ing-Marie Larsson, Miklós Lipcsey, Chelsea Liu, Callan D. Loflin, Andrei Malinovschi, Wenhui Mao, Lyudmila Mazankova, Denise McCulloch, Dominik Menges, Noushin Mohammadifard, Daniel Munblit, Nikita A. Nekliudov, Osondu Ogbuoji, Ismail M. Osmanov, José L. Peñalvo, Maria Skaalum Petersen, Milo A. Puhan, Mujibur Rahman, Verena Rass, Nickolas Reinig, Gerard M. Ribbers, Antonia Ricchiuto, Sten Rubertsson, Elmira Samitova, Nizal Sarrafzadegan, Anastasia Shikhaleva, Kyle E. Simpson, Dario Sinatti, Joan B. Soriano, Ekaterina Spiridonova, Fridolin Steinbeis, Andrey A. Svistunov, Piero Valentini, Brittney J. van de Water, Rita van den Berg-Emons, Ewa Wallin, Martin Witzenrath, Yifan Wu, Hanzhang Xu, Thomas Zoller, Christopher Adolph, James Albright, Joanne O. Amlag, Aleksandr Y. Aravkin, Bree L. Bang-Jensen, Catherine Bisignano, Rachel Castellano, Emma Castro, Suman Chakrabarti, James K. Collins, Xiaochen Dai, Farah Daoud, Carolyn Dapper, Amanda Deen, Bruce B. Duncan, Megan Erickson, Samuel B. Ewald, Alize J. Ferrari, Abraham D. Flaxman, Nancy Fullman, Amiran Gamkrelidze, John R. Giles, Gaorui Guo, Simon I. Hay, Jiawei He, Monika Helak, Erin N. Hulland, Maia Kereselidze, Kris J. Krohn, Alice Lazzar-Atwood, Akiaja Lindstrom, Rafael Lozano, Deborah Carvalho Malta, Johan Månsson, Ana M. Mantilla Herrera, Ali H. Mokdad, Lorenzo Monasta, Shuhei Nomura, Maja Pasovic, David M. Pigott, Robert C. Reiner, Grace Reinke, Antonio Luiz P. Ribeiro, Damian Francesco Santomauro, Aleksei Sholokhov, Emma Elizabeth Spurlock, Rebecca Walcott, Ally Walker, Charles Shey Wiysonge, Peng Zheng, Janet Prvu Bettger, Christopher J. L. Murray, Theo Vos

JAMA (American Medical Association (AMA)) 328 ( 16 ) 1604 - 1615 2022.10

Accepted, ISSN 00987484

Importance

Some individuals experience persistent symptoms after initial symptomatic SARS-CoV-2 infection (often referred to as Long COVID).

Objective

To estimate the proportion of males and females with COVID-19, younger or older than 20 years of age, who had Long COVID symptoms in 2020 and 2021 and their Long COVID symptom duration.

Design, Setting, and Participants

Bayesian meta-regression and pooling of 54 studies and 2 medical record databases with data for 1.2 million individuals (from 22 countries) who had symptomatic SARS-CoV-2 infection. Of the 54 studies, 44 were published and 10 were collaborating cohorts (conducted in Austria, the Faroe Islands, Germany, Iran, Italy, the Netherlands, Russia, Sweden, Switzerland, and the US). The participant data were derived from the 44 published studies (10 501 hospitalized individuals and 42 891 nonhospitalized individuals), the 10 collaborating cohort studies (10 526 and 1906), and the 2 US electronic medical record databases (250 928 and 846 046). Data collection spanned March 2020 to January 2022.

Exposures

Symptomatic SARS-CoV-2 infection.

Main Outcomes and Measures

Proportion of individuals with at least 1 of the 3 self-reported Long COVID symptom clusters (persistent fatigue with bodily pain or mood swings; cognitive problems; or ongoing respiratory problems) 3 months after SARS-CoV-2 infection in 2020 and 2021, estimated separately for hospitalized and nonhospitalized individuals aged 20 years or older by sex and for both sexes of nonhospitalized individuals younger than 20 years of age.

Results

A total of 1.2 million individuals who had symptomatic SARS-CoV-2 infection were included (mean age, 4-66 years; males, 26%-88%). In the modeled estimates, 6.2% (95% uncertainty interval [UI], 2.4%-13.3%) of individuals who had symptomatic SARS-CoV-2 infection experienced at least 1 of the 3 Long COVID symptom clusters in 2020 and 2021, including 3.2% (95% UI, 0.6%-10.0%) for persistent fatigue with bodily pain or mood swings, 3.7% (95% UI, 0.9%-9.6%) for ongoing respiratory problems, and 2.2% (95% UI, 0.3%-7.6%) for cognitive problems after adjusting for health status before COVID-19, comprising an estimated 51.0% (95% UI, 16.9%-92.4%), 60.4% (95% UI, 18.9%-89.1%), and 35.4% (95% UI, 9.4%-75.1%), respectively, of Long COVID cases. The Long COVID symptom clusters were more common in women aged 20 years or older (10.6% [95% UI, 4.3%-22.2%]) 3 months after symptomatic SARS-CoV-2 infection than in men aged 20 years or older (5.4% [95% UI, 2.2%-11.7%]). Both sexes younger than 20 years of age were estimated to be affected in 2.8% (95% UI, 0.9%-7.0%) of symptomatic SARS-CoV-2 infections. The estimated mean Long COVID symptom cluster duration was 9.0 months (95% UI, 7.0-12.0 months) among hospitalized individuals and 4.0 months (95% UI, 3.6-4.6 months) among nonhospitalized individuals. Among individuals with Long COVID symptoms 3 months after symptomatic SARS-CoV-2 infection, an estimated 15.1% (95% UI, 10.3%-21.1%) continued to experience symptoms at 12 months.

Conclusions and Relevance

This study presents modeled estimates of the proportion of individuals with at least 1 of 3 self-reported Long COVID symptom clusters (persistent fatigue with bodily pain or mood swings; cognitive problems; or ongoing respiratory problems) 3 months after symptomatic SARS-CoV-2 infection.

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Characterising reasons for reversals of COVID-19 vaccination hesitancy among Japanese people: One-year follow-up survey

Shuhei Nomura, Akifumi Eguchi, Daisuke Yoneoka, Michio Murakami, Cyrus Ghaznavi, Stuart Gilmour, Satoshi Kaneko, Takayuki Kawashima, Hiroyuki Kunishima, Wataru Naito, Haruka Sakamoto, Keiko Maruyama-Sakurai, Arata Takahashi, Yoshihiro Takayama, Yuta Tanoue, Yoshiko Yamamoto, Tetsuo Yasutaka, Hiroaki Miyata

The Lancet Regional Health - Western Pacific (Elsevier BV) 27 100541 - 100541 2022.10

Accepted, ISSN 2666-6065

Background: Vaccine hesitancy is a global public health threat. We present unique data that characterises those who experienced reversals of COVID-19 vaccination hesitancy in Japan. Methods: We administered a questionnaire on vaccination intention among 30053 Japanese adults aged 20 years or older before the COVID-19 vaccination was available to the general population (first survey) and conducted a follow-up survey on vaccination status one year later in February 2022 (second survey). Those who responded in the first survey that they did not intend to be vaccinated or were unsure and then responded in the second survey that they were vaccinated or intend to be vaccinated were asked about the reasons for their change of heart. Based on previous literature and expert opinion, 31 reasons for changing vaccination intention were compiled and respondents were asked to choose which among them applied to themselves, with multiple responses possible. Based on the results of those responses, each individual was then clustered using the Uniform Manifold Approximation and Projection (UMAP) dimensionality reduction technique and Ordering Points To Identify the Clustering Structure (OPTICS) algorithm. We then identified unique characteristics among each of the sub-populations (clusters). Findings: In the second survey we received 19195 responses (response rate 63.9%), of which 8077 responded ‘no’ or ‘not sure’ in the first survey regarding their intention to be vaccinated. Of these, 5861 responded having received or intending to receive the vaccine (72.6%). We detected six and five sub-populations (clusters) among the ‘no’ group and ‘not sure’ group, respectively. The clusters were characterized by perceived benefits of vaccination, including the COVID-19 vaccine, awareness of the COVID-19 vaccination status of those close to them, recognition of the social significance of COVID-19 vaccination for the spread of infection, and dispelled concerns about short-term adverse reactions and the safety of the COVID-19 vaccine. Work and personal relationship reasons were also found to be a unique overarching reason for vaccination changes of heart only among those who did not intend to vaccinate. Interpretation: Those who changed their intention to accept COVID-19 vaccination as well as their unique characteristics as detailed in this study will be important entry points when discussing how to promote vaccination to those who are hesitant to vaccinate in the future. Funding: The present work was supported in part by a grant from the Kanagawa Prefectural Government of Japan and by AIST government subsidies.

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Factors associated with reversals of COVID-19 vaccination willingness: Results from two longitudinal, national surveys in Japan 2021-2022

Cyrus Ghaznavi, Daisuke Yoneoka, Takayuki Kawashima, Akifumi Eguchi, Michio Murakami, Stuart Gilmour, Satoshi Kaneko, Hiroyuki Kunishima, Wataru Naito, Haruka Sakamoto, Keiko Maruyama-Sakurai, Arata Takahashi, Yoshihiro Takayama, Yuta Tanoue, Yoshiko Yamamoto, Tetsuo Yasutaka, Hiroaki Miyata, Shuhei Nomura

The Lancet Regional Health - Western Pacific (Elsevier BV) 27 100540 - 100540 2022.10

Accepted, ISSN 2666-6065

Background: Research characterizing changes of heart with respect to vaccine intention is scarce, and very little research considers those who were initially vaccine willing but became hesitant. Here, we sought to assess the factors related to reversals of vaccine willingness. Methods: We conducted a longitudinal, national survey on vaccination intention among Japanese adults aged 20 years or older, with the first questionnaire performed in February-March 2021 (N = 30,053) and the follow-up in February 2022 (N = 19,195, response rate 63.9%). The study population comprised those who reported vaccine willingness in the first survey, with the outcome variable being development of vaccine hesitancy at follow-up. We performed a regression analysis of vaccination status using sociodemographic, health-related, psychologic/attitudinal, and information-related variables as predictors. We used the sparse group minimax concave penalty (MCP) to select the optimum group of covariates for the logistic regression. Findings: Of 11,118 (57.9%) respondents who previously expressed interest in vaccination, 10,684 (96.1%) and 434 (3.9%) were in the vaccine willing and hesitant groups, respectively. Several covariates were found to significantly predict vaccine hesitancy, including marital status, influenza vaccine history, COVID-19 infection/testing history, engagement in COVID-19 preventive measures, perceived risks/benefits of the COVID-19 vaccine, and attitudes regarding vaccination policies and norms. The use of certain information sources was also associated with vaccine hesitancy. Interpretation: Sociodemographic, health-related, psychologic/attitudinal, and information-related variables predicted the development of vaccine hesitancy among those with prior willingness. Most of these predictors were also associated with vaccination status. Funding: The present work was supported in part by a grant from the Kanagawa Prefectural Government of Japan and by AIST government subsidies.

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Effect of the Tokyo 2020 Summer Olympic Games on COVID-19 incidence in Japan: a synthetic control approach

Daisuke Yoneoka, Akifumi Eguchi, Kentato Fukumoto, Takayuki Kawashima, Yuta Tanoue, Takahiro Tabuchi, Hiroaki Miyata, Cyrus Ghaznavi, Kenji Shibuya, Shuhei Nomura

BMJ Open 12 ( 9 ) e061444 2022.09

Accepted, ISSN 2044-6055

BACKGROUND: The Tokyo 2020 Summer Olympic Games (23 July-8 August 2021) were held in the middle of Japan's fifth wave of COVID-19, when the number of cases was on the rise, and coincided with the fourth state of emergency implemented by the host city, Tokyo. AIM: This study aimed to assess whether the hosting of the Games was associated with a change in the number of COVID-19 cases in Japan using a synthetic control method. METHODS: A weighted average of control countries with a variety of predictors was used to estimate the counterfactual trajectory of daily COVID-19 cases per 1 000 000 population in the absence of the Games in Japan. Outcome and predictor data were extracted using official and open sources spanning several countries. The predictors comprise the most recent country-level annual or daily data accessible during the Games, including the stringency of the government's COVID-19 response, testing capacity and vaccination capacity; human mobility index; electoral democracy index and demographic, socioeconomic, health and weather information. After excluding countries with missing data, 42 countries were ultimately used as control countries. RESULTS: The number of observed cases per 1 000 000 population on the last day of the Games was 109.2 (7-day average), which was 115.7% higher than the counterfactual trajectory comprising 51.0 confirmed cases per 1 000 000 population. During the Olympic period (since 23 July), the observed cumulative number of cases was 61.0% higher than the counterfactual trajectory, comprising 143 072 and 89 210 confirmed cases (p=0.023), respectively. The counterfactual trajectory lagged 10 days behind the observed trends. CONCLUSIONS: Given the increasing likelihood that new emerging infectious diseases will be reported in the future, we believe that the results of this study should serve as a sentinel warning for upcoming mega-events during COVID-19 and future pandemics.

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Eliciting national and subnational sets of disability weights in mainland China: Findings from the Chinese disability weight measurement study

Xiaoxue Liu, Fang Wang, Chuanhua Yu, Maigeng Zhou, Yong Yu, Jinlei Qi, Peng Yin, Shicheng Yu, Yuchang Zhou, Lin Lin, Yunning Liu, Qiqi Wang, Wenling Zhong, Shaofen Huang, Yanxia Li, Li Liu, Yuan Liu, Fang Ma, Yine Zhang, Yuan Tian, Qiuli Yu, Jing Zeng, Jingju Pan, Mengge Zhou, Weiwei Kang, Jin-Yi Zhou, Hao Yu, Yuehua Liu, Shaofang Li, Huiting Yu, Chunfang Wang, Tian Xia, Jinen Xi, Xiaolan Ren, Xiuya Xing, Qianyao Cheng, Fangrong Fei, Dezheng Wang, Shuang Zhang, Yuling He, Haoyu Wen, Yan Liu, Fang Shi, Yafeng Wang, Panglin Sun, Jianjun Bai, Xuyan Wang, Hui Shen, Yudiyang Ma, Donghui Yang, Sumaira Mubarik, Jinhong Cao, Runtang Meng, Yunquan Zhang, Yan Guo, Yaqiong Yan, Wei Zhang, Sisi Ke, Runhua Zhang, Dingyi Wang, Tingting Zhang, Shuhei Nomura, Simon I. Hay, Joshua A. Salomon, Juanita A. Haagsma, Christopher J.L. Murray, Theo Vos

The Lancet Regional Health - Western Pacific (Elsevier {BV}) 26 100520 - 100520 2022.09

Accepted, ISSN 2666-6065

Background: The disability weight (DW) quantifies the severity of health states from disease sequela and is a pivotal parameter for disease burden calculation. We conducted a national and subnational DW measurement in China. Methods: In 2020–2021, we conducted a web-based survey to assess DWs for 206 health states in 31 Chinese provinces targeting health workers via professional networks. We fielded questions of paired comparison (PC) and population health equivalence (PHE). The PC data were analysed by probit regression analysis, and the regression results were anchored by results from the PHE responses on the DW scale between 0 (no loss of health) and 1 (health loss equivalent to death). Findings: We used PC responses from 468,541 respondents to estimate DWs of health states. Eight of 11 domains of health had significantly negative coefficients in the regression of the difference between Chinese and Global Burden of Disease (GBD) DWs, suggesting lower DW values for health states with mention of these domains in their lay description. We noted considerable heterogeneity within domains, however. After applying these Chinese DWs to the 2019 GBD estimates for China, total years lived with disability (YLDs) increased by 14·9% to 177 million despite lower estimates for musculoskeletal disorders, cardiovascular diseases, mental disorders, diabetes and chronic kidney disease. The lower estimates of YLDs for these conditions were more than offset by higher estimates of common, low-severity conditions. Interpretation: The differences between the GBD and Chinese DWs suggest that there might be some contextual factors influencing the valuation of health states. While the reduced estimates for mental disorders, alcohol use disorder, and dementia could hint at a culturally different valuation of these conditions in China, the much greater shifts in YLDs from low-severity conditions more likely reflects methodological difficulty to distinguish between health states that vary a little in absolute DW value but a lot in relative terms. Funding: This work was supported by the National Natural Science Foundation of China [grant number 82173626], the National Key Research and Development Program of China [grant numbers 2018YFC1315302], Wuhan Medical Research Program of Joint Fund of Hubei Health Committee [grant number WJ2019H304], and Ningxia Natural Science Foundation Project [grant number 2020AAC03436].

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Excess deaths from non-COVID-19-related causes in Japan and 47 prefectures from January 2020 through May 2021 by place of death

Shuhei Nomura, Akifumi Eguchi, Cyrus Ghaznavi, Yuta Tanoue, Takayuki Kawashima, Daisuke Yoneoka, Lisa Yamasaki, Motoi Suzuki, Masahiro Hashizume

SSM - Population Health (Elsevier BV) 19 101196 - 101196 2022.09

ISSN 2352-8273

Excess deaths, including all-causes mortality, were confirmed for the first time in Japan in April 2021. However, little is known about the indirect effects of COVID-19 on the number of non-COVID-19-related deaths. We then estimated the excess deaths from non-COVID-19-related causes in Japan and its 47 prefectures from January 2020 through May 2021 by place of death. Vital statistical data on deaths were obtained from the Ministry of Health, Labour and Welfare. Using quasi-Poisson regression models, we estimated the expected weekly number of deaths due to all-causes excluding COVID-19 (non-COVID-19) and due to respiratory disease, circulatory disease, malignant neoplasms, and senility. Estimates were made separately for deaths in all locations, as well as for deaths in hospitals and clinics, in nursing homes and elderly care facilities, and at home. We defined a week with excess deaths as one in which the observed number of deaths exceeded the upper bound of the two-sided 95% prediction interval. Excess death was expressed as a range of differences between the observed and expected number of deaths and the 95% upper bound of the two-sided predictive interval. The excess percentage was calculated as the number of excess deaths divided by the expected number of deaths. At the national level, excess deaths from non-COVID-19-related all-causes were observed during April 19 to May 16, 2021. The largest excess percentage was 2.73-8.58% (excess deaths 689-2161) in the week of May 3-9. Similar trends were observed for all four cause categories. The cause-of-death categories which contributed to the excesses showed heterogeneity among prefectures. When stratified by place of death, excess mortality tended to be observed in nursing homes and elderly care facilities for all categories, in hospitals and clinics for circulatory disease, and at home for respiratory disease, malignant neoplasms, and senility. A caution is necessary that for the lastest three months (March-May 2021), adjusted data were used to account for possible reporting delays.

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Decreased incidence followed by comeback of pediatric infections during the COVID-19 pandemic in Japan.

Cyrus Ghaznavi, Haruka Sakamoto, Takayuki Kawashima, Sayaka Horiuchi, Masahiro Ishikane, Sarah Krull Abe, Daisuke Yoneoka, Akifumi Eguchi, Yuta Tanoue, Masahiro Hashizume, Shuhei Nomura

World journal of pediatrics : WJP (Springer Science and Business Media {LLC}) 18 ( 8 ) 564 - 567 2022.08

Accepted, ISSN 17088569

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Changes in Health Care Access during the COVID-19 Pandemic: Estimates of National Japanese Data, June 2020–October 2021

Yuta Tanoue, Cyrus Ghaznavi, Takayuki Kawashima, Akifumi Eguchi, Daisuke Yoneoka, Shuhei Nomura

International Journal of Environmental Research and Public Health (MDPI AG) 19 ( 14 ) 8810 - 8810 2022.07

ISSN 16617827

The COVID-19 pandemic has disrupted health care access around the world, both for inpatients and outpatients. We applied a quasi-Poisson regression to national, monthly data on the number of outpatients, number of inpatients, length of average hospital stay, and the number of new hospitalizations from March 2015 to October 2021 to assess how these outcomes changed between June 2020 to October 2021. The number of outpatient visits were lower-than-predicted during the early phases of the pandemic but normalized by the fall of 2021. The number of inpatients and new hospitalizations were lower-than-predicted throughout the pandemic, and deficits in reporting continued to be observed in late 2021. The length of hospital stays was within the predicted range for all beds, but when stratified by bed type, was higher than predicted for psychiatric beds, lower-than-predicted for tuberculosis beds, and showed variable changes in long-term care insurance beds. Health care access in Japan was impacted by the COVID-19 pandemic.

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Attributable risk of household solid fuel use and second-hand smoke associated with under-5 mortality in 46 low- and lower-middle-income countries, 2010–2020

Kaung Suu Lwin, Shuhei Nomura, Khin Thet Swe, Stuart Gilmour, Md Ashraful Alam, Masahiro Hashizume

International Journal of Hygiene and Environmental Health (Elsevier BV) 243 113986 - 113986 2022.06

Accepted, ISSN 14384639

BACKGROUND: Household solid fuel use (including indoor and outdoor) and second-hand smoke (SHS) are considered to be major contributors of under-5 mortality (U5M) in low- and lower-middle-income countries (LMICs). This study provides a comprehensive assessment of their odds ratios and attributable mortality in LMICs. METHODS: We used the Demographic Health Surveys data for under-5 children in 46 LMICs (n = 778,532) from 2010 to 2020. Mixed effect multilevel logistic regressions were conducted to estimate the pooled adjusted odds ratio (aOR) for U5M due to solid fuel use, SHS and their combination compared to no exposure to them in 46 LMICs. The attributable mortality of solid fuel use, SHS, and their combination were assessed for each LMIC. FINDINGS: The pooled aOR of solid fuel use and SHS for U5M was estimated to be 1.27 (95% Confidence Interval (CI): 1.19-1.36) and 1.13 (95%CI: 1.06-1.25), respectively, whereas those of their combination was 1.40 (95%CI: 1.31-1.50). U5M attributable to indoor and outdoor solid fuel use was the highest in Myanmar (18.0%) and the Gambia (16.5%), respectively, while those attributable to SHS was the highest in Indonesia (9.8%). U5M attributable to the combination of solid fuel use and SHS was the highest in Timor-Leste (22.7%). INTERPRETATION: The combined effect of exposure to solid fuel and SHS had a higher risk of U5M than the individual risk. The use of clean fuel and tobacco control measures should be integrated with other child health promotion policies. FUNDING: This research was partially supported by a research grant from the Ministry of Education, Culture, Sports, Science and Technology of Japan (21H03203).

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Pre- and post-COVID-19 all-cause mortality of Japanese citizens versus foreign residents living in Japan, 2015–2021

Cyrus Ghaznavi, Akifumi Eguchi, Yuta Tanoue, Daisuke Yoneoka, Takayuki Kawashima, Motoi Suzuki, Masahiro Hashizume, Shuhei Nomura

SSM - Population Health (Elsevier BV) 18 101114 - 101114 2022.06

Accepted, ISSN 2352-8273

Immigrants in Japan face multiple health care challenges. There is limited research addressing how all-cause mortality differs between foreign residents and Japanese citizens, including the impact of the COVID-19 pandemic. We assessed whether all-cause mortality rates between Japanese citizens and foreign residents living in Japan differ, and whether these differentials changed after the start of the COVID-19 pandemic. We conducted a cross-sectional analysis using vital statistical data of all deaths among citizens and foreign residents that occurred within Japanese borders aggregated every 6 months between January 1, 2015 and June 30, 2021. Data were used to calculate sex-, region-, and 20-year age group-specific standardized mortality rates using the direct method based on the population distribution of Japanese citizens in 2021 by sex, region, and 20-year age groups. Chi-squared tests and linear regression were used to assess whether the pandemic was associated with changes in mortality rates among groups and changes in the mortality differentials between citizens and non-citizens, respectively. All-cause mortality increased monotonically with age for men and women. Men had higher mortality than women, regardless of age or nationality. All-cause mortality is lower among immigrants than Japanese citizens between the ages of 20-59, but higher under the age of 20 and over the age of 59. The pandemic was associated with significant changes in mortality in most groups, but no statistically significant changes in the mortality differentials between immigrants and Japanese citizens were detected. Young immigrants are generally healthier than their Japanese counterparts, in line with the healthy migrant hypothesis. Younger migrants are at higher risk of mortality, possibly due to increased vulnerability to psychologic stress. Older migrant mortality converged with citizen mortality, consistent with acculturation that occurs with longer duration of residence. The pandemic did not exacerbate health inequities for foreign residents with respect to mortality.

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Factors associated with the risk perception of COVID-19 infection and severe illness: A cross-sectional study in Japan

Megumi Adachi, Michio Murakami, Daisuke Yoneoka, Takayuki Kawashima, Masahiro Hashizume, Haruka Sakamoto, Akifumi Eguchi, Cyrus Ghaznavi, Stuart Gilmour, Satoshi Kaneko, Hiroyuki Kunishima, Keiko Maruyama-Sakurai, Yuta Tanoue, Yoshiko Yamamoto, Hiroaki Miyata, Shuhei Nomura

SSM - Population Health (Elsevier BV) 18 101105 - 101105 2022.06

Accepted, ISSN 2352-8273

Understanding COVID-19 risk perception may help inform public health messaging aimed at encouraging preventive measures and improving countermeasures against the pandemic. We conducted an online survey of 29,708 Japanese adults in February 2021 and estimated the associations between COVID-19 risk perception and a broad array of individual factors. Two logistic regressions were constructed to estimate factors associated with the risk perception of COVID-19 (defined as responding that one might become infected within the next 6 months), and of severe illness among those who responded that they might become infected (defined as responding that one would become severely ill). After adjusting for covariates, those with a higher perceived risk of the COVID-19 vaccine had higher odds of risk perception for both infection and severe illness. Interestingly, those with higher odds of risk perception of being infected were more likely to report obtaining their information from healthcare workers whereas those with lower odds were more likely to report obtaining their information from the Internet or the government; those with lower odds of risk perception of being severely ill were more likely to report obtaining their information from the Internet. The higher the trust level in the government as a COVID-19 information source, the lower the odds of both risk perception of being infected and becoming severely ill. The higher the trust levels in social networking services as a COVID-19 information source, the higher the odds of risk perception of becoming severely ill. Public health messaging should address the factors identified in our study.

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Changes in marriage, divorce and births during the COVID-19 pandemic in Japan

Cyrus Ghaznavi, Takayuki Kawashima, Yuta Tanoue, Daisuke Yoneoka, Koji Makiyama, Haruka Sakamoto, Peter Ueda, Akifumi Eguchi, Shuhei Nomura

BMJ Global Health 7 ( 5 ) e007866 2022.05

Accepted, ISSN 2059-7908

INTRODUCTION: Marriage, divorce and fertility are declining in Japan. There is concern that the COVID-19 pandemic may have accelerated the decrease in marriages and births while increasing the number of divorces. Changes in partnership behaviours and fertility have significant implications for mental health, well-being and population demographics. METHODS: Japanese vital statistical data were collected for December 2011-May 2021. We used the Farrington algorithm on the daily numbers of marriages, divorces and births (per month) in order to determine whether any given month between January 2017 and May 2021 had a significant excess or deficit. Analyses were conducted at the national and regional levels. RESULTS: During the pandemic, significant deficits in the national number of marriages were noted in January 2020, April 2020, May 2020, July 2020, September 2020 and April 2021. Regional marriage patterns reflected national trends. Divorces were noted to be in deficit during April 2020, May 2020 and May 2021 at the country level. Regional analyses mirrored national divorce trends with the exception of Shikoku, which showed no deficits during the pandemic. Significant deficits in the number of total births were noted in December 2020, January 2021 and February 2021. Regionally, birth deficits were concentrated in Chubu, Kansai and Kanto. After the start of the pandemic, no significant excesses in marriages, divorces or births were noted at the national or regional level. CONCLUSIONS: Marriages and divorces declined during the pandemic in Japan, especially during state of emergency declarations. There were decreased births between December 2020 and February 2021, approximately 8-10 months after the first state of emergency, suggesting that couples altered their pregnancy intention in response to the pandemic. Metropolitan regions were more affected by the pandemic than their less metropolitan counterparts.

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Japan's development assistance for health: Historical trends and prospects for a new era

Shuhei Nomura, Lisa Yamasaki, Kazuki Shimizu, Cyrus Ghaznavi, Haruka Sakamoto

The Lancet Regional Health - Western Pacific (Elsevier BV) 22 100403 - 100403 2022.05

ISSN 2666-6065

The year 2020 marked an important turning point in Japan's global health policy. While the global health community has been suffering serious damage to sustainable health financing due to the COVID-19 pandemic, an independent commission on Japan's Strategy on Development Assistance for Health (DAH) launched an ambitious policy recommendation to double the amount of Japan's DAH during the post-COVID-19 era. This paper examines historical trends in DAH in Japan over the past 30 years based on published literature and comprehensive DAH tracking data and highlights priority areas for discussion on how DAH can be advanced to ensure equitable and efficient use of limited resources to support the achievement of the Sustainable Development Goals, including universal health coverage and pandemic preparedness, in low- and middle-income countries. Priority areas for discussion include: how and where to focus DAH for equitable health gains; how to provide DAH to support health system strengthening, including pandemic preparedness; and clarifying the role of DAH in global health functions.

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Assessment of Traffic Accidents in Japan during the COVID-19 Pandemic vs. Previous Years: A Preliminary Report

Kazuki Shimizu, Peter Ueda, Cyrus Ghaznavi, Haruka Sakamoto, Shuhei Nomura

Healthcare ({MDPI} {AG}) 10 ( 5 ) 860 - 860 2022.05

Accepted, ISSN 2227-9032

Beginning in April 2020, social distancing measures were implemented to mitigate the COVID-19 pandemic in Japan. We assessed whether traffic accident rates had decreased from April 2020 to December 2021 as compared with previous years. The analysis included 2,934,477 traffic accidents, and the trend of decreasing rates of traffic accidents in recent years and seasonal fluctuations in traffic accidents were considered. The yearly change in the traffic accident rate between 2015 and 2019 was estimated, and the traffic accident rate in 2020 and 2021 was predicted. This was followed by the comparison of observed vs. predicted traffic accident rate. In 2020, the observed vs. expected rates of traffic accidents were lower in April to December 2020, and the rate of traffic accidents in Japan was 30–40% lower in April–May 2020 than would be expected based on trends from previous years. In 2021, rates of traffic accidents remained lower than expected between January and November, but the magnitude of decrease was not as pronounced. These findings could be explained by social distancing policies, including the declaration of the state of emergency, and the relaxation of public health and social measures over time.

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Estimating excess mortality due to the COVID-19 pandemic: a systematic analysis of COVID-19-related mortality, 2020–21

Haidong Wang, Katherine R Paulson, Spencer A Pease, Stefanie Watson, Haley Comfort, Peng Zheng, Aleks, r Y Aravkin, Catherine Bisignano, Ryan M Barber, Tahiya Alam, John E Fuller, Erin A May, Darwin Phan Jones, Meghan E Frisch, Cristiana Abbafati, Christopher Adolph, Adrien Allorant, Joanne O Amlag, Bree Bang-Jensen, Gregory J Bertolacci, Sabina S Bloom, Austin Carter, Emma Castro, Suman Chakrabarti, Jhilik Chattopadhyay, Rebecca M Cogen, James K Collins, Kimberly Cooperrider, Xiaochen Dai, William James Dangel, Farah Daoud, Carolyn Dapper, Am, a Deen, Bruce B Duncan, Megan Erickson, Samuel B Ewald, Tatiana Fedosseeva, Alize J Ferrari, Joseph Jon Frostad, Nancy Fullman, John Gallagher, Amiran Gamkrelidze, Gaorui Guo, Jiawei He, Monika Helak, Nathaniel J Henry, Erin N Hull, Bethany M Huntley, Maia Kereselidze, Alice Lazzar-Atwood, Kate E LeGr, Akiaja Lindstrom, Emily Linebarger, Paulo A Lotufo, Rafael Lozano, Beatrice Magistro, Deborah Carvalho Malta, Johan M{\aa}nsson, Ana M Mantilla Herrera, Fatima Marinho, Alemnesh H Mirkuzie, Awoke Temesgen Misganaw, Lorenzo Monasta, Paulami Naik, Shuhei Nomura, Edward G O{\textquotesingle}Brien, James Kevin O{\textquotesingle}Halloran, Latera Tesfaye Olana, Samuel M Ostroff, Louise Penberthy, Robert C Reiner Jr, Grace Reinke, Antonio Luiz P Ribeiro, Damian Francesco Santomauro, Maria In{\^{e } }s Schmidt, David H Shaw, Brittney S Sheena, Aleksei Sholokhov, Natia Skhvitaridze, Reed J D Sorensen, Emma Elizabeth Spurlock, Ruri Syailendrawati, Roman Topor-Madry, Christopher E Troeger, Rebecca Walcott, Ally Walker, Charles Shey Wiysonge, Nahom Alemseged Worku, Bethany Zigler, David M Pigott, Mohsen Naghavi, Ali H Mokdad, Stephen S Lim, Simon I Hay, Emmanuela Gakidou, Christopher J L Murray

The Lancet (Elsevier {BV}) 399 ( 10334 ) 1513 - 1536 2022.04

Accepted, ISSN 01406736

Background: Mortality statistics are fundamental to public health decision making. Mortality varies by time and location, and its measurement is affected by well known biases that have been exacerbated during the COVID-19 pandemic. This paper aims to estimate excess mortality from the COVID-19 pandemic in 191 countries and territories, and 252 subnational units for selected countries, from Jan 1, 2020, to Dec 31, 2021. Methods: All-cause mortality reports were collected for 74 countries and territories and 266 subnational locations (including 31 locations in low-income and middle-income countries) that had reported either weekly or monthly deaths from all causes during the pandemic in 2020 and 2021, and for up to 11 year previously. In addition, we obtained excess mortality data for 12 states in India. Excess mortality over time was calculated as observed mortality, after excluding data from periods affected by late registration and anomalies such as heat waves, minus expected mortality. Six models were used to estimate expected mortality; final estimates of expected mortality were based on an ensemble of these models. Ensemble weights were based on root mean squared errors derived from an out-of-sample predictive validity test. As mortality records are incomplete worldwide, we built a statistical model that predicted the excess mortality rate for locations and periods where all-cause mortality data were not available. We used least absolute shrinkage and selection operator (LASSO) regression as a variable selection mechanism and selected 15 covariates, including both covariates pertaining to the COVID-19 pandemic, such as seroprevalence, and to background population health metrics, such as the Healthcare Access and Quality Index, with direction of effects on excess mortality concordant with a meta-analysis by the US Centers for Disease Control and Prevention. With the selected best model, we ran a prediction process using 100 draws for each covariate and 100 draws of estimated coefficients and residuals, estimated from the regressions run at the draw level using draw-level input data on both excess mortality and covariates. Mean values and 95% uncertainty intervals were then generated at national, regional, and global levels. Out-of-sample predictive validity testing was done on the basis of our final model specification. Findings: Although reported COVID-19 deaths between Jan 1, 2020, and Dec 31, 2021, totalled 5·94 million worldwide, we estimate that 18·2 million (95% uncertainty interval 17·1–19·6) people died worldwide because of the COVID-19 pandemic (as measured by excess mortality) over that period. The global all-age rate of excess mortality due to the COVID-19 pandemic was 120·3 deaths (113·1–129·3) per 100 000 of the population, and excess mortality rate exceeded 300 deaths per 100 000 of the population in 21 countries. The number of excess deaths due to COVID-19 was largest in the regions of south Asia, north Africa and the Middle East, and eastern Europe. At the country level, the highest numbers of cumulative excess deaths due to COVID-19 were estimated in India (4·07 million [3·71–4·36]), the USA (1·13 million [1·08–1·18]), Russia (1·07 million [1·06–1·08]), Mexico (798 000 [741 000–867 000]), Brazil (792 000 [730 000–847 000]), Indonesia (736 000 [594 000–955 000]), and Pakistan (664 000 [498 000–847 000]). Among these countries, the excess mortality rate was highest in Russia (374·6 deaths [369·7–378·4] per 100 000) and Mexico (325·1 [301·6–353·3] per 100 000), and was similar in Brazil (186·9 [172·2–199·8] per 100 000) and the USA (179·3 [170·7–187·5] per 100 000). Interpretation: The full impact of the pandemic has been much greater than what is indicated by reported deaths due to COVID-19 alone. Strengthening death registration systems around the world, long understood to be crucial to global public health strategy, is necessary for improved monitoring of this pandemic and future pandemics. In addition, further research is warranted to help distinguish the proportion of excess mortality that was directly caused by SARS-CoV-2 infection and the changes in causes of death as an indirect consequence of the pandemic. Funding: Bill & Melinda Gates Foundation, J Stanton, T Gillespie, and J and E Nordstrom

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Salaries, degrees, and babies: Trends in fertility by income and education among Japanese men and women born 1943-1975-Analysis of national surveys.

Cyrus Ghaznavi, Haruka Sakamoto, Lisa Yamasaki, Shuhei Nomura, Daisuke Yoneoka, Kenji Shibuya, Peter Ueda

PloS one (Public Library of Science ({PLoS})) 17 ( 4 April ) e0266835 2022.04

Accepted, ISSN 1932-6203

BACKGROUND: While fertility rates have decreased during the second half of the 20th century in Japan, little is known regarding trends in the number of children that men and women have across birth cohorts and whether these differ by education and income. METHODS: We used data from four rounds of the National Fertility Survey (1992, 2005, 2010 and 2015) and included men and women aged 40-49 years (16728 men and 17628 women). By 5-year birth cohorts, we assessed the distribution of number of children (0, 1, 2 and 3 or more) and total fertility (the mean number of children) at completed fertility (age 45-49 or 40-44 years depending on birth cohort). We assessed trends in these fertility outcomes in men and women separately, and by education (no university education; university education) for men and women and by reported annual income (0 to <3 000 000 JPY; 3 000 000 to <6 000 000 JPY; ≥6 000 000 JPY) for men. RESULTS: When comparing those born in 1943-1948 with those born in 1971-1975, the proportion with no children had increased from 14.3 to 39.9% for men and from 11.6 to 27.6% for women. This increase coincided with a decrease in the proportions of individuals with 2 or more children. Total fertility had decreased from 1.92 to 1.17 among men and from 1.96 to 1.42 among women. For men, those with a university degree were more likely to have children than those without a university degree in all birth cohorts except 1943-1947. Men with higher income were more likely to have children across birth cohorts. While the proportion who had children had decreased in all income groups, the decrease was steeper among those in the lowest income group. Among women born 1956-1970, those with a university degree were less likely to have children than those without a university degree; this difference was no longer seen among those born 1971-1975. For both men and women, trends in having children and total fertility across birth cohorts did not differ by educational status. CONCLUSIONS: The decline in the total fertility rate in Japan can be attributed to both an increasing proportion of the population who have no children and a lower number of children among those who have children. Men with lower education and income were less likely to have children and the disparity in the number of children that men have by income had increased in more recent birth cohorts. Among women, higher education was associated with lower fertility, although this pattern was no longer observed among those born in 1971-1975.

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Toward a third term of Health Japan 21 – implications from the rise in non-communicable disease burden and highly preventable risk factors

Shuhei Nomura, Haruka Sakamoto, Cyrus Ghaznavi, Manami Inoue

The Lancet Regional Health - Western Pacific (Elsevier BV) 21 100377 - 100377 2022.04

Accepted, ISSN 2666-6065

In 2000, the Japanese government launched the National Health Promotion Movement known as Health Japan 21 (HJ21), a 13-year national health promotion policy (2000–2012) aimed at preventing and controlling non-communicable diseases (NCDs) and their underlying risk factors. After the revision in 2013 (2013–2023), the target NCDs and risk factors are being reviewed and a new strategy for the third term of HJ21 is going to be discussed. Using the latest findings from the Global Burden of Disease Study 2019, this paper highlights NCDs that continue to increase health losses and preventable metabolic and behavioural risk factors. These NCDs and risk factors are associated with an increased risk of serious illness and death from the novel coronavirus disease (COVID-19). The third term of HJ21 will be formulated during the continuing threat of acute health crises like the current COVID-19 pandemic and thus offers an important opportunity to renew public health efforts to halt the growing burden of NCDs in Japan. This article may serve as one of the roadmaps for the formulation of the third term of HJ21.

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Long-Term Mental Health Support after Natural Hazard Events: A Report from an Online Survey among Experts in Japan

Ryoma Kayano, Mingming Lin, Yasuko Shinozaki, Shuhei Nomura, Yoshiharu Kim

International Journal of Environmental Research and Public Health ({MDPI} {AG}) 19 ( 5 ) 3022 - 3022 2022.03

Accepted, ISSN 16617827

This paper aims to provide preliminary evidence on the degree of consensus on the approach to long-term mental health and psychosocial support after a natural hazard event. We conducted an online survey among mental health experts in Japan. The questionnaire was divided into five categories: (A) terminology setting definition of “long-term”, (B) priority in activity for long-term mental health support, (C) system and preparedness for better support, (D) transition from acute support to long-term support, and (E) actions to improve preparedness for future disasters. Invitations to participate in the survey were sent by e-mail in November 2017 to mental health experts in Japan, who had participated in workshops related to disaster mental health or trauma care organized by the National Institute of Mental Health over the last 15 years. Out of 1385 experts who received the invitation, a total of 305 participants responded to the survey. Participants were for the most part in agreement regarding focuses and required preparedness and actions for long-term support. There was still low consensus especially on defining the timeframe “long-term”. The acute phase and long-term phase were identified as being different in dimension rather than category. Although caution is necessary around the representativeness of these findings, they will provide important scientific evidence for the development of future plans for a qualitative improvement in long-term mental health support.

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Global, regional, and national burden of diseases and injuries for adults 70 years and older: systematic analysis for the Global Burden of Disease 2019 Study

GBD 2019 Ageing Collaborators

BMJ 2022.03

Accepted, ISSN 1756-1833

<jats:title>Abstract</jats:title><jats:sec><jats:title>Objectives</jats:title><jats:p>To use data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 (GBD 2019) to estimate mortality and disability trends for the population aged ≥70 and evaluate patterns in causes of death, disability, and risk factors.</jats:p></jats:sec><jats:sec><jats:title>Design</jats:title><jats:p>Systematic analysis.</jats:p></jats:sec><jats:sec><jats:title>Setting</jats:title><jats:p>Participants were aged ≥70 from 204 countries and territories, 1990-2019.</jats:p></jats:sec><jats:sec><jats:title>Main outcomes measures</jats:title><jats:p>Years of life lost, years lived with disability, disability adjusted life years, life expectancy at age 70 (LE-70), healthy life expectancy at age 70 (HALE-70), proportion of years in ill health at age 70 (PYIH-70), risk factors, and data coverage index were estimated based on standardised GBD methods.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>Globally the population of older adults has increased since 1990 and all cause death rates have decreased for men and women. However, mortality rates due to falls increased between 1990 and 2019. The probability of death among people aged 70-90 decreased, mainly because of reductions in non-communicable diseases. Globally disability burden was largely driven by functional decline, vision and hearing loss, and symptoms of pain. LE-70 and HALE-70 showed continuous increases since 1990 globally, with certain regional disparities. Globally higher LE-70 resulted in higher HALE-70 and slightly increased PYIH-70. Sociodemographic and healthcare access and quality indices were positively correlated with HALE-70 and LE-70. For high exposure risk factors, data coverage was moderate, while limited data were available for various dietary, environmental or occupational, and metabolic risks.</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>Life expectancy at age 70 has continued to rise globally, mostly because of decreases in chronic diseases. Adults aged ≥70 living in high income countries and regions with better healthcare access and quality were found to experience the highest life expectancy and healthy life expectancy. Disability burden, however, remained constant, suggesting the need to enhance public health and intervention programmes to improve wellbeing among older adults.</jats:p></jats:sec>

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Reduced mortality during the COVID-19 outbreak in Japan, 2020: a two-stage interrupted time-series design

Daisuke Onozuka, Yuta Tanoue, Shuhei Nomura, Takayuki Kawashima, Daisuke Yoneoka, Akifumi Eguchi, Chris Fook Sheng Ng, Kentaro Matsuura, Shoi Shi, Koji Makiyama, Shinya Uryu, Yumi Kawamura, Shinichi Takayanagi, Stuart Gilmour, Takehiko I Hayashi, Hiroaki Miyata, Francesco Sera, Tomimasa Sunagawa, Takuri Takahashi, Yuuki Tsuchihashi, Yusuke Kobayashi, Yuzo Arima, Kazuhiko Kanou, Motoi Suzuki, Masahiro Hashizume

International Journal of Epidemiology (Oxford University Press (OUP)) 51 ( 1 ) 75 - 84 2022.02

ISSN 03005771

<title>Abstract</title>
<sec>
<title>Background</title>
Coronavirus disease 2019 (COVID-19) continues to be a major global health burden. This study aims to estimate the all-cause excess mortality occurring in the COVID-19 outbreak in Japan, 2020, by sex and age group.

</sec>
<sec>
<title>Methods</title>
Daily time series of mortality for the period January 2015–December 2020 in all 47 prefectures of Japan were obtained from the Ministry of Health, Labour and Welfare, Japan. A two-stage interrupted time-series design was used to calculate excess mortality. In the first stage, we estimated excess mortality by prefecture using quasi-Poisson regression models in combination with distributed lag non-linear models, adjusting for seasonal and long-term variations, weather conditions and influenza activity. In the second stage, we used a random-effects multivariate meta-analysis to synthesize prefecture-specific estimates at the nationwide level.

</sec>
<sec>
<title>Results</title>
In 2020, we estimated an all-cause excess mortality of −20 982 deaths [95% empirical confidence intervals (eCI): −38 367 to −5472] in Japan, which corresponded to a percentage excess of −1.7% (95% eCI: −3.1 to −0.5) relative to the expected value. Reduced deaths were observed for both sexes and in all age groups except those aged &lt;60 and 70–79 years.

</sec>
<sec>
<title>Conclusions</title>
All-cause mortality during the COVID-19 outbreak in Japan in 2020 was decreased compared with a historical baseline. Further evaluation of cause-specific excess mortality is warranted.

</sec>

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Excess deaths from COVID-19 in Japan and 47 prefectures from January through June 2021

S. Nomura, A. Eguchi, Y. Tanoue, D. Yoneoka, T. Kawashima, M. Suzuki, M. Hashizume

Public Health (Elsevier BV) 203 15 - 18 2022.02

ISSN 00333506

Objectives: In Japan, several studies have reported no excess all-cause deaths (the difference between the observed and expected number of deaths) during the coronavirus disease 2019 (COVID-19) pandemic in 2020. This study aimed to estimate the weekly excess deaths in Japan's 47 prefectures for 2021 until June 27. Study design: Vital statistical data on deaths were obtained from the Ministry of Health, Labour and Welfare of Japan. For this analysis, we used data from January 2012 to June 2021. Methods: A quasi-Poisson regression was used to estimate the expected weekly number of deaths. Excess deaths were expressed as the range of differences between the observed and expected number of all-cause deaths and the 95% upper bound of the one-sided prediction interval. Results: Since January 2021, excess deaths were observed for the first time in the week corresponding to April 12–18 and have continued through mid-June, with the highest excess percentage occurring in the week corresponding to May 31–June 6 (excess deaths: 1431–2587; excess percentage: 5.95–10.77%). Similarly, excess deaths were observed in consecutive weeks from April to June 2021 in 18 of 47 prefectures. Conclusions: For the first time since February 2020, when the first COVID-19 death was reported in Japan, excess deaths possibly related to COVID-19 were observed in April 2021 in Japan, during the fourth wave. This may reflect the deaths of non-infected people owing to the disruption that the pandemic has caused.

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Fish in the sea: Number, characteristics, and partner preferences of unmarried Japanese adults - analysis of a national survey

Cyrus Ghaznavi, Haruka Sakamoto, Shuhei Nomura, Anna Kubota, Daisuke Yoneoka, Kenji Shibuya, Peter Ueda

Plos One (Public Library of Science ({PLoS})) 17 ( 2 February ) e0262528 2022.02

Accepted, ISSN 1932-6203

BACKGROUND: A large proportion of adults in Japan remain unmarried even though they intend to marry during their lifetime. To provide data for policy makers and those searching for partners in the Japanese marriage market, we estimated the number and characteristics of unmarried women and men with marriage intention and assessed their partner preferences. Based on the findings, we hypothesized regarding potential mismatches between the individuals available in the marriage market and the type of partners they are looking for. METHODS: We used data from the National Fertility Survey (2015), a nationally representative survey in Japan, and included 20,344 participants aged 18-49 years, of which 6,568 were unmarried with marriage intention. We estimated the total number of unmarried women and men who intend to marry, extrapolated their characteristics to the Japanese population, and assessed their partner preferences, as well as their ideal age of marriage and the ideal age of their partner. RESULTS: In 2015, there were 8.48 million unmarried women and 9.83 million unmarried men aged 18-49 years with marriage intention in Japan. Surpluses of around 600,000 men were observed in non-densely inhabited areas (men-to-women ratio: 1.31) and in the Kanto region (1.23). Most of the women and men in the marriage market had annual incomes lower than 3,000,000 JPY (28,000 USD) and only 263,000 women (3%) and 883,000 men (9%) had an income of 5,000,000 JPY (47,000 USD) or more; 167,000 men (2%) had an income of 7,000,000 JPY (66,000 USD) or more, with roughly three-quarters of them having a university degree. When asked about eight items that one may consider in a potential partner, the proportion of women listing an item as "important" tended to be larger than those of men across all items (education, occupation, finances, personality, mutual hobbies, cooperation/understanding regarding one's work, and attitude towards/skills in housework and childrearing) except appearance. The largest differences were observed for finances (proportion of women vs. men listing the item as "important" or "would consider:" 94.0% vs. 40.5%, p<0.001), occupation (84.9% vs. 43.9%, p<0.001), and education (53.9% vs. 28.7%, p<0.001). While women, on average, preferred men who were around 1-3 years older than themselves, men preferred women around their own age until the age of 26 years, at which point men preferred women who were younger than themselves, with the preferred age difference increasing substantially with age. As such, the number of men preferring a younger partner was larger than the number of women who preferred an older partner. CONCLUSIONS: By providing data on the number, characteristics and partner preferences of individuals in the marriage market, our study could inform decisions for those searching for marriage partners in Japan. Moreover, we hypothesize that mismatches in geographical location, the supply-demand disparity for partners with higher income, and age preferences could partly explain the large number of Japanese women and men who remain unmarried despite intending to get married. Further studies are needed to assess if, and to what extent, the identified mismatches may affect marriage rates.

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Variation in the COVID-19 infection–fatality ratio by age, time, and geography during the pre-vaccine era: a systematic analysis

Reed J D Sorensen, Ryan M Barber, David M Pigott, Austin Carter, Cory N Spencer, Samuel M Ostroff, Robert C Reiner Jr, Cristiana Abbafati, Christopher Adolph, Adrien Allorant, Joanne O Amlag, Aleksandr Y Aravkin, Steven D Bachmeier, Bree L Bang-Jensen, Catherine Bisignano, Sabina S Bloom, Rachel Castellano, Emma Castro, James K Collins, Haley Comfort, Xiaochen Dai, William James Dangel, Carolyn Dapper, Amanda Deen, Lucas Earl, Megan Erickson, Samuel B Ewald, Alize J Ferrari, Abraham D Flaxman, Joseph Jon Frostad, Nancy Fullman, Amiran Gamkrelidze, John R Giles, Gaorui Guo, Jiawei He, Monika Helak, Erin N Hulland, Bethany M Huntley, Maia Kereselidze, Alice Lazzar-Atwood, Kate E LeGrand, Akiaja Lindstrom, Emily Linebarger, Rafael Lozano, Beatrice Magistro, Deborah Carvalho Malta, Johan Månsson, Ana M Mantilla Herrera, Fatima Marinho, Alemnesh H Mirkuzie, Ali H Mokdad, Lorenzo Monasta, Mohsen Naghavi, Hasan Nassereldine, Shuhei Nomura, Christopher M Odell, Latera Tesfaye Olana, Maja Pasovic, Spencer A Pease, Louise Penberthy, Grace Reinke, Antonio Luiz, P Ribeiro, Damian Francesco Santomauro, Aleksei Sholokhov, Natia Skhvitaridze, Emma Elizabeth Spurlock, Ruri Syailendrawati, Roman Topor-Madry, Anh Truc Vo, Theo Vos, Rebecca Walcott, Ally Walker, Stefanie Watson, Charles Shey Wiysonge, Nahom Alemseged Worku, Peng Zheng, Simon I Hay, Emmanuela Gakidou, Christopher J L Murray

The Lancet (Elsevier BV) 2022.02

Accepted, ISSN 0140-6736

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Alcohol intake and stomach cancer risk in Japan: A pooled analysis of six cohort studies

Takashi Tamura, Kenji Wakai, Yingsong Lin, Akiko Tamakoshi, Mai Utada, Kotaro Ozasa, Yumi Sugawara, Ichiro Tsuji, Ayami Ono, Norie Sawada, Shoichiro Tsugane, Hidemi Ito, Chisato Nagata, Tetsuhisa Kitamura, Mariko Naito, Keitaro Tanaka, Taichi Shimazu, Tetsuya Mizoue, Keitaro Matsuo, Manami Inoue, Sarah K. Abe, Motoki Iwasaki, Michihiro Muto, Eiko Saito, Shiori Tanaka, Taiki Yamaji, Hadrien Charvat, Tetsuya Otani, Shizuka Sasazuki, Yoshikazu Nishino, Yoshitaka Tsubono, Shuhei Nomura, Hidekazu Suzuki, Isao Oze, Keiko Wada, Yuri Kitamura, Tomio Nakayama, Atsuko Sadakane

Cancer Science (Wiley) 113 ( 1 ) 261 - 276 2022.01

ISSN 13479032

The association between alcohol intake and stomach cancer risk remains controversial. We undertook a pooled analysis of data from six large-scale Japanese cohort studies with 256 478 participants on this topic. Alcohol intake as ethanol was estimated using a validated questionnaire. The participants were followed for incidence of stomach cancer. We calculated study-specific hazard ratios (HRs) and 95% confidence intervals (CIs) for stomach cancer according to alcohol intake using a Cox regression model. Summary HRs were estimated by pooling the study-specific HRs using a random-effects model. During 4 265 551 person-years of follow-up, 8586 stomach cancer cases were identified. In men, the multivariate-adjusted HRs (95% CIs) of stomach cancer were 1.00 (0.87-1.15) for occasional drinkers, and 1.00 (0.91-1.11) for <23 g/d, 1.09 (1.01-1.18) for 23 to <46 g/d, 1.18 (1.09-1.29) for 46 to <69 g/d, 1.21 (1.05-1.39) for 69 to <92 g/d, and 1.29 (1.11-1.51) for ≥92 g/d ethanol in regular drinkers compared with nondrinkers. In women, the multivariate-adjusted HRs were 0.93 (0.80-1.08) for occasional drinkers, and 0.85 (0.74-0.99) for <23 g/d, and 1.22 (0.98-1.53) for ≥23 g/d in regular drinkers compared with nondrinkers. The HRs for proximal and distal cancer in drinkers vs nondrinkers were 1.69 (1.15-2.47) and 1.24 (0.99-1.55) for ≥92 g/d in men, and 1.60 (0.76-3.37) and 1.18 (0.88-1.57) for ≥23 g/d in women, respectively. Alcohol intake increased stomach cancer risk in men, and heavy drinkers showed a greater point estimate of risk for proximal cancer than for distal cancer.

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Identification of optimum combinations of media channels for approaching COVID-19 vaccine unsure and unwilling groups in Japan

Daisuke Yoneoka, Akifumi Eguchi, Shuhei Nomura, Takayuki Kawashima, Yuta Tanoue, Michio Murakami, Haruka Sakamoto, Keiko Maruyama-Sakurai, Stuart Gilmour, Shoi Shi, Hiroyuki Kunishima, Satoshi Kaneko, Megumi Adachi, Koki Shimada, Yoshiko Yamamoto, Hiroaki Miyata

The Lancet Regional Health - Western Pacific (Elsevier BV) 18 100330 - 100330 2022.01

Accepted, ISSN 2666-6065

BACKGROUND: Optimizing media campaigns for those who were unsure or unwilling to take coronavirus disease (COVID-19) vaccines is required urgently to effectively present public health messages aimed at increasing vaccination coverage. We propose a novel framework for selecting tailor-made media channels and their combinations for this task. METHODS: An online survey was conducted in Japan during February to March, 2021, with 30,053 participants. In addition to their sociodemographic characteristics, it asked the attitude toward vaccination and information sources (i.e., media channels) for COVID-19 issues. Multinomial logic regression was fitted to estimate the combinations of the media channels and their odds ratio (OR) associated with vaccination attitudes. FINDINGS: The proportion of respondents who were unsure or unwilling to take the vaccination was skewed toward younger generation: 58.1% were aged under 35, while 28.1% were 65 years or older. Media channels such as "Non-medical and Non-TV" and "Non-medical and Non-government" were associated with the unsure group: OR (95% Confidence intervals, (CI)) = 1.75 (1.62, 1.89) and 1.53 (1.44, 1.62), respectively. In addition, media channels such as "Newspapers or the Novel Coronavirus Expert Meeting", "Medical or Local government", and "Non-TV" were associated with the unwilling group: OR (95% CI) were 2.00 (1.47, 2.75), 3.13 (2.58, 3.81), and 2.25 (1.84, 2.77), respectively. INTERPRETATION: To effectively approach COVID-19 vaccine unsure and unwilling groups, generation-specific online and offline media campaigns should be optimized to the type of vaccine attitude. FUNDING: Funded by the Ministry of Health, Labour and Welfare of Japan (H29-Gantaisaku-ippan-009) and the Japan Agency for Medical Research and Development (AMED) (JP20fk0108535).

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Pandemic preparedness and COVID-19: an exploratory analysis of infection and fatality rates, and contextual factors associated with preparedness in 177 countries, from Jan 1, 2020, to Sept 30, 2021

Thomas J Bollyky, Erin N Hull, Ryan M Barber, James K Collins, Samantha Kiernan, Mark Moses, David M Pigott, Robert C Reiner Jr, Reed J D Sorensen, Cristiana Abbafati, Christopher Adolph, Adrien Allorant, Joanne O Amlag, Aleks, r Y Aravkin, Bree Bang-Jensen, Austin Carter, Rachel Castellano, Emma Castro, Suman Chakrabarti, Emily Combs, Xiaochen Dai, William James Dangel, Carolyn Dapper, Am, a Deen, Bruce B Duncan, Lucas Earl, Megan Erickson, Samuel B Ewald, Tatiana Fedosseeva, Alize J Ferrari, Abraham D Flaxman, Nancy Fullman, Emmanuela Gakidou, Bayan Galal, John Gallagher, John R Giles, Gaorui Guo, Jiawei He, Monika Helak, Bethany M Huntley, Bulat Idrisov, Casey Johanns, Kate E LeGr, Ian D Letourneau, Akiaja Lindstrom, Emily Linebarger, Paulo A Lotufo, Rafael Lozano, Beatrice Magistro, Deborah Carvalho Malta, Johan M{\aa}nsson, Ana M Mantilla Herrera, Fatima Marinho, Alemnesh H Mirkuzie, Ali H Mokdad, Lorenzo Monasta, Paulami Naik, Shuhei Nomura, James Kevin O{\textquotesingle}Halloran, Christopher M Odell, Latera Tesfaye Olana, Samuel M Ostroff, Maja Pasovic, Valeria Maria de Azeredo Passos, Louise Penberthy, Grace Reinke, Damian Francesco Santomauro, Maria In{\^{e } }s Schmidt, Aleksei Sholokhov, Emma Spurlock, Christopher E Troeger, Elena Varavikova, Anh T Vo, Theo Vos, Rebecca Walcott, Ally Walker, Simon D Wigley, Charles Shey Wiysonge, Nahom Alemseged Worku, Yifan Wu, Sarah Wulf Hanson, Peng Zheng, Simon I Hay, Christopher J L Murray, Joseph L Dieleman

The Lancet (Elsevier {BV}) 2022

Accepted, ISSN 01406736

Background: National rates of COVID-19 infection and fatality have varied dramatically since the onset of the pandemic. Understanding the conditions associated with this cross-country variation is essential to guiding investment in more effective preparedness and response for future pandemics. Methods: Daily SARS-CoV-2 infections and COVID-19 deaths for 177 countries and territories and 181 subnational locations were extracted from the Institute for Health Metrics and Evaluation's modelling database. Cumulative infection rate and infection-fatality ratio (IFR) were estimated and standardised for environmental, demographic, biological, and economic factors. For infections, we included factors associated with environmental seasonality (measured as the relative risk of pneumonia), population density, gross domestic product (GDP) per capita, proportion of the population living below 100 m, and a proxy for previous exposure to other betacoronaviruses. For IFR, factors were age distribution of the population, mean body-mass index (BMI), exposure to air pollution, smoking rates, the proxy for previous exposure to other betacoronaviruses, population density, age-standardised prevalence of chronic obstructive pulmonary disease and cancer, and GDP per capita. These were standardised using indirect age standardisation and multivariate linear models. Standardised national cumulative infection rates and IFRs were tested for associations with 12 pandemic preparedness indices, seven health-care capacity indicators, and ten other demographic, social, and political conditions using linear regression. To investigate pathways by which important factors might affect infections with SARS-CoV-2, we also assessed the relationship between interpersonal and governmental trust and corruption and changes in mobility patterns and COVID-19 vaccination rates. Findings: The factors that explained the most variation in cumulative rates of SARS-CoV-2 infection between Jan 1, 2020, and Sept 30, 2021, included the proportion of the population living below 100 m (5·4% [4·0–7·9] of variation), GDP per capita (4·2% [1·8–6·6] of variation), and the proportion of infections attributable to seasonality (2·1% [95% uncertainty interval 1·7–2·7] of variation). Most cross-country variation in cumulative infection rates could not be explained. The factors that explained the most variation in COVID-19 IFR over the same period were the age profile of the country (46·7% [18·4–67·6] of variation), GDP per capita (3·1% [0·3–8·6] of variation), and national mean BMI (1·1% [0·2–2·6] of variation). 44·4% (29·2–61·7) of cross-national variation in IFR could not be explained. Pandemic-preparedness indices, which aim to measure health security capacity, were not meaningfully associated with standardised infection rates or IFRs. Measures of trust in the government and interpersonal trust, as well as less government corruption, had larger, statistically significant associations with lower standardised infection rates. High levels of government and interpersonal trust, as well as less government corruption, were also associated with higher COVID-19 vaccine coverage among middle-income and high-income countries where vaccine availability was more widespread, and lower corruption was associated with greater reductions in mobility. If these modelled associations were to be causal, an increase in trust of governments such that all countries had societies that attained at least the amount of trust in government or interpersonal trust measured in Denmark, which is in the 75th percentile across these spectrums, might have reduced global infections by 12·9% (5·7–17·8) for government trust and 40·3% (24·3–51·4) for interpersonal trust. Similarly, if all countries had a national BMI equal to or less than that of the 25th percentile, our analysis suggests global standardised IFR would be reduced by 11·1%. Interpretation: Efforts to improve pandemic preparedness and response for the next pandemic might benefit from greater investment in risk communication and community engagement strategies to boost the confidence that individuals have in public health guidance. Our results suggest that increasing health promotion for key modifiable risks is associated with a reduction of fatalities in such a scenario. Funding: Bill & Melinda Gates Foundation, J Stanton, T Gillespie, J and E Nordstrom, and Bloomberg Philanthropies.

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Myanmar's coup risks a flood of vaccine-preventable disease

Kaung Suu Lwin, Cyrus Ghaznavi, Khine Lae Win, Stuart Gilmour, Masahiro Hashizume, Shuhei Nomura

Journal of Global Health (International Global Health Society) 12 2022

Accepted, ISSN 20472978

In line with the Sustainable Development Goals (SDGs), the reduction of the under-5 mortality rate to ≤25 deaths per 1000 live births by 2030 is the primary target of Myanmar’s national strategic plan for newborn and child health [1]. Myanmar made considerable strides in decreasing under-5 mortality with a 61% reduction between 1990 and 2019; however, the rate remained high at 45 per 1000 live births as of 2019 and more progress is needed [2]. In Myanmar, more than 45 000 under-5 children died in 2017 primarily due to newborn causes (46.7%), pneumonia (15.1%), diarrhea (8.7%) and injuries (8.5%) [2]. Because immunization is one of the most cost-effective and efficient ways to improve child health [3], Myanmar’s 1978 Expanded Program on Immunization (EPI) [4] was later broadened between 2016 and 2020 to include pneumococcal conjugate vaccines (PCVs), Japanese encephalitis (JE) and rotavirus vaccines [5]. Since then, EPI has been supplying nine types of vaccines for children in Myanmar (Table 1) [4,5].

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Inter-prefectural travel and network connectedness during the COVID-19 pandemic in Japan

C Ghaznavi, D Yoneoka, Y Tanoue, S Gilmour, T Kawashima, A Eguchi, ...

Journal of epidemiology 32 (11), 510-518 (Japan Epidemiological Association) 32 ( 11 ) 510 - 518 2022

Accepted, ISSN 09175040

BackgroundIncreases in human mobility have been linked to rises in COVID-19 transmission. The pandemic era in Japan has been characterized by changes in inter-prefectural mobility across state of emergency declarations (SOE) and travel campaigns, but they have yet to be characterized.MethodsUsing Yahoo Japan mobility data extracted from the smartphones of more than 10 million Japanese residents, we calculated the monthly number of inter-prefectural travel instances, stratified by residential prefecture and destination prefecture. We then used this adjacency matrix to calculate two network connectedness metrics, closeness centrality and effective distance, that reliably predict disease transmission.ResultsInter-prefectural mobility and network connectedness decreased most considerably during the first SOE, but this decrease dampened with each successive SOE. Mobility and network connectedness increased during the Go To Travel campaign. Travel volume between distant prefectures decreased more than travel between prefectures with geographic proximity. Closeness centrality was found to be negatively correlated with the rate of COVID-19 infection across prefectures, with the strength of this association increasing in tandem with the infection rate. Changes in effective distance were more visible among geographically isolated prefectures (Hokkaido and Okinawa) than among metropolitan, central prefectures (Tokyo, Aichi, Osaka, and Fukuoka).ConclusionsThe magnitude of reductions in human mobility decreased with each subsequent state of emergency, consistent with pandemic fatigue. The association between network connectedness and rates of COVID-19 infection remained visible throughout the entirety of the pandemic period, suggesting that inter-prefectural mobility may have contributed to disease spread.

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Global warming and the Summer Olympic and Paralympic games: a perspective from the Tokyo 2020 Games

Lisa Yamasaki, Shuhei Nomura

Environmental Health and Preventive Medicine (Japanese Society for Hygiene) 27 ( 1 ) 7 - 7 2022

Accepted, ISSN 1342078X

The Tokyo 2020 Olympic and Paralympic Games provided a significant opportunity to consider global warming as an issue to be seriously addressed to run the safe and fair games in the era of climate change. As the global temperature continuously rises and extreme hot-weather events increase in frequency and intensity, the future summer Olympic and Paralympic games will need to deal with the heat by applying thorough and appropriate countermeasures. In the recent decades, many mitigation measures to protect athletes from heat have been rapidly discussed by the sports community, including countermeasures to hold games at times and places with moderate temperature and climatic risk assessments with Wet Bulb Globe Temperature (WBGT) during the games. However, the excessive heat conditions in the Tokyo 2020 Games affected not only athletes, but also all people concerned the events. While deliberate considerations by organizers had been given to mitigate extraordinary heat, the evaluations of these measures and epidemiological analyses of risk factors of patients must be further enhanced to develop efficient measures for the future. Therefore, we discussed the underlying climate-related problems of the summer Olympic and Paralympic Games in view of what we had experienced in the Tokyo 2020 Games. Facing with emerging global warming, future intervention against heat in the summer Olympic and Paralympic games will need to integrate systematic disease surveillance and evaluation of intervention with an effective combination with the approaches previously conducted. The Tokyo 2020 Games is a wake-up call to accelerate the public health measures towards the creeping global warming.

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Reasons for Suicide During the COVID-19 Pandemic in Japan

Masahide Koda, Nahoko Harada, Akifumi Eguchi, Shuhei Nomura, Yasushi Ishida

JAMA Network Open (American Medical Association (AMA)) 5 ( 1 ) e2145870 - e2145870 2022

Accepted

Importance: Although the suicide rate in Japan increased during the COVID-19 pandemic, the reasons for suicide have yet to be comprehensively investigated. Objective: To assess which reasons for suicide had rates that exceeded the expected number of suicide deaths for that reason during the COVID-19 pandemic. Design, Setting, and Participants: This national, population-based cross-sectional study of data on suicides gathered by the Ministry of Health, Labor, and Welfare from January 2020 to May 2021 used a times-series analysis on the numbers of reason-identified suicides. Data of decedents were recorded by the National Police Agency and compiled by the Ministry of Health, Labor, and Welfare. Exposure: For category analysis, we compared data from January 2020 to May 2021 with data from December 2014 to June 2020. For subcategory analysis, data from January 2020 to May 2021 were compared with data from January 2019 to June 2020. Main Outcomes and Measures: The main outcome was the monthly excess suicide rate, ie, the difference between the observed number of monthly suicide deaths and the upper bound of the 1-sided 95% CI for the expected number of suicide deaths in that month. Reasons for suicide were categorized into family, health, economy, work, relationships, school, and others, which were further divided into 52 subcategories. A quasi-Poisson regression model was used to estimate the expected number of monthly suicides. Individual regression models were used for each of the 7 categories, 52 subcategories, men, women, and both genders. Results: From the 29 938 suicides (9984 [33.3%] women; 1093 [3.7%] aged <20 years; 3147 [10.5%] aged >80 years), there were 21 027 reason-identified suicides (7415 [35.3%] women). For both genders, all categories indicated monthly excess suicide rates, except for school in men. October 2020 had the highest excess suicide rates for all cases (observed, 1577; upper bound of 95% CI for expected number of suicides, 1254; 25.8% greater). In men, the highest monthly excess suicide rate was 24.3% for the other category in August 2020 (observed, 87; upper bound of 95% CI for expected number, 70); in women, it was 85.7% for school in August 2020 (observed, 26; upper bound of 95% CI for expected number, 14). Conclusions and Relevance: In this study, observed suicides corresponding to all 7 categories of reasons exceeded the monthly estimates (based on data from before or during the COVID-19 pandemic), except for school-related reasons in men. This study can be used as a basis for developing intervention programs for suicide prevention.

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Alkali-free glass substrate, laminated substrate, and method for manufacturing glass substrate

S Nomura, K Ono

US Patent 11,370,694 2022

Alkali-free glass substrate, laminated substrate, and glass substrate production method

S Nomura, K Ono

US Patent 11,247,933 2022

A global systematic analysis of the occurrence, severity, and recovery pattern of long COVID in 2020 and 2021

SW Hanson, C Abbafati, JG Aerts, Z Al-Aly, C Ashbaugh, T Ballouz, ...

MedRxiv 2022

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Glass substrate, liquid crystal antenna and high-frequency device

S Nomura, K Ono

US Patent 11,239,549 2022

Sleep duration and risk of cancer incidence and mortality: a pooled analysis of six population‐based cohorts in Japan

C Wilunda, SK Abe, T Svensson, N Sawada, S Tsugane, K Wada, ...

International Journal of Cancer 151 (7), 1068-1080 2022

Pandemic preparedness and COVID-19: an exploratory analysis of infection and fatality rates, and contextual factors associated with preparedness in 177 countries, from Jan 1 …

TJ Bollyky, EN Hulland, RM Barber, JK Collins, S Kiernan, M Moses, ...

The Lancet 399 (10334), 1489-1512 2022

Impact of near-infrared fluorescence imaging with indocyanine green on structural sequelae of anastomotic leakage after laparoscopic intersphincteric resection of malignant …

H Hasegawa, Y Tsukada, M Wakabayashi, S Nomura, T Sasaki, ...

Techniques in Coloproctology 26 (7), 561-570 2022

Variation in the COVID-19 infection-fatality ratio by age, time, and geography during the pre-vaccine era: A systematic analysis

RJD Sorensen, RM Barber, DM Pigott, A Carter, CN Spencer, SM Ostroff, ...

The Lancet 399 (10334), 1469-1488 2022

Additional file 1 of Distributed lag interrupted time series model for unclear intervention timing: effect of a statement of emergency during COVID-19 pandemic

D Yoneoka, T Kawashima, Y Tanoue, S Nomura, A Eguchi

(No Title) 2022

Geographically weighted generalized Farrington algorithm for rapid outbreak detection over short data accumulation periods

Daisuke Yoneoka, Takayuki Kawashima, Koji Makiyama, Yuta Tanoue, Shuhei Nomura, Akifumi Eguchi

Statistics in Medicine (Wiley) 40 ( 28 ) 6277 - 6294 2021.12

Accepted, ISSN 02776715

The demand for rapid surveillance and early detection of local outbreaks has been growing recently. The rapid surveillance can select timely and appropriate interventions toward controlling the spread of emerging infectious diseases, such as the coronavirus disease 2019 (COVID-19). The Farrington algorithm was originally proposed by Farrington et al (1996), extended by Noufaily et al (2012), and is commonly used to estimate excess death. However, one of the major challenges in implementing this algorithm is the lack of historical information required to train it, especially for emerging diseases. Without sufficient training data the estimation/prediction accuracy of this algorithm can suffer leading to poor outbreak detection. We propose a new statistical algorithm-the geographically weighted generalized Farrington (GWGF) algorithm-by incorporating both geographically varying and geographically invariant covariates, as well as geographical information to analyze time series count data sampled from a spatially correlated process for estimating excess death. The algorithm is a type of local quasi-likelihood-based regression with geographical weights and is designed to achieve a stable detection of outbreaks even when the number of time points is small. We validate the outbreak detection performance by using extensive numerical experiments and real-data analysis in Japan during COVID-19 pandemic. We show that the GWGF algorithm succeeds in improving recall without reducing the level of precision compared with the conventional Farrington algorithm.

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Correction to: Tracking Japan’s development assistance for health, 2012–2016 (Globalization and Health, (2020), 16, 1, (32), 10.1186/s12992-020-00559-2)

Shuhei Nomura, Haruka Sakamoto, Maaya Kita Sugai, Haruyo Nakamura, Keiko Maruyama-Sakurai, Sangnim Lee, Aya Ishizuka, Kenji Shibuya

Globalization and Health (BioMed Central Ltd) 17 ( 1 ) 2021.12

ISSN 1744-8603

Following publication of the original article [1], the authors reported a conversion error that concerned the estimated amounts of development assistance for health (DAH) for 2012–2015
when the authors converted the current prices of 2012–2015 to the constant prices of 2016 using the gross domestic product (GDP) deflator, they erroneously multiplied the current prices by the GDP deflator instead of dividing them. Please find the details of this error in this correction. Firstly, the ‘Results’ in the article’s Abstract stated that “Japan’s DAH was estimated at 1,472.94 (2012), 823.15 (2013), 832.06 (2014), 701.98 (2015), and 894.57 million USD (2016) in constant prices of 2016”, while it should state that “Japan’s DAH was estimated at 853.87 (2012), 718.16 (2013), 824.95 (2014), 873.04 (2015), and 894.57 million USD (2016) in constant prices of 2016”. Secondly, the first sentence of the article’s Results section stated that “Japan’s DAH was estimated at 1, 472.94 (2012), 823.15 (2013), 832.06 (2014), 701.98 (2015), and 894.57 million USD (2016) in constant prices of 2016”, while it should state that “Japan’s DAH was estimated at 853.87 (2012), 718.16 (2013), 824.95 (2014), 873.04 (2015), and 894.57 million USD (2016) in constant prices of 2016”. In addition to the above mentioned parts of the article, the conversion error affected Table 1, Fig. 1a, Fig. 2a, and Additional file 2, for the data of 2012–2015
please find (the corrected version of) these files in this correction. The errors have now been corrected in the original article. Furthermore, the authors would like to assure the reader that the discussions proposed in their article were based on the part of the results not related to the conversion by the GBD deflator (i.e. percentage value rather than amount) and, therefore, that the miscalculated amounts of DAH mentioned above do not affect the interpretation or conclusions of the study. The authors thank you for reading this correction, and apologize for any inconvenience caused.

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A prospective evaluation of AI-augmented epidemiology to forecast COVID-19 in the USA and Japan

J Ledsam, S Arik, J Shor, R Sinha, J Yoon, L Le, M Dusenberry, N Yoder, ...

NPJ digital medicine 4 (1), 146 (Springer Science and Business Media LLC) 4 ( 1 ) 146 - 146 2021.12

Accepted, ISSN 2398-6352

<title>Abstract</title>The COVID-19 pandemic has highlighted the global need for reliable models of disease spread. We propose an AI-augmented forecast modeling framework that provides daily predictions of the expected number of confirmed COVID-19 deaths, cases, and hospitalizations during the following 4 weeks. We present an international, prospective evaluation of our models’ performance across all states and counties in the USA and prefectures in Japan. Nationally, incident mean absolute percentage error (MAPE) for predicting COVID-19 associated deaths during prospective deployment remained consistently <8% (US) and <29% (Japan), while cumulative MAPE remained <2% (US) and <10% (Japan). We show that our models perform well even during periods of considerable change in population behavior, and are robust to demographic differences across different geographic locations. We further demonstrate that our framework provides meaningful explanatory insights with the models accurately adapting to local and national policy interventions. Our framework enables counterfactual simulations, which indicate continuing Non-Pharmaceutical Interventions alongside vaccinations is essential for faster recovery from the pandemic, delaying the application of interventions has a detrimental effect, and allow exploration of the consequences of different vaccination strategies. The COVID-19 pandemic remains a global emergency. In the face of substantial challenges ahead, the approach presented here has the potential to inform critical decisions.

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National genotype prevalence and age distribution of human papillomavirus from infection to cervical cancer in Japanese women: a systematic review and meta-analysis protocol

Matthew Palmer, Kota Katanoda, Eiko Saito, Cecilia Acuti Martellucci, Shiori Ostuki, Shuhei Nomura, Erika Ota, Julia M. L. Brotherton, Jane Hocking

Systematic Reviews (Springer Science and Business Media LLC) 10 ( 1 ) 135 - 135 2021.12

Accepted

<title>Abstract</title><sec>
<title>Background</title>
Despite prophylactic human papillomavirus (HPV) vaccination being a safe, effective and cost-effective public health intervention for the prevention of cervical cancer, the HPV vaccine is not actively recommended or promoted by the Ministry of Health Labour and Welfare in Japan. With already very low levels of cervical screening below 30%, and vaccination levels that are below levels that award any population effect at 0.3% of the eligible population, cervical cancer mortality is higher than other similar high-income countries at 4.4/100,000 (2900) deaths per year in 2015. There is limited population-based or nationally representative data for HPV genotype distribution in Japan, thus making an assessment of the burden of vaccine-preventable cervical cancer difficult. Therefore, this systematic review and meta-analysis aims to determine the HPV genotype prevalence and age distribution of HPV infection in women with a cytological or histological diagnosis of normal through cervical cancer in Japan. We anticipate this information will guide and enhance programme interventions to reduce vaccine-preventable cervical cancer mortality in Japan.

</sec><sec>
<title>Methods</title>
PubMed, Embase and the Japan Medical Abstract Society Database will be searched from the date of establishment to March 2021 to identify original research articles that report the prevalence of HPV genotypes in Japanese women with normal cervical cytology, low grade, high grade and cancerous cervical lesions. No exclusion criteria relating to language or publication date will be applied. The quality of the studies will be assessed using the Joanna Briggs checklist for prevalence studies. Randomised control trials, cohort studies, cross-sectional and prevalence studies will be considered eligible. Study findings will be combined using a traditional random-effects or fixed-effects meta-analysis to summarise pooled prevalence and 95% confidence intervals depending on heterogeneity. Subgroup analyses and meta-regression will be used to investigate heterogeneity, and sensitivity analyses will be conducted to assess the robustness of the findings.

</sec><sec>
<title>Discussion</title>
To our knowledge, this is the first systematic review protocol that includes both Japanese and English peer-reviewed articles for the determination of genotype-specific HPV prevalence in cytological or histological confirmed normal cervical specimens, low- and high-grade intraepithelial lesions and cervical cancers by age in Japan. We anticipate this information will guide and enhance programme interventions to reduce vaccine-preventable cervical cancer mortality in Japan.

</sec><sec>
<title>Systematic review registration</title>
PROSPERO CRD42018117596

</sec>

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Impact of domestic travel restrictions on transmission of COVID-19 infection using public transportation network approach

Yayoi Murano, Ryo Ueno, Shoi Shi, Takayuki Kawashima, Yuta Tanoue, Shiori Tanaka, Shuhei Nomura, Hiromichi Shoji, Toshiaki Shimizu, Huy Nguyen, Hiroaki Miyata, Stuart Gilmour, Daisuke Yoneoka

Scientific Reports (Springer Science and Business Media LLC) 11 ( 1 ) 3109 - 3109 2021.12

Accepted

<title>Abstract</title>The international spread of COVID-19 infection has attracted global attention, but the impact of local or domestic travel restriction on public transportation network remains unclear. Passenger volume data for the domestic public transportation network in Japan and the time at which the first confirmed COVID-19 case was observed in each prefecture were extracted from public data sources. A survival approach in which a hazard was modeled as a function of the closeness centrality on the network was utilized to estimate the risk of importation of COVID-19 in each prefecture. A total of 46 prefectures with imported cases were identified. Hypothetical scenario analyses indicated that both strategies of locking down the metropolitan areas and restricting domestic airline travel would be equally effective in reducing the risk of importation of COVID-19. While caution is necessary that the data were limited to June 2020 when the pandemic was in its initial stage and that no other virus spreading routes have been considered, domestic travel restrictions were effective to prevent the spread of COVID-19 on public transportation network in Japan. Instead of lockdown that might seriously damage the economy, milder travel restrictions could have the similar impact on controlling the domestic transmission of COVID-19.

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How do Japanese rate the severity of different diseases and injuries?—an assessment of disability weights for 231 health states by 37,318 Japanese respondents

S Nomura, Y Yamamoto, D Yoneoka, JA Haagsma, JA Salomon, P Ueda, ...

Population health metrics 19, 1-25 (Springer Science and Business Media {LLC}) 19 ( 1 ) 21 - 21 2021.12

Accepted, ISSN 1478-7954

BACKGROUND: Disability weights (DWs) are weight factors that reflect the severity of health states for estimates of disability-adjusted life years. A new set of global DWs was published for the Global Burden of Diseases and Injuries (GBD) 2013 study, which relied on sampling from various world regions, but included little data for countries in East Asia. This study aimed to measure DWs in Japan using comparable methods, and compare the results with previous estimates from the GBD 2013 DW study. METHODS: We conducted a web-based survey in 2019 to estimate DWs for 231 health states for the Japanese population. The survey included five new health states but otherwise followed the method of the GBD DW measurement study. The survey consisted of 15 paired comparison (PC) questions and 3 population health equivalence questions (PHE) per respondent. We analyzed PC data using probit regression and rescaled results to DW units between 0 (equivalent to full health) and 1 (equivalent to death). FINDINGS: We considered 37,318 nationally representative respondents. The values of the resulting DWs ranged from 0.707 (95% uncertainty interval (UI) 0.527-0.842) for spinal cord injury at neck level (untreated) to 0.004 (UI 0.001-0.009) for mild anemia. High correlation between Japanese DW and GBD 2013 DW was observed, but there was considerable disagreement. Out of 226 comparable health states, 55 (24.3%) showed more than a factor-of-two difference, of which 41 (74.6%) had a higher value in Japanese DW. Many of the health states with higher DW in the Japan study were injuries, including amputation and fracture, and hearing and vision loss, while mental, behavioral, and substance use disorders generally tended to be lower. CONCLUSIONS: This study has created an empirical basis for assessment of Japanese DWs of health status. The findings from this study based on the Japanese population suggest that there might be contextual differences in rating the severity of health states compared to previous surveys conducted elsewhere.

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Analysis of the relationship between the HbA1c screening results and the development and worsening of diabetes among adults aged over 40 years: a 4-year follow-up study of 140,000 people in Japan – the Shizuoka study

Shuhei Nomura, Haruka Sakamoto, Santosh Kumar Rauniyar, Koki Shimada, Hiroyuki Yamamoto, Shun Kohsaka, Nao Ichihara, Hiraku Kumamaru, Hiroaki Miyata

BMC Public Health (Springer Science and Business Media LLC) 21 ( 1 ) 1880 - 1880 2021.12

Accepted, ISSN 1471-2458

<title>Abstract</title><sec>
<title>Background</title>
Hemoglobin A1c (HbA1c) levels are routinely measured during health check-ups and are used as an indicator of glycemic control in Japan. However, only a few studies have followed up individuals to assess the risk of diabetes development and worsening based on HbA1c screening results. This study evaluated the relationship between HbA1c screening results and the risk of diabetes development and worsening.

</sec><sec>
<title>Methods</title>
Data were collected from the Shizuoka Kokuho Database, a Japanese administrative claims database of insured individuals aged > 40 years. We included individuals available for follow-up from April 2012 to March 2018 who had not received any diabetes treatment before March 2014. HbA1c screening results were categorized into 4 groups based on the HbA1c levels at the 2012 and 2013 health check-ups: group A, those whose HbA1c levels were < 6.5% in 2012 and 2013; group B, those whose HbA1c levels > 6.5% in 2012 but < 6.5% in 2013; group C, those whose HbA1c levels were > 6.5% in 2012 and 2013; and group D, those whose HbA1c levels were < 6.5% in 2012 and > 6.5% in 2013. Logistic regression models were used to analyze diabetes development and worsening, defined as the initiation of diabetes treatment by March 2018 and the use of injection drugs by participants who initiated diabetes treatment by March 2018.

</sec><sec>
<title>Results</title>
Overall, 137,852 individuals were analyzed. After adjusting for covariates, compared with group A, group B was more likely to initiate treatment within 4 years (odds ratio: 22.64; 95% confidence interval: 14.66–34.99). In patients who initiated diabetes treatment by March 2018, injection drugs were less likely used by group D than by group A (odds ratio: 0.28; 95% confidence interval: 0.12–0.61).

</sec><sec>
<title>Conclusions</title>
Our study suggests that although HbA1c levels measured during health check-ups were correlated with the risk of diabetes development and worsening, HbA1c levels in a single year may not necessarily provide sufficient information to consider these future risks.

</sec>

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Age-appropriate vaccination coverage and its determinants in children aged 12–36 months in Nepal: a national and subnational assessment

SK Rauniyar, Y Iwaki, D Yoneoka, M Hashizume, S Nomura

BMC Public Health 21, 1-12 (Springer Science and Business Media LLC) 21 ( 1 ) 2063 - 2063 2021.12

Accepted

<title>Abstract</title><sec>
<title>Background</title>
Vaccination is one of the effective ways to develop immunity against potential life-threatening diseases in children in early age. This study is focused on analysing the age-appropriate vaccination coverage at national and subnational levels and identify the factors associated with age-appropriate coverage in Nepal.

</sec><sec>
<title>Methods</title>
460 children aged 12–36 months were included in the study. The data was obtained from Nepal Demographic and Health Survey (NDHS) 2016–17. Age-appropriate coverage of Bacillus Calmette-Guerin vaccine (BCG), oral polio vaccine (OPV) doses 1–3, pentavalent vaccine (PE) doses 1–3, and first dose of measles, mumps, and rubella vaccine (MMR) were estimated using Kaplan Meier method. Multilevel logistic regression with random intercept was used to identify the factors associated with age-appropriate vaccination.

</sec><sec>
<title>Results</title>
The crude coverage of the vaccines included in the study ranged from 91.5% (95% CI, 88.5–93.7) for PE3 to 97.8% (95.8–98.7) for BCG. Although the crude coverage of all the vaccines was above 90%, the age-appropriate coverage was significantly low, ranging from 41.5% (36.5–46.6) for PE3 to 73.9% (69.2–78.1) for PE1. Furthermore, high disparity in timely vaccination coverage was observed at regional level. Compared to the age-appropriate vaccination coverage in other provinces, Province 2 had the lowest coverage of all, followed by that in Province 6. The timeliness of vaccination was significantly associated with subnational regions i.e., provinces and the season of childbirth.

</sec><sec>
<title>Conclusion</title>
Although the immunization program in Nepal has achieved the target of 90% crude coverage of all the childhood vaccines, the age-appropriate coverage is significantly low which undermines the effectiveness of the vaccines administered. Thus, along with crude coverage, timeliness of the vaccines administered should be taken into consideration and thoroughly monitored at national and subnational levels. Provincial government should formulate tailored strategies to ensure the timely administration of the childhood vaccines.

</sec>

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Projections of disability-adjusted life years for major diseases due to a change in vegetable intake in 2017–2040 in Japan

Shiori Tanaka, Daisuke Yoneoka, Aya Ishizuka, Peter Ueda, Keiji Nakamura, Hisayuki Uneyama, Naoki Hayashi, Kenji Shibuya, Shuhei Nomura

BMC Public Health 21 ( 1 ) 770 - 770 2021.12

Accepted

BACKGROUND: Low vegetable intake is one of the key dietary risk factors known to be associated with a range of health problems, including cardiovascular diseases (CVDs), cancer, and diabetes and kidney diseases (DKDs). Using data from Japan's National Health and Nutrition Surveys and the Global Burden of Diseases study in 2017, this study aimed to forecast the impact of change in vegetable intake on disability-adjusted life years (DALYs) between 2017 and 2040 for three diseases. METHODS: We generated a three-component model of cause-specific DALYs, including changes in major behavioural and metabolic risk predictors, the socio-demographic index and an autoregressive integrated moving average model to project future DALY rates for 2017-2040 using the data between 1990 and 2016. Data on Vegetable consumption and risk predictors, and DALY rate were obtained from Japan's National Health and Nutrition Surveys and the Global Burden of Diseases Study in 2017. We also modelled three scenarios of better, moderate and worse cases to evaluate the impact of change in vegetable consumption on the DALY rates for three diseases (CVDs, cancer, and DKDs). RESULTS: Projected mean vegetable intake in the total population showed a decreasing trend through 2040 to 237.7 g/day. A significant difference between the reference scenario and the better case scenario was observed with un-overlapped 95% prediction intervals of DALY rates in females aged 20-49 years (- 8.0%) for CVDs, the total population for cancer (- 5.6%), and in males (- 8.2%) and females (- 13.7%) for DKDs. CONCLUSIONS: Our analysis indicates that increased vegetable consumption would have a significant reduction in the burdens of CVDs, cancer and DKDs in Japan. By estimating the disease burden attributable to low vegetable intake under different scenarios of future vegetable consumption, our study can inform the design of targeted interventions for public health challenges.

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Global prevalence and burden of depressive and anxiety disorders in 204 countries and territories in 2020 due to the COVID-19 pandemic

Damian F Santomauro, Ana M Mantilla Herrera, Jamileh Shadid, Peng Zheng, Charlie Ashbaugh, David M Pigott, Cristiana Abbafati, Christopher Adolph, Joanne O Amlag, Aleksandr Y Aravkin, Bree L Bang-Jensen, Gregory J Bertolacci, Sabina S Bloom, Rachel Castellano, Emma Castro, Suman Chakrabarti, Jhilik Chattopadhyay, Rebecca M Cogen, James K Collins, Xiaochen Dai, William James Dangel, Carolyn Dapper, Amanda Deen, Megan Erickson, Samuel B Ewald, Abraham D Flaxman, Joseph Jon Frostad, Nancy Fullman, John R Giles, Ababi Zergaw Giref, Gaorui Guo, Jiawei He, Monika Helak, Erin N Hulland, Bulat Idrisov, Akiaja Lindstrom, Emily Linebarger, Paulo A Lotufo, Rafael Lozano, Beatrice Magistro, Deborah Carvalho Malta, Johan C Månsson, Fatima Marinho, Ali H Mokdad, Lorenzo Monasta, Paulami Naik, Shuhei Nomura, James Kevin O'Halloran, Samuel M Ostroff, Maja Pasovic, Louise Penberthy, Robert C Reiner Jr, Grace Reinke, Antonio Luiz P Ribeiro, Aleksei Sholokhov, Reed J D Sorensen, Elena Varavikova, Anh Truc Vo, Rebecca Walcott, Stefanie Watson, Charles Shey Wiysonge, Bethany Zigler, Simon I Hay, Theo Vos, Christopher J L Murray, Harvey A Whiteford, Alize J Ferrari

The Lancet (Elsevier BV) 398 ( 10312 ) 1700 - 1712 2021.11

ISSN 01406736

Background: Before 2020, mental disorders were leading causes of the global health-related burden, with depressive and anxiety disorders being leading contributors to this burden. The emergence of the COVID-19 pandemic has created an environment where many determinants of poor mental health are exacerbated. The need for up-to-date information on the mental health impacts of COVID-19 in a way that informs health system responses is imperative. In this study, we aimed to quantify the impact of the COVID-19 pandemic on the prevalence and burden of major depressive disorder and anxiety disorders globally in 2020. Methods: We conducted a systematic review of data reporting the prevalence of major depressive disorder and anxiety disorders during the COVID-19 pandemic and published between Jan 1, 2020, and Jan 29, 2021. We searched PubMed, Google Scholar, preprint servers, grey literature sources, and consulted experts. Eligible studies reported prevalence of depressive or anxiety disorders that were representative of the general population during the COVID-19 pandemic and had a pre-pandemic baseline. We used the assembled data in a meta-regression to estimate change in the prevalence of major depressive disorder and anxiety disorders between pre-pandemic and mid-pandemic (using periods as defined by each study) via COVID-19 impact indicators (human mobility, daily SARS-CoV-2 infection rate, and daily excess mortality rate). We then used this model to estimate the change from pre-pandemic prevalence (estimated using Disease Modelling Meta-Regression version 2.1 [known as DisMod-MR 2.1]) by age, sex, and location. We used final prevalence estimates and disability weights to estimate years lived with disability and disability-adjusted life-years (DALYs) for major depressive disorder and anxiety disorders. Findings: We identified 5683 unique data sources, of which 48 met inclusion criteria (46 studies met criteria for major depressive disorder and 27 for anxiety disorders). Two COVID-19 impact indicators, specifically daily SARS-CoV-2 infection rates and reductions in human mobility, were associated with increased prevalence of major depressive disorder (regression coefficient [B] 0·9 [95% uncertainty interval 0·1 to 1·8; p=0·029] for human mobility, 18·1 [7·9 to 28·3; p=0·0005] for daily SARS-CoV-2 infection) and anxiety disorders (0·9 [0·1 to 1·7; p=0·022] and 13·8 [10·7 to 17·0; p<0·0001]. Females were affected more by the pandemic than males (B 0·1 [0·1 to 0·2; p=0·0001] for major depressive disorder, 0·1 [0·1 to 0·2; p=0·0001] for anxiety disorders) and younger age groups were more affected than older age groups (−0·007 [–0·009 to −0·006; p=0·0001] for major depressive disorder, −0·003 [–0·005 to −0·002; p=0·0001] for anxiety disorders). We estimated that the locations hit hardest by the pandemic in 2020, as measured with decreased human mobility and daily SARS-CoV-2 infection rate, had the greatest increases in prevalence of major depressive disorder and anxiety disorders. We estimated an additional 53·2 million (44·8 to 62·9) cases of major depressive disorder globally (an increase of 27·6% [25·1 to 30·3]) due to the COVID-19 pandemic, such that the total prevalence was 3152·9 cases (2722·5 to 3654·5) per 100 000 population. We also estimated an additional 76·2 million (64·3 to 90·6) cases of anxiety disorders globally (an increase of 25·6% [23·2 to 28·0]), such that the total prevalence was 4802·4 cases (4108·2 to 5588·6) per 100 000 population. Altogether, major depressive disorder caused 49·4 million (33·6 to 68·7) DALYs and anxiety disorders caused 44·5 million (30·2 to 62·5) DALYs globally in 2020. Interpretation: This pandemic has created an increased urgency to strengthen mental health systems in most countries. Mitigation strategies could incorporate ways to promote mental wellbeing and target determinants of poor mental health and interventions to treat those with a mental disorder. Taking no action to address the burden of major depressive disorder and anxiety disorders should not be an option. Funding: Queensland Health, National Health and Medical Research Council, and the Bill and Melinda Gates Foundation.

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Developing and validating regression models for predicting household consumption to introduce an equitable and sustainable health insurance system in Cambodia

Haruyo Nakamura, Floriano Amimo, Siyan Yi, Sovannary Tuot, Tomoya Yoshida, Makoto Tobe, Md. Mizanur Rahman, Daisuke Yoneoka, Aya Ishizuka, Shuhei Nomura

International Journal of Health Planning and Management (WILEY) 36 ( 6 ) 2094 - 2105 2021.11

Accepted, ISSN 07496753

Background Financial protection is a challenge for low- and middle-income countries, where the fiscal space is limited, and majority of the population is engaged in the informal economy. This study developed and validated household consumption predictive models for Cambodia to collect contributions according to one's ability to pay. Methods This study used nationally representative survey data collected annually between 2010 and 2017, involving 38,472 households. We developed four alternative models: the manually selected linear model, the linear model with stepwise technique, the mixed effects linear model, and the model with regularisation technique. Subsequently, we performed out-of-sample cross-validation for each model, and evaluated the model prediction performance. Results Overall, observed and predicted household consumptions were linearly related in all four models. While the prediction performance of the models did not substantially differ, the stepwise linear model showed the best performance. The regularisation and the mixed effects were not particularly effective in these regressions. The household consumption was better predicted for those with lower consumption, and the predictivity declined as the consumption level increased. Conclusions This study suggests the possibility of predicting household consumption at a reasonable level. This would maximise the contribution revenue, optimise the government subsidy, and ensure equity in healthcare access.

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Suicide by gender and 10-year age groups during the COVID-19 pandemic vs previous five years in Japan: an analysis of national vital statistics

Akifumi Eguchi, Shuhei Nomura, Stuart Gilmour, Nahoko Harada, Haruka Sakamoto, Peter Ueda, Daisuke Yoneoka, Yuta Tanoue, Takayuki Kawashima, Takehiko I. Hayashi, Yuzo Arima, Motoi Suzuki, Masahiro Hashizume

Psychiatry Research (Elsevier BV) 305 114173 - 114173 2021.11

Accepted, ISSN 01651781

Using daily vital statistics data from the Japanese Ministry of Health, Labour and Welfare, we provide the first weekly and age-group-specific estimates of the additional suicide burden during the COVID-19 pandemic in Japan by gender, from January through November 2020. Our results indicate that compared with the previous five years, suicide cases in 2020 in Japan have increased from late July to November for women in all age groups and for men in the 20-29 and 80+ years age group. Targeted interventions based on age and gender might be more effective in reducing suicide during the COVID-19 pandemic in Japan.

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Global, regional, and national mortality among young people aged 10–24 years, 1950–2019: a systematic analysis for the Global Burden of Disease Study 2019

GBD 2019 Adolescent Mortality Collaborators

The Lancet (Elsevier BV) 398 ( 10311 ) 1593 - 1618 2021.10

Accepted, ISSN 01406736

Background: Documentation of patterns and long-term trends in mortality in young people, which reflect huge changes in demographic and social determinants of adolescent health, enables identification of global investment priorities for this age group. We aimed to analyse data on the number of deaths, years of life lost, and mortality rates by sex and age group in people aged 10–24 years in 204 countries and territories from 1950 to 2019 by use of estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. Methods: We report trends in estimated total numbers of deaths and mortality rate per 100 000 population in young people aged 10–24 years by age group (10–14 years, 15–19 years, and 20–24 years) and sex in 204 countries and territories between 1950 and 2019 for all causes, and between 1980 and 2019 by cause of death. We analyse variation in outcomes by region, age group, and sex, and compare annual rate of change in mortality in young people aged 10–24 years with that in children aged 0–9 years from 1990 to 2019. We then analyse the association between mortality in people aged 10–24 years and socioeconomic development using the GBD Socio-demographic Index (SDI), a composite measure based on average national educational attainment in people older than 15 years, total fertility rate in people younger than 25 years, and income per capita. We assess the association between SDI and all-cause mortality in 2019, and analyse the ratio of observed to expected mortality by SDI using the most recent available data release (2017). Findings: In 2019 there were 1·49 million deaths (95% uncertainty interval 1·39–1·59) worldwide in people aged 10–24 years, of which 61% occurred in males. 32·7% of all adolescent deaths were due to transport injuries, unintentional injuries, or interpersonal violence and conflict; 32·1% were due to communicable, nutritional, or maternal causes; 27·0% were due to non-communicable diseases; and 8·2% were due to self-harm. Since 1950, deaths in this age group decreased by 30·0% in females and 15·3% in males, and sex-based differences in mortality rate have widened in most regions of the world. Geographical variation has also increased, particularly in people aged 10–14 years. Since 1980, communicable and maternal causes of death have decreased sharply as a proportion of total deaths in most GBD super-regions, but remain some of the most common causes in sub-Saharan Africa and south Asia, where more than half of all adolescent deaths occur. Annual percentage decrease in all-cause mortality rate since 1990 in adolescents aged 15–19 years was 1·3% in males and 1·6% in females, almost half that of males aged 1–4 years (2·4%), and around a third less than in females aged 1–4 years (2·5%). The proportion of global deaths in people aged 0–24 years that occurred in people aged 10–24 years more than doubled between 1950 and 2019, from 9·5% to 21·6%. Interpretation: Variation in adolescent mortality between countries and by sex is widening, driven by poor progress in reducing deaths in males and older adolescents. Improving global adolescent mortality will require action to address the specific vulnerabilities of this age group, which are being overlooked. Furthermore, indirect effects of the COVID-19 pandemic are likely to jeopardise efforts to improve health outcomes including mortality in young people aged 10–24 years. There is an urgent need to respond to the changing global burden of adolescent mortality, address inequities where they occur, and improve the availability and quality of primary mortality data in this age group. Funding: Bill & Melinda Gates Foundation.

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Salt intake reduction using umami substance-incorporated food in the United States

Shuhei Nomura, Shiori Tanaka, Akifumi Eguchi, Takayuki Kawashima, Daisuke Yoneoka, Yuta Tanoe, Megumi Adachi, Hitomi Hayabuchi, Shosei Koganemaru, Toshihide Nishimura, Byron Sigel, Hisayuki Uneyama, Kenji Shibuya

2021.10

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Tracking development assistance for health and for COVID-19: a review of development assistance, government, out-of-pocket, and other private spending on health for 204 countries and territories, 1990–2050

Micah A.E., Cogswell I.E., Cunningham B., Ezoe S., Harle A.C., Maddison E.R., McCracken D., Nomura S., Simpson K.E., Stutzman H.N., Tsakalos G., Wallace L.E., Zhao Y., Zende R.R., Abbafati C., Abdelmasseh M., Abedi A., Abegaz K.H., Abhilash E.S., Abolhassani H., Abrigo M.R.M., Adhikari T.B., Afzal S., Ahinkorah B.O., Ahmadi S., Ahmed H., Ahmed M.B., Ahmed Rashid T., Ajami M., Aji B., Akalu Y., Akunna C.J., Al Hamad H., Alam K., Alanezi F.M., Alanzi T.M., Alemayehu Y., Alhassan R.K., Alinia C., Aljunid S.M., Almustanyir S.A., Alvis-Guzman N., Alvis-Zakzuk N.J., Amini S., Amini-Rarani M., Amu H., Ancuceanu R., Andrei C.L., Andrei T., Angell B., Anjomshoa M., Antonio C.A.T., Antony C.M., Aqeel M., Arabloo J., Arab-Zozani M., Aripov T., Arrigo A., Ashraf T., Atnafu D.D., Ausloos M., Avila-Burgos L., Awan A.T., Ayano G., Ayanore M.A., Azari S., Azhar G.S., Babalola T.K., Bahrami M.A., Baig A.A., Banach M., Barati N., Bärnighausen T.W., Barrow A., Basu S., Baune B.T., Bayati M., Benzian H., Berman A.E., Bhagavathula A.S., Bhardwaj N., Bhardwaj P., Bhaskar S., Bibi S., Bijani A., Bodolica V., Bragazzi N.L., Braithwaite D., Breitborde N.J.K., Breusov A.V., Briko N.I., Busse R., Cahuana-Hurtado L., Callander E.J., Cámera L.A., Castañeda-Orjuela C.A., Catalá-López F., Charan J., Chatterjee S., Chattu S.K.

The Lancet 398 ( 10308 ) 1317 - 1343 2021.10

ISSN 01406736

Background: The rapid spread of COVID-19 renewed the focus on how health systems across the globe are financed, especially during public health emergencies. Development assistance is an important source of health financing in many low-income countries, yet little is known about how much of this funding was disbursed for COVID-19. We aimed to put development assistance for health for COVID-19 in the context of broader trends in global health financing, and to estimate total health spending from 1995 to 2050 and development assistance for COVID-19 in 2020. Methods: We estimated domestic health spending and development assistance for health to generate total health-sector spending estimates for 204 countries and territories. We leveraged data from the WHO Global Health Expenditure Database to produce estimates of domestic health spending. To generate estimates for development assistance for health, we relied on project-level disbursement data from the major international development agencies' online databases and annual financial statements and reports for information on income sources. To adjust our estimates for 2020 to include disbursements related to COVID-19, we extracted project data on commitments and disbursements from a broader set of databases (because not all of the data sources used to estimate the historical series extend to 2020), including the UN Office of Humanitarian Assistance Financial Tracking Service and the International Aid Transparency Initiative. We reported all the historic and future spending estimates in inflation-adjusted 2020 US$, 2020 US$ per capita, purchasing-power parity-adjusted US$ per capita, and as a proportion of gross domestic product. We used various models to generate future health spending to 2050. Findings: In 2019, health spending globally reached $8·8 trillion (95% uncertainty interval [UI] 8·7–8·8) or $1132 (1119–1143) per person. Spending on health varied within and across income groups and geographical regions. Of this total, $40·4 billion (0·5%, 95% UI 0·5–0·5) was development assistance for health provided to low-income and middle-income countries, which made up 24·6% (UI 24·0–25·1) of total spending in low-income countries. We estimate that $54·8 billion in development assistance for health was disbursed in 2020. Of this, $13·7 billion was targeted toward the COVID-19 health response. $12·3 billion was newly committed and $1·4 billion was repurposed from existing health projects. $3·1 billion (22·4%) of the funds focused on country-level coordination and $2·4 billion (17·9%) was for supply chain and logistics. Only $714·4 million (7·7%) of COVID-19 development assistance for health went to Latin America, despite this region reporting 34·3% of total recorded COVID-19 deaths in low-income or middle-income countries in 2020. Spending on health is expected to rise to $1519 (1448–1591) per person in 2050, although spending across countries is expected to remain varied. Interpretation: Global health spending is expected to continue to grow, but remain unequally distributed between countries. We estimate that development organisations substantially increased the amount of development assistance for health provided in 2020. Continued efforts are needed to raise sufficient resources to mitigate the pandemic for the most vulnerable, and to help curtail the pandemic for all. Funding: Bill & Melinda Gates Foundation.

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Mobility Patterns in Different Age Groups in Japan during the COVID-19 Pandemic: a Small Area Time Series Analysis through March 2021

Shuhei Nomura, Yuta Tanoue, Daisuke Yoneoka, Stuart Gilmour, Takayuki Kawashima, Akifumi Eguchi, Hiroaki Miyata

Journal of Urban Health (Springer Science and Business Media LLC) 98 ( 5 ) 635 - 641 2021.10

Accepted, ISSN 10993460

<title>Abstract</title>In the COVID-19 era, movement restrictions are crucial to slow virus transmission and have been implemented in most parts of the world, including Japan. To find new insights on human mobility and movement restrictions encouraged (but not forced) by the emergency declaration in Japan, we analyzed mobility data at 35 major stations and downtown areas in Japan—each defined as an area overlaid by several 125-meter grids—from September 1, 2019 to March 19, 2021. Data on the total number of unique individuals per hour passing through each area were obtained from Yahoo Japan Corporation (i.e., more than 13,500 data points for each area). We examined the temporal trend in the ratio of the rolling seven-day daily average of the total population to a baseline on January 16, 2020, by ten-year age groups in five time frames. We demonstrated that the degree and trend of mobility decline after the declaration of a state of emergency varies across age groups and even at the subregional level. We demonstrated that monitoring dynamic geographic and temporal mobility information stratified by detailed population characteristics can help guide not only exit strategies from an ongoing emergency declaration, but also initial response strategies before the next possible resurgence. Combining such detailed data with data on vaccination coverage and COVID-19 incidence (including the status of the health care delivery system) can help governments and local authorities develop community-specific mobility restriction policies. This could include strengthening incentives to stay home and raising awareness of cognitive errors that weaken people's resolve to refrain from nonessential movement.

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Global, regional, and national progress towards Sustainable Development Goal 3.2 for neonatal and child health: all-cause and cause-specific mortality findings from the Global Burden of Disease Study 2019

GBD 2019 Under-5 Mortality Collaborators

The Lancet (Elsevier BV) 398 ( 10303 ) 870 - 905 2021.09

Accepted, ISSN 01406736

Background: Sustainable Development Goal 3.2 has targeted elimination of preventable child mortality, reduction of neonatal death to less than 12 per 1000 livebirths, and reduction of death of children younger than 5 years to less than 25 per 1000 livebirths, for each country by 2030. To understand current rates, recent trends, and potential trajectories of child mortality for the next decade, we present the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 findings for all-cause mortality and cause-specific mortality in children younger than 5 years of age, with multiple scenarios for child mortality in 2030 that include the consideration of potential effects of COVID-19, and a novel framework for quantifying optimal child survival. Methods: We completed all-cause mortality and cause-specific mortality analyses from 204 countries and territories for detailed age groups separately, with aggregated mortality probabilities per 1000 livebirths computed for neonatal mortality rate (NMR) and under-5 mortality rate (U5MR). Scenarios for 2030 represent different potential trajectories, notably including potential effects of the COVID-19 pandemic and the potential impact of improvements preferentially targeting neonatal survival. Optimal child survival metrics were developed by age, sex, and cause of death across all GBD location-years. The first metric is a global optimum and is based on the lowest observed mortality, and the second is a survival potential frontier that is based on stochastic frontier analysis of observed mortality and Healthcare Access and Quality Index. Findings: Global U5MR decreased from 71·2 deaths per 1000 livebirths (95% uncertainty interval [UI] 68·3–74·0) in 2000 to 37·1 (33·2–41·7) in 2019 while global NMR correspondingly declined more slowly from 28·0 deaths per 1000 live births (26·8–29·5) in 2000 to 17·9 (16·3–19·8) in 2019. In 2019, 136 (67%) of 204 countries had a U5MR at or below the SDG 3.2 threshold and 133 (65%) had an NMR at or below the SDG 3.2 threshold, and the reference scenario suggests that by 2030, 154 (75%) of all countries could meet the U5MR targets, and 139 (68%) could meet the NMR targets. Deaths of children younger than 5 years totalled 9·65 million (95% UI 9·05–10·30) in 2000 and 5·05 million (4·27–6·02) in 2019, with the neonatal fraction of these deaths increasing from 39% (3·76 million [95% UI 3·53–4·02]) in 2000 to 48% (2·42 million; 2·06–2·86) in 2019. NMR and U5MR were generally higher in males than in females, although there was no statistically significant difference at the global level. Neonatal disorders remained the leading cause of death in children younger than 5 years in 2019, followed by lower respiratory infections, diarrhoeal diseases, congenital birth defects, and malaria. The global optimum analysis suggests NMR could be reduced to as low as 0·80 (95% UI 0·71–0·86) deaths per 1000 livebirths and U5MR to 1·44 (95% UI 1·27–1·58) deaths per 1000 livebirths, and in 2019, there were as many as 1·87 million (95% UI 1·35–2·58; 37% [95% UI 32–43]) of 5·05 million more deaths of children younger than 5 years than the survival potential frontier. Interpretation: Global child mortality declined by almost half between 2000 and 2019, but progress remains slower in neonates and 65 (32%) of 204 countries, mostly in sub-Saharan Africa and south Asia, are not on track to meet either SDG 3.2 target by 2030. Focused improvements in perinatal and newborn care, continued and expanded delivery of essential interventions such as vaccination and infection prevention, an enhanced focus on equity, continued focus on poverty reduction and education, and investment in strengthening health systems across the development spectrum have the potential to substantially improve U5MR. Given the widespread effects of COVID-19, considerable effort will be required to maintain and accelerate progress. Funding: Bill & Melinda Gates Foundation.

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Reasons for being unsure or unwilling regarding intention to take COVID-19 vaccine among Japanese people: A large cross-sectional national survey

Shuhei Nomura, Akifumi Eguchi, Daisuke Yoneoka, Takayuki Kawashima, Yuta Tanoue, Michio Murakami, Haruka Sakamoto, Keiko Maruyama-Sakurai, Stuart Gilmour, Shoi Shi, Hiroyuki Kunishima, Satoshi Kaneko, Megumi Adachi, Koki Shimada, Yoshiko Yamamoto, Hiroaki Miyata

The Lancet Regional Health - Western Pacific (Elsevier BV) 14 100223 - 100223 2021.09

Accepted, ISSN 2666-6065

BACKGROUND: Identifying and understanding reasons for being unsure or unwilling regarding intention to be vaccinated against coronavirus disease (COVID-19) may help to inform future public health messages aimed at increasing vaccination coverage. We analyzed a broad array of individual's psychological dispositions with regard to decision-making about COVID-19 vaccination in Japan. METHODS: A nationally representative cross-sectional web survey was conducted with 30053 Japanese adults aged 20 years or older at the end of February 2021. In addition to the question on the individual's intention to be vaccinated against COVID-19, respondents were asked about their sociodemographic, health-related, and psychological characteristics as well as information sources about COVID-19 and their levels of trust. Also, those who responded 'not sure' or 'no' regarding intention to take COVID-19 vaccine were asked why. Multinomial logistic regression with sparse group Lasso (Least Absolute Shrinkage and Selection Operator) penalty was used to compute adjusted odds ratios for factors associated with the intention (not sure/no versus yes). FINDINGS: The percentages of respondents who answered 'not sure' or 'no' regarding intention to be vaccinated against COVID-19 vaccine were 32.9% and 11.0%, respectively. After adjusting for covariates, the perceived risks of COVID-19, perceived risk of a COVID-19 vaccine, perceived benefits of a COVID-19 vaccine, trust in scientists and public authorities, and the belief that healthcare workers should be vaccinated were significantly associated with vaccination intention. Several sources of information about COVID-19 were also significantly associated with vaccination intention, including physicians, nurses, and television, medical information sites with lower odds of being unsure or unwilling, and internet news sites, YouTube, family members, and scientists and researchers with higher odds. The higher the level of trust in television as a source of COVID-19 information, the higher the odds of responding 'not sure' (odds ratio 1.11, 95% confidence interval 1.01-1.21). We also demonstrated that many respondents presented concerns about the side effects and safety of a COVID-19 vaccine as a major reason for being unsure or unwilling. To decide whether or not to get the vaccine, many respondents requested more information about the compatibilities between the vaccine and their personal health conditions, whether other people had been vaccinated, the effectiveness of vaccines against variants, and doctors' recommendations. INTERPRETATION: Our findings suggest that public health messaging based on the sociodemographic and psychological characteristics of those who are unsure or unwilling regarding intention to be vaccinated against COVID-19 vaccine may help to increase vaccine uptake amongst this population. FUNDING: The present work was supported in part by a grant from the Ministry of Health, Labour and Welfare of Japan (H29-Gantaisaku-ippan-009).

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Tracking Development Assistance for Health: A Comparative Study of the 29 Development Assistance Committee Countries, 2011–2019

Shuhei Nomura, haruka sakamoto, Aya Ishizuka, Kenji Shibuya

International Journal of Environmental Research and Public Health (MDPI AG) 18 ( 16 ) 8519 - 8519 2021.08

Accepted, ISSN 16617827

Development assistance for health (DAH) is an important part of financing healthcare in low- and middle-income countries. We estimated the gross disbursement of DAH of the 29 Development Assistance Committee (DAC) member countries of the Organisation for Economic Co-operation and Development (OECD) for 2011–2019; and clarified its flows, including aid type, channel, target region, and target health focus area. Data from the OECD iLibrary were used. The DAH definition was based on the OECD sector classification. For core funding to non-health-specific multilateral agencies, we estimated DAH and its flows based on the OECD methodology for calculating imputed multilateral official development assistance (ODA). The total amount of DAH for all countries combined was 18.5 billion USD in 2019, at 17.4 USD per capita, with the 2011–2019 average of 19.7 billion USD. The average share of DAH in ODA for the 29 countries was about 7.9% in 2019. Between 2011 and 2019, most DAC countries allocated approximately 60% of their DAH to primary health care, with the remaining 40% allocated to health system strengthening. We expect that the estimates of this study will help DAC member countries strategize future DAH wisely, efficiently, and effectively while ensuring transparency.

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Hospital admission for type 2 diabetes mellitus under the Universal Coverage Scheme in Thailand: A time- and geographical-trend analysis, 2009–2016

Tanapat Laowahutanon, Haruyo Nakamura, Hisateru Tachimori, Shuhei Nomura, Tippawan Liabsuetrakul, Apiradee Lim, Petch Rawdaree, Netnapis Suchonwanich, Hiroyuki Yamamoto, Aya Ishizuka, Kenji Shibuya, Hiroaki Miyata, Virasakdi Chongsuvivatwong

PLOS ONE (Public Library of Science (PLoS)) 16 ( 7 July ) e0253434 - e0253434 2021.07

Accepted, ISSN 1932-6203

<sec id="sec001">
<title>Background</title>
Descriptive analyses of 2009–2016 were performed using the data of the Universal Coverage Scheme (UCS) which covers nearly 70 percent of the Thai population. The analyses described the time and geographical trends of nationwide admission rates of type 2 diabetes mellitus (T2DM) and its complications, including chronic kidney disease (CKD), myocardial infarction, cerebrovascular diseases, retinopathy, cataract, and diabetic foot amputation.

</sec>
<sec id="sec002">
<title>Methods and findings</title>
The database of T2DM patients aged 15–100 years who were admitted between 2009 and 2016 under the UCS and that of the UCS population were retrieved for the analyses. The admitted cases of T2DM were extracted from the database using disease codes of principal and secondary diagnoses defined by the International Classification of Diseases 9th and 10th Revisions. The T2DM admission rates in 2009–2016 were the number of admissions divided by the number of the UCS population. The standardized admission rates (SARs)were further estimated in contrast to the expected number of admissions considering age and sex composition of the UCS population in each region. A linearly increased trend was found in T2DM admission rates from 2009 to 2016. Female admission rates were persistently higher than that of males. In 2016, an increase in the T2DM admission rates was observed among the older ages relative to that in 2009. Although the SARs of T2DM were generally higher in Bangkok and central regions in 2009, except that with CKD and foot amputation which had higher trends in northeastern regions, the geographical inequalities were fairly reduced by 2016.

</sec>
<sec id="sec003">
<title>Conclusion</title>
Admission rates of T2DM and its major complications increased in Thailand from 2009 to 2016. Although the overall geographical inequalities in the SARs of T2DM were reduced in the country, further efforts are required to improve the health system and policies focusing on risk factors and regions to manage the increasing T2DM.

</sec>

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Prediction of disability-adjusted life years for diseases due to low fruit intake in 2017–2040 in Japan

Daisuke Yoneoka, Shuhei Nomura, Shiori Tanaka, Aya Ishizuka, Ueda Peter, Santosh Kumar Rauniyar, Keiji Nakamura, Hisayuki Uneyama, Naoki Hayashi, Kenji Shibuya

Public Health Nutrition (Cambridge University Press (CUP)) 24 ( 10 ) 3156 - 3166 2021.07

Accepted, ISSN 13689800

<title>Abstract</title>
<sec id="S1368980020004541_as1">
<title>Objective:</title>
The current study aimed to predict disability-adjusted life years (DALY) rate in Japan through 2040 with plausible future scenarios of fruit intake for neoplasms, cardiovascular diseases (CVD) and diabetes and kidney diseases (DKD).

</sec>
<sec id="S1368980020004541_as2">
<title>Design:</title>
Data from National Health and Nutrition Surveys and the Global Burden of Diseases study in 2017 were used. We developed an autoregressive integrated moving average model with four future scenarios. Reference scenario maintains the current trend. Best scenario assumes that the goal defined in Health Japan 21 is achieved in 2023 and is kept constant afterwards. Moderate scenario assumes that the goal is achieved in 2040. Constant scenario applies the same proportion of 2016 for the period between 2017 and 2040.

</sec>
<sec id="S1368980020004541_as3">
<title>Setting:</title>
DALY rates in Japan were predicted for the period between 2017 and 2040.

</sec>
<sec id="S1368980020004541_as4">
<title>Participants:</title>
Population aged more than than 20 years old.

</sec>
<sec id="S1368980020004541_as5">
<title>Results:</title>
In our reference forecast, the DALY rates in all-ages group were projected to be stable for CVD and continue increasing for neoplasms and DKD. Age group-specific DALY rates for these three disease groups were forecasted to decrease, with some exceptions. Among men aged 20–49 years, DALY attributable to CVD differed substantially between the scenarios, implying that there is a significant potential for reducing the burden of CVD by increasing fruit intake at the population level.

</sec>
<sec id="S1368980020004541_as6">
<title>Conclusions:</title>
Our scenario analysis shows that higher fruit intake is associated with lower disease burden in Japan. Further research is required to assess which policies and interventions can be used to achieve an increase in fruit intake as modelled in the scenarios of the current study.

</sec>

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Umami: An Alternative Japanese Approach to Reducing Sodium While Enhancing Taste Desirability

Shuhei Nomura, Aya Ishizuka, Shiori Tanaka, Daisuke Yoneoka, Hisayuki Uneyama, Kenji Shibuya

Health (Scientific Research Publishing, Inc.) 13 ( 06 ) 629 - 636 2021.06

Lead author, Accepted, ISSN 1949-4998

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Trends in emergency transportation due to heat illness under the new normal lifestyle in the COVID-19 era, in Japan and 47 prefectures

Shinya Uryu, Yuta Tanoue, Shuhei Nomura, Kentaro Matsuura, Koji Makiyama, Takayuki Kawashima, Daisuke Yoneoka, Akifumi Eguchi, Yumi Kawamura, Stuart Gilmour, Haruka Sakamoto, Kazuki Shimizu, Chris Fook Sheng Ng, Masahiro Hashizume

Science of The Total Environment (Elsevier BV) 768 144723 - 144723 2021.05

Accepted, ISSN 00489697

In Japan, in response to the spread of the new coronavirus disease (COVID-19), a 'new normal' in the era of the COVID-19 was proposed by the government, which calls for thorough wearing of masks as an infection control measure in the era of the COVID-19, but related heat illness has been a great concern this summer. We applied quasi-Poisson regression models to the daily number of emergency transportations due to heat illness from 2008 to 2020 from the Fire and Disaster Management Agency, Ministry of Internal Affairs and Communications, Japan, to estimate the expected weekly number of emergency transportations from heat illness, with adjustment for their long-term trend and the weather conditions, including temperatures. We found that, at the national level, the number of heat illness emergency transports did not significantly increase or decrease from the annual trend in 2020. By prefecture, on the other hand, there were some prefectures in which the number of heat illness emergency transports was less than the average year, and most of them were in the week of August 10-16. By age group, the number of heat illness emergency transports in the 0-17 and 18-64 age groups was particularly low in some prefectures, and by severity, those in mild cases was particularly low. A caution is necessary that there is a possibility that a decrease in cases possibly associated with COVID-19 measures, such as, outdoor activity restrictions at schools/universities and cancellation of public events, may offset the possible increase in heat illness cases occurring elsewhere associated with wearing masks. Given that the end of the COVID-19 pandemic is not expected yet, continuous and appropriate awareness-raising activities to prevent heat-related illness remain important.

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Assessing Factors Associated with TB Awareness in Nepal: A National and Subnational Study

Yoko Iwaki, Santosh Kumar Rauniyar, Shuhei Nomura, Michael C. Huang

International Journal of Environmental Research and Public Health ({MDPI} {AG}) 18 ( 10 ) 5124 - 5124 2021.05

Accepted, ISSN 16617827

Tuberculosis (TB) has still remained a serious global health threat in low- and middle-income countries in recent years. As of 2021, Nepal is one of the high TB burden countries, with an increasing prevalence of cases. This study evaluates factors associated with TB awareness in Nepal. This study uses data from the Nepal Demographic and Health Survey, a cross-sectional survey carried out from June 2016 to January 2017. Multilevel logistic regression is performed to examine the association of demographic and socioeconomic factors with TB awareness. Our findings show a high level of TB awareness in all seven provinces of Nepal. Province 5 has the highest level of awareness (98.1%) among all provinces, followed by provinces 3 and 4, while province 6 has the lowest awareness level (93.2%) compared to others. Socioeconomic factors such as wealth, education and owning a mobile phone are significantly associated with TB awareness. Socioeconomic determinants are influential factors associated with TB awareness in Nepal. The wide variation in the proportion of awareness at a regional level emphasizes the importance of formulating tailored strategies to increase TB awareness. For instance, the use of mobile phones could be an effective strategy to promote TB awareness at a regional level. This study provides valuable evidence to support further research on the contribution of information and communication technology (ICT) usage to improving TB awareness in Nepal.

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Expected Scopes of Health Emergency and Disaster Risk Management (Health EDRM): Report on the Expert Workshop at the Annual Conference for the Japanese Association for Disaster Medicine 2020

Shuhei Nomura, Ryoma Kayano, Shinichi Egawa, Nahoko Harada, Yuichi Koido

International Journal of Environmental Research and Public Health (MDPI AG) 18 ( 9 ) 4447 - 4447 2021.05

Accepted, ISSN 16617827

The World Health Organization (WHO) and its partners established the WHO Thematic Platform for Health Emergency and Disaster Risk Management Research Network (HEALTH EDRM RN) in 2016 to respond to the increasing burden of recent health emergencies and disasters. The mission of the HEALTH EDRM RN, whose secretariat is located at the WHO Kobe Centre (WKC), is to promote global research collaboration and strengthen research activities to inform policies and programs by generating new evidence to manage health risks associated with all types of emergencies and disasters. With the strong support and involvement of all WHO regional offices, the HEALTH EDRM RN now works with more than 200 global experts and partners to pursue its mission. The first Core Group Meetings of the HEALTH EDRM RN were held on 17–18 October 2019, and concluded with the HEALTH EDRM RN-activity priorities to (1) promote operational research to better meet the needs of emergency- and disaster-exposed individuals and communities and efforts to translate science to policies and programs and (2) strengthen the research capacity of the Health EDRM community. In collaboration with the Japanese Association for Disaster Medicine, the WKC held a workshop on 21 February 2020, in which 20 Japanese experts from different research fields participated to further discuss these two points. This paper summarizes the discussion at the workshop.

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Progress towards the Development of Research Agenda and the Launch of Knowledge Hub: The WHO Thematic Platform for Health Emergency and Disaster Risk Management Research Network (Health EDRM RN)

Ryoma Kayano, Shuhei Nomura, Jonathan Abrahams, Qudsia Huda, Emily Y. Y. Chan, Virginia Murray

International Journal of Environmental Research and Public Health 18 ( 9 ) 4959 2021.05

Accepted, ISSN 16617827

In response to the increasing burden of recent health emergencies and disasters, the World Health Organization (WHO) and its partners established the WHO thematic platform for health emergency and disaster risk management research network (health EDRM RN) in 2016, with the purposes of promoting global research collaboration among various stakeholders and enhancing research activities that generate evidence to manage health risks associated with all types of emergencies and disasters. With the strong support and involvement of all WHO regional offices, the health EDRM RN now works with more than 200 global experts and partners to implement its purposes. The 1st and 2nd Core Group Meetings of the health EDRM RN were held on 17–18 October 2019 and 27 November 2020, respectively, to discuss the development of a global research agenda that the health EDRM RN will focus on facilitating, promoting, synthesizing and implementing, taking into account the emergence of the coronavirus disease 2019 (COVID-19) (health EDRM RN research agenda). A focus of the meetings was the establishment of an online platform to share information and knowledge, including the databases that the health EDRM RN accumulates (WHO health EDRM knowledge hub). This paper presents a summary of the discussion results of the meetings.

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Association between Daily Living Walking Speed and Lifestyle and Physiological Factors in Older, Female Pokémon GO Players

Shuhei Nomura, Akifumi Eguchi, Daisuke Yoneoka, Takayuki Kawashima, Norimichi Hirahara, Yuta Tanoue, Stuart Gilmour, Hisateru Tachimori, Hiroaki Miyata

Health (Scientific Research Publishing, Inc.) 13 ( 05 ) 564 - 573 2021.05

Lead author, Accepted, ISSN 1949-4998

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COVID-19 and Heat Illness in Tokyo, Japan: Implications for the Summer Olympic and Paralympic Games in 2021.

Kazuki Shimizu, Stuart Gilmour, Hiromi Mase, Phuong Mai Le, Ayaka Teshima, Haruka Sakamoto, Shuhei Nomura

International journal of environmental research and public health 18 ( 7 ) 2021.04

ISSN 16617827

The 2020 summer Olympic and Paralympic Games in Tokyo were postponed to July-September 2021 due to the coronavirus disease 2019 (COVID-19) pandemic. While COVID-19 has emerged as a monumental health threat for mass gathering events, heat illness must be acknowledged as a potentially large health threat for maintaining health services. We examined the number of COVID-19 admissions and the Tokyo rule for emergency medical care, in Tokyo, from March to September 2020, and investigated the weekly number of emergency transportations due to heat illness and weekly averages of the daily maximum Wet Bulb Globe Temperature (WBGT) in Tokyo in the summer (2016-2020). The peak of emergency transportations due to heat illness overlapped the resurgence of COVID-19 in 2020, and an increase of heat illness patients and WBGT has been observed. Respect for robust science is critical for the decision-making process of mass gathering events during the pandemic, and science-based countermeasures and implementations for COVID-19 will be warranted. Without urgent reconsiderations and sufficient countermeasures, the double burden of COVID-19 and heat-related illnesses in Tokyo will overwhelm the healthcare provision system, and maintaining essential health services will be challenging during the 2021 summer Olympic and Paralympic Games.

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Military coup during COVID-19 pandemic and health crisis in Myanmar

Su Myat Han, Kaung Suu Lwin, Khin Thet Swe, Stuart Gilmour, Shuhei Nomura

BMJ Global Health (BMJ) 6 ( 4 ) e005801 - e005801 2021.04

Last author, Accepted

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Trends in suicide in Japan by gender during the COVID-19 pandemic, through December 2020

Shuhei Nomura, Takayuki Kawashima, Nahoko Harada, Daisuke Yoneoka, Yuta Tanoue, Akifumi Eguchi, Stuart Gilmour, Yumi Kawamura, Masahiro Hashizume

Psychiatry Research (Elsevier BV) 300 113913 - 113913 2021.04

Lead author, Accepted, ISSN 0165-1781

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Trends in healthcare access in Japan during the first wave of the COVID-19 pandemic, up to June 2020

K Makiyama, T Kawashima, S Nomura, A Eguchi, D Yoneoka, Y Tanoue, ...

International journal of environmental research and public health 18 (6), 3271 (MDPI AG) 18 ( 6 ) 1 - 11 2021.03

Accepted, ISSN 16617827

We evaluated the impact of the new coronavirus disease (COVID-19) on healthcare access in Japan in terms of the number of outpatients and hospitalized patients as well as the length of hospital stays, during the first wave of the pandemic, up to June 2020. This observational study evaluated the monthly average number of outpatients per day at hospitals, the average number of hospitalized patients per day, and the average length of hospital stays per patient, from December 2010 to June 2020, using the hospital reports data, which are open aggregated data on the utilization of hospitals from the Ministry of Health, Labour and Welfare. These numbers were compared with those from the same period of previous years, using a quasi-Poisson regression model. We found a nationwide decrease in the number of outpatients in general hospitals and hospitalized patients, particularly in long-term care beds in Japan, as well as the excess length of hospital stays among psychiatric care patients during the first wave of the COVID-19. This limited access to healthcare demonstrated the importance of the long-term health monitoring of vulnerable populations and the need for urgent management support to healthcare facilities in preparation for possible prolonged pandemics in the future.

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Excess All-Cause Deaths during Coronavirus Disease Pandemic, Japan, January–May 20201

Takayuki Kawashima, Shuhei Nomura, Yuta Tanoue, Daisuke Yoneoka, Akifumi Eguchi, Chris Fook Sheng Ng, Kentaro Matsuura, Shoi Shi, Koji Makiyama, Shinya Uryu, Yumi Kawamura, Shinichi Takayanagi, Stuart Gilmour, Hiroaki Miyata, Tomimasa Sunagawa, Takuri Takahashi, Yuuki Tsuchihashi, Yusuke Kobayashi, Yuzo Arima, Kazuhiko Kanou, Motoi Suzuki, Masahiro Hashizume

Emerging Infectious Diseases (Centers for Disease Control and Prevention (CDC)) 27 ( 3 ) 789 - 795 2021.03

Accepted, ISSN 10806040

To provide insight into the mortality burden of coronavirus disease (COVID-19) in Japan, we estimated the excess all-cause deaths for each week during the pandemic, January-May 2020, by prefecture and age group. We applied quasi-Poisson regression models to vital statistics data. Excess deaths were expressed as the range of differences between the observed and expected number of all-cause deaths and the 95% upper bound of the 1-sided prediction interval. A total of 208-4,322 all-cause excess deaths at the national level indicated a 0.03%-0.72% excess in the observed number of deaths. Prefecture and age structure consistency between the reported COVID-19 deaths and our estimates was weak, suggesting the need to use cause-specific analyses to distinguish between direct and indirect consequences of COVID-19.

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The relationship between fever rate and telework implementation as a social distancing measure against the COVID-19 pandemic in Japan

Takayuki Kawashima, Shuhei Nomura, Yuta Tanoue, Daisuke Yoneoka, Akifumi Eguchi, Shoi Shi, Hiroaki Miyata

Public Health (Elsevier BV) 192 12 - 14 2021.03

Accepted, ISSN 00333506

Objectives: On March 28, the Japanese government decided on the “Basic Policies for Novel Coronavirus Disease Control” and called on the public to thoroughly implement social distancing measures (i.e., behavioral restrictions to limit the frequency and intensity of human contact), especially telework. Methods: We used population-level questionnaire data from a social networking service (SNS), with 275,560 respondents from March 5 to April 6, to evaluate the relationship between telework implementation and the presence of a fever (body temperature higher than 37.5 °C) within 1 month as a surrogate indicator of COVID-19 infection, by occupation type and age-group. Results: Among company employees, statistical significance was identified in the 15- to 29-year and 30- to 59-year age-groups, showing higher fever rates in the non-teleworker group (for the 15- to 29-year age-group, non-teleworkers: 7.64%; teleworkers: 6.45%; P = 0.02; for the 30- to 59-year age-group, non-teleworkers: 3.46%; teleworkers: 3.14%; P = 0.02). Conclusions: Telework remains a controversial topic in Japan as the government called for emergency measures. Although caution is warranted in interpreting our findings because our data are limited to the voluntary SNS users, they will be essential to push forward with more measures to promote social distancing measures in the midst of Japan's current tense political climate.

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Comparison of short-term outcomes between transthoracic and robot-assisted transmediastinal radical surgery for esophageal cancer: a prospective study.

Yoshimura S and Mori K and Ri M and Aikou S and Yagi K and Yamagata Y and Nishida M and Yamashita H and Nomura S and Seto Y

BMC cancer 2021.03

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Age-appropriate vaccination coverage and its determinants in children aged 12-36 months in Nepal: a national and subnational assessment

Rauniyar SK and Iwaki Y and Yoneoka D and Hashizume M and Nomura S

2021.03

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Assessing the regional impact of Japan’s COVID-19 state of emergency declaration: a population-level observational study using social networking services

Daisuke Yoneoka, Shoi Shi, Shuhei Nomura, Yuta Tanoue, Takayuki Kawashima, Akifumi Eguchi, Kentaro Matsuura, Koji Makiyama, Shinya Uryu, Keisuke Ejima, Haruka Sakamoto, Toshibumi Taniguchi, Hiroyuki Kunishima, Stuart Gilmour, Hiroshi Nishiura, Hiroaki Miyata

BMJ Open (BMJ) 11 ( 2 ) e042002 - e042002 2021.02

Accepted, ISSN 2044-6055

<sec><title>Objective</title>On 7 April 2020, the Japanese government declared a state of emergency in response to the novel coronavirus outbreak. To estimate the impact of the declaration on regional cities with low numbers of COVID-19 cases, large-scale surveillance to capture the current epidemiological situation of COVID-19 was urgently conducted in this study.

</sec><sec><title>Design</title>Cohort study.

</sec><sec><title>Setting</title>Social networking service (SNS)-based online survey conducted in five prefectures of Japan: Tottori, Kagawa, Shimane, Tokushima and Okayama.

</sec><sec><title>Participants</title>127 121 participants from the five prefectures surveyed between 24 March and 5 May 2020.

</sec><sec><title>Interventions</title>An SNS-based healthcare system named COOPERA (COvid-19: Operation for Personalized Empowerment to Render smart prevention And care seeking) was launched. It asks questions regarding postcode, personal information, preventive actions, and current and past symptoms related to COVID-19.

</sec><sec><title>Primary and secondary outcome measures</title>Empirical Bayes estimates of age-sex-standardised incidence rate (EBSIR) of symptoms and the spatial correlation between the number of those who reported having symptoms and the number of COVID-19 cases were examined to identify the geographical distribution of symptoms in the five prefectures.

</sec><sec><title>Results</title>97.8% of participants had no subjective symptoms. We identified several geographical clusters of fever with significant spatial correlation (r=0.67) with the number of confirmed COVID-19 cases, especially in the urban centres of prefectural capital cities.

</sec><sec><title>Conclusions</title>Given that there are still several high-risk areas measured by EBSIR, careful discussion on which areas should be reopened at the end of the state of emergency is urgently required using real-time SNS system to monitor the nationwide epidemic.

</sec>

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Human papillomavirus vaccine effectiveness within a cervical cancer screening programme: cohort study

C. Acuti Martellucci, S. Nomura, D. Yoneoka, P. Ueda, J. M.L. Brotherton, K. Canfell, M. Palmer, L. Manzoli, P. Giorgi Rossi, A. De Togni, C. Palmonari, A. Califano, E. Saito, M. Hashizume, K. Shibuya

BJOG: An International Journal of Obstetrics and Gynaecology 128 ( 3 ) 532 - 539 2021.02

ISSN 14700328

Objective: To assess the effectiveness of an HPV vaccination programme in reducing the risk of cervical abnormalities identified at subsequent screening. Design: Retrospective cohort study using administrative health data. Setting: General population of Ferrara Province, Italy. Population: Female residents born in 1986–1993 and participating in the organized cervical screening programme in 2011–2018, who were eligible for HPV vaccination in catch-up cohorts. Methods: Logistic regression to evaluate the potential association between abnormal cervical cytology and one, two, three or at least one dose of HPV vaccine. Main outcome measures: Cervical abnormalities, as predicted by low-grade or high-grade cytology, by number of vaccine doses, stratified by age. Results: The sample consisted of 7785 women (mean age 27.5 years, SD 2.3). Overall, 391 (5.0%) were vaccinated with ≥1 dose and 893 (11.5%) had abnormal cytology. Women receiving at least one vaccine dose were significantly less likely to have an abnormal cytology (adjusted odds ratio 0.52; 95% confidence interval 0.34–0.79). Similar results were observed for women receiving a single dose, for both bivalent and quadrivalent vaccines, and applying buffer periods (excluding cytological outcomes within 1 month, 6 months and 1 year of the first dose). Conclusions: In the context of an organised cervical screening programme in Italy, catch-up HPV vaccination almost halved the risk of cytological abnormalities. Tweetable abstract: Among Ferrara women, vaccination against human papillomavirus halved the risk of screening cervical abnormalities.

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Development and Worsening of Diabetes Among Adults Aged Over 40 Years: A 6-Year Follow-Up Study of 140,000 People in Japan – The Shizuoka Study

Nomura S, Sakamoto H, Rauniyar SK, Shimada K, Yamamoto H, Kohsaka S, Ichihara N, Kumamaru H, Miyata H

2021.02

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Trends in suicide in Japan by gender during the COVID-19 pandemic, up to September 2020

Shuhei Nomura, Takayuki Kawashima, Daisuke Yoneoka, Yuta Tanoue, Akifumi Eguchi, Stuart Gilmour, Yumi Kawamura, Nahoko Harada, Masahiro Hashizume

Psychiatry Research (Elsevier BV) 295 113622 - 113622 2021.01

Accepted, ISSN 01651781

Suicide is an extreme consequence of the psychological burden associated with the coronavirus disease 2019 (COVID-19) counter-measures. A quasi-Poisson regression was applied to monthly suicide mortality data obtained from the National Police Agency to estimate the gender-specific excess/exiguous suicide deaths during the COVID-19 pandemic in Japan up to September 2020. We found excess suicide deaths among women in July, August and September, but not among men. Our results indicate the importance of COVID-19 related suicide prevention, especially for women. Timely access to mental health care and financial and social support is urgently needed, as is optimal treatment for mental illness.

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Overall health information exposure, its barriers and impacts on attitude toward healthcare among cancer patients. The long-term aftermath of the 2011 triple disaster in Fukushima, Japan: A single institution cross-sectional study

Akihiko Ozaki, Michio Murakami, Shuhei Nomura, Toyoaki Sawano, Masaharu Tsubokura, Kyoko Ono, Yoshitake Takebayashi, Manabu Tsukada, Kazue Yamaoka, Yoshinori Nakata, Hiromichi Ohira

Health Informatics Journal (SAGE Publications) 27 ( 2 ) 146045822199642 - 146045822199642 2021

Accepted, ISSN 14604582

Disasters can hinder access to health information among cancer patients. However, little is known regarding overall health information exposure (HIE), its barriers and its impacts on attitudes toward healthcare among cancer patients in the long-term aftermath of disasters. The aims of this study were threefold: assess the extent of HIE; identify associations between family composition and a non-engagement with HIE; and examine the effects of HIE on attitudes toward healthcare among local cancer patients—5 years after the 2011 triple disaster (earthquake, tsunami, and nuclear disaster) in Fukushima, Japan. We conducted self-administered surveys with all cancer and non-cancer surgery department outpatients at Minamisoma Municipal General Hospital (MMGH), Minamisoma City, from October 2016 to January 2017. In total, 404 patients (263 cancer patients and 141 non-cancer patients) voluntarily participated in the study. The results revealed that a regular level of HIE occurred among 90.5% of the cancer patients. In cancer patients, family composition was not significantly associated with HIE, and HIE was not associated with attitude toward healthcare. In conclusion, most cancer patients visiting the MMGH surgical department were regularly engaged in HIE.

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Loss of working life years due to mortality, sickness absence, or ill-health retirement: A comprehensive approach to estimating disease burden in the workplace.

Yosuke Inoue, Shuhei Nomura, Chihiro Nishiura, Ai Hori, Kenya Yamamoto, Tohru Nakagawa, Toru Honda, Shuichiro Yamamoto, Masafumi Eguchi, Takeshi Kochi, Toshiaki Miyamoto, Hiroko Okazaki, Teppei Imai, Akiko Nishihara, Takayuki Ogasawara, Naoko Sasaki, Akihiko Uehara, Makoto Yamamoto, Makiko Shimizu, Maki Konishi, Isamu Kabe, Tetsuya Mizoue, Seitaro Dohi

Journal of epidemiology (Japan Epidemiological Association) 31 ( 7 ) 403 - 409 2021

ISSN 09175040

BACKGROUND: While much effort has focused on quantifying disease burden in occupational health, no study has simultaneously assessed disease burden in terms of mortality and morbidity. We aimed to propose a new comprehensive method of quantifying the disease burden in the workplace. METHOD: The data were obtained from the Japan Epidemiology Collaboration on Occupational Health (J-ECOH) Study, a large-scale prospective study of approximately 80,000 workers. We defined disease burden in the workplace as the number of working years lost among the working population during a 6-year period (April 2012 to March 2018). We calculated the disease burden according to consequences of health problems (i.e., mortality, sickness absence [SA], and ill-health retirement) and disease category. We also calculated the age-group- (20-39 and 40-59 years old) and sex-specific disease burden. RESULTS: The largest contributors to disease burden in the workplace were mental and behavioural disorders (47.0 person-years lost per 10,000 person-years of working years, i.e., per myriad [proportion]), followed by neoplasms (10.8 per myriad) and diseases of the circulatory system (7.1 per myriad). While mental and behavioural disorders made a greater contribution to SA and ill-health retirement compared to mortality, the latter two disorders were the largest contributors to the disease burden in the workplace due to mortality. The number of working years lost was greater among younger vs. older female participants, whereas the opposite trend was observed in males. CONCLUSIONS: Our approach is in contrast to those in previous studies that focused exclusively on mortality or morbidity.

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Hypertensive disorders of pregnancy by oocyte donation pregnancy in Japanese women aged 40 years or older: a single-center retrospective cohort study.

Gekka Y, Adachi T, Oi R, Nakayama S, Kawana Y, Takeda Y, Nomura S, Ozaki A, Tanimoto T, Sakamoto H, Yamashita T

Hypertension in pregnancy (Informa UK Limited) 40 ( 1 ) 36 - 44 2021

Accepted, ISSN 10641955

This study aimed to examine the incidence of hypertensive disorders of pregnancy (HDP) among Japanese women with oocyte donation pregnancy (ODP) aged 40 years or older and estimate whether the women with ODP were more likely to develop HDP than those with autologous oocyte pregnancy (AOP) and spontaneous pregnancy (SP). In our study (N = 1361), the proportions of women who developed HDP were 20.5%, 12.8%, and 7.6% for ODP, AOP, and SP, respectively. After adjustment of covariables, the women with ODP were more likely to develop HDP than those with AOP or SP.

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Effect of emergency declaration on mental health during the COVID-19 pandemic in Japan: A social network service-based difference-in-differences approach

Akifumi Eguchi, Daisuke Yoneoka, Shoi Shi, Yuta Tanoue, Takayuki Kawashima, Shuhei Nomura, Koji Makiyama, Shinya Uryu, Masayuki Sawada, Yumi Kawamura, Shinichi Takayanagi, Stuart Gilmour, Hiroaki Miyata

Science Progress (SAGE Publications) 104 ( 3 ) 003685042110297 - 003685042110297 2021

ISSN 00368504

Strong lockdowns to control COVID-19 pandemic have been enforced globally and strongly restricted social activities with consequent negative effects on mental health. Japan has effectively implemented a unique voluntary policy to control COVID-19, but the mental health impact of the policy has not been examined on a large scale. In this study, we examined the effect of the first declaration on the mental health of affected residents. We used population-level questionnaire data of 17,400 people living under the state of emergency and 9208 who were not through a social-networking-service app and applied a difference-in-differences regression model to estimate the causal effect of the declaration of the state of emergency on psychological wellbeing, stratified by job category. No statistically significant effect of the declaration was observed among all job categories. This suggests that residents’ psychological situation has gradually changed, possibly influenced by other factors such as the surrounding environment, rather than the declaration itself. Given that Japan has a unique policy to control COVID-19 instead of a strict lockdown, our results showed the Japanese-style policy may serve as a form of harm reduction strategy, to control the epidemic with minimal psychological harm, and enable a policy that balances disease control and mental health. Caution is necessary that this study used self-reported data from a limited time period before and after the first declaration in April 2020.

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Comparative risk assessment of non-communicable diseases by evacuation scenario– a retrospective study in the 7 years following the Fukushima Daiichi nuclear power plant accident

Shuhei Nomura, Michio Murakami, Akihiko Ozaki, Toyoaki Sawano, Claire Leppold, Yoshitaka Nishikawa, Hiroaki Saito, Tomoyoshi Oikawa, Masaharu Tsubokura

Global Health Action (Informa UK Limited) 14 ( 1 ) 1918886 - 1918886 2021

Accepted, ISSN 1654-9716

Background: As a result of the Fukushima Daiichi nuclear power plant accident, many residents evacuated and were exposed to changes in their living environment and socioeconomic status, and to persistent stressors. Past studies have suggested the potential for these circumstances to contribute to long-term changes to population health.Objective: The objective of this study was to gain a better understanding of long-term health effects of evacuation, by evaluating the risk of non-communicable diseases among evacuees from Minamisoma City (one of the closest municipalities to the power plant) until 2017.Methods: The study evaluated data from annual health check-ups for residents aged 40-74 years covered by National Health Insurance (who are largely self-employed) from 2010 to 2017 administered by Minamisoma City. Diabetes, hyperlipidemia, and hypertension were defined from the results of blood sampling. Annual changes in age-adjusted prevalence were estimated by evacuation scenario. We also performed an inverse-probability weighting (IPW) analysis to adjust for baseline covariates in 2010 and estimated the differences in the risk of diabetes, hyperlipidemia, and hypertension by evacuation scenario as of the 2017 health check-up in reference to the no-evacuation group.Results: A total of 1,837 individuals were considered in this study. Regardless of evacuation scenario, there was statistical evidence suggesting an upward and a downward trend in diabetes and hypertension from 2010 to 2017, respectively, while hyperlipidemia showed no remarkable change. IPW analyses demonstrated that disease risks in 2017 did not differ significantly among people with different evacuation scenarios.Conclusions: Region-specific factors played an important role in the health effects of the evacuation. Our findings have important implications for the need of an assessment of the health effects of evacuations in more localized manner. Further research in this area will strengthen the communities' preparedness for future disasters that require mass evacuation.

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Profiling of Androgen-Dependent Enhancer RNAs Expression in Human Prostate Tumors: Search for Malignancy Transition Markers

Koichi Nishimura, Jinichi Mori, Takahiro Sawada, Shuhei Nomura, Alexander Kouzmenko, Kaori Yamashita, Yoshiaki Kanemoto, Tomohiro Kurokawa, Akira Hayakawa, Suguru Tokiwa, Michihisa Ochi, Hiroaki Shimmura, Shigeaki Kato

Research and Reports in Urology (Informa UK Limited) 13 705 - 713 2021

Accepted

INTRODUCTION: Although the ability of androgens to promote prostate cancer development has been known for decades, the molecular mechanisms of androgen receptor (AR) signaling in the tumorigenesis remain unclear. Enhancer RNAs (eRNAs) transcribed from strong enhancers, or super-enhancers (SEs), have recently emerged as a novel class of regulatory non-coding RNAs (ncRNAs) that facilitate transcription, including that of androgen target genes, through chromatin looping to position enhancers proximate to the promoters. The aim of this study was to assess androgen-dependent transcription in prostate tumors of eRNAs (designated as KLK3eRNAs) from the SE of the KLK3 gene encoding the prostate-specific antigen (PSA) protein, a clinical marker of prostate carcinogenesis. MATERIALS AND METHODS: The androgen-induced KLK3eRNAs were identified in the LNCaP human prostate cancer cell line. The expressions of these KLK3eRNAs together with KLK3 and AR mRNA transcripts were assessed by qRT-PCR in prostate tumor samples from five prostate cancer patients. RESULTS: Androgen-induced KLK3eRNAs have been identified in the LNCaP cells, and their expression was further analyzed in tumors of prostate cancer patients. Transcripts of the tested KLK3eRNAs have been detected in all clinical samples, but their expression patterns differed between individual tumor specimens. We found a statistically significant correlation between the levels of the KLK3 and AR mRNAs with those of the previously reported KLK3eRNAs, while such correlation was not observed for novel KLK3eRNAs described in our recent report. CONCLUSION: Presented data suggest that prostate tumor development may associate with epigenetic reorganization in the KLK3 genomic regulatory elements reflected by changes of the KLK3eRNA expression. Our findings support a potential of eRNAs profiling to be used as diagnostic marker.

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Excess all-cause deaths during coronavirus disease pandemic, Japan, January–May 2020

T Kawashima, S Nomura, Y Tanoue, D Yoneoka, A Eguchi, CFS Ng, ...

Emerging Infectious Diseases 27 (3), 789 2021

Correction to: Tracking Japan’s development assistance for health, 2012–2016

S Nomura, H Sakamoto, MK Sugai, H Nakamura, K Maruyama-Sakurai, ...

Globalization and Health 17, 1-4 2021

Analysis of the relationship between the HbA1c screening results and the development and worsening of diabetes among adults aged over 40 years: a 4-year follow-up study of 140 …

S Nomura, H Sakamoto, SK Rauniyar, K Shimada, H Yamamoto, ...

BMC public health 21, 1-11 2021

Tracking sectoral allocation of official development assistance: a comparative study of the 29 Development Assistance Committee countries, 2011–2018

Shuhei Nomura, Haruka Sakamoto, Aya Ishizuka, Kazuki Shimizu, Kenji Shibuya

Global Health Action (Informa {UK} Limited) 14 ( 1 ) 1903222 - 1903222 2021

Accepted, ISSN 1654-9716

Background: Official development assistance (ODA) is one of the most important means for donor countries to foster diplomatic relations with low- and middle-income countries and contribute to the welfare of the international community. Objective: This study estimated the sectoral allocation of gross disbursements of ODA of the 29 Development Assistance Committee (DAC) member countries of the Organisation for Economic Co-operation and Development (OECD) for the duration of 2011 to 2018, by aid type (bilateral, multilateral, and both aids). Methods: Data from the OECD iLibrary were used. The sector definition was based on the OECD sector classification. For core funding to multilateral agencies that do not specialize in each aid sector, we estimated ODA and its flows based on the OECD methodology for calculating imputed multilateral ODA. Results: For all 29 countries, during the period of 2014–2018 where data were available for all the countries, the sector with the highest average annual ODA contribution was health at 20.34 billion USD (13.21%), followed by humanitarian aid at 18.04 billion (11.72%). Humanitarian aid has increased in the sectoral share rankings in both bilateral and multilateral aid, and the sectoral share for refugees in donor countries has increased in bilateral aid. While the 29 countries show relatively similar trends for sectoral shares, some countries and sectors display unique trends. For instance, infrastructure and energy sectors in bilateral aid of Japan are particularly high accounts for 48.48% of the total bilateral ODA of the country in 2018. Conclusions: This paper evaluated ODA trends by major donors of DAC countries in the pre-COVID-19 pandemic periods. We hope that our estimates will contribute to the review of the strategic decision-making and the effective implementation of future ODA policy discussions in the DAC countries while ensuring transparency.

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Expected scopes of health emergency and disaster risk management (Health edrm): Report on the expert workshop at the annual conference for the japanese association for disaster …

S Nomura, R Kayano, S Egawa, N Harada, Y Koido

International journal of environmental research and public health 18 (9), 4447 2021

Tracking Japan's development assistance for health, 2012-2016 (vol 16, 32, 2020)

S Nomura, H Sakamoto, MK Sugai, H Nakamura, K Maruyama-Sakurai, ...

GLOBALIZATION AND HEALTH 17 (1) 2021

Tracking development assistance for health and for COVID-19: a review of development assistance, government, out-of-pocket, and other private spending on health for 204 …

AE Micah, IE Cogswell, B Cunningham, S Ezoe, AC Harle, ER Maddison, ...

The Lancet 398 (10308), 1317-1343 2021

Progress towards the development of research agenda and the launch of knowledge hub: the WHO thematic platform for health emergency and disaster risk management research …

R Kayano, S Nomura, J Abrahams, Q Huda, EYY Chan, V Murray

International journal of environmental research and public health 18 (9), 4959 2021

Policy and technical considerations for implementing a risk-based approach to international travel in the context of COVID-19

SL James, D Abate, KH Abate, SM Abay, C Abbafati, N Abbasi, ...

The Lancet 392 (10159), 1789-1858 2021

Overall health information exposure, its barriers and impacts on attitude toward healthcare among cancer patients. The long-term aftermath of the 2011 triple disaster in …

A Ozaki, M Murakami, S Nomura, T Sawano, M Tsubokura, K Ono, ...

Health Informatics Journal 27 (2), 1460458221996420 2021

Modelling salt intake reduction with umami substance’s incorporation into Japanese foods: A cross-sectional study

S Tanaka, D Yoneoka, A Ishizuka, M Adachi, H Hayabuchi, T Nishimura, ...

2021

Global, regional, and national progress towards Sustainable Development Goal 3.2 for neonatal and child health: all-cause and cause-specific mortality findings from the Global …

KR Paulson, AM Kamath, T Alam, K Bienhoff, GG Abady, J Abbas, ...

The Lancet 398 (10303), 870-905 2021

Ongoing debate on data governance principles for achieving Universal Health Coverage: a proposal to post-G20 Osaka Summit meetings

Shuhei Nomura, Haruka Sakamoto, Aya Ishizuka, Yasushi Katsuma, Hidechika Akashi, Hiroaki Miyata

Global Health Action (Informa {UK} Limited) 13 ( 1 ) 1859822 - 1859822 2020.12

Lead author, Corresponding author, Accepted, ISSN 1654-9716

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Reduced burden from major diseases due to an increase in vegetable intake in Japan: projections of disability-adjusted life years, 2017-2040

Tanaka S, Yoneoka D, Ishizuka A, Ueda P, Nakamura K, Uneyama H, Hayashi N, Shibuya K, Nomura S

2020.12

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Trends in deaths from road injuries during the COVID-19 pandemic in Japan, January to September 2020

Shuhei Nomura, Takayuki Kawashima, Daisuke Yoneoka, Yuta Tanoue, Akifumi Eguchi, Stuart Gilmour, Masahiro Hashizume

Injury Epidemiology (Springer Science and Business Media LLC) 7 ( 66 ) 66 - 66 2020.12

Lead author, Accepted

<title>Abstract</title><sec>
<title>Background</title>
In Japan, the latest estimates of excess all-cause deaths through January to July 2020 showed that the overall (direct and indirect) mortality burden from the Coronavirus Disease 2019 (COVID-19) in Japan was relatively low compared to Europe and the United States. However, consistency between the reported number of COVID-19 deaths and excess all-cause deaths was limited across prefectures, suggesting the necessity of distinguishing the direct and indirect consequences of COVID-19 by cause-specific analysis. To examine whether deaths from road injuries decreased during the COVID-19 pandemic in Japan, consistent with a possible reduction of road transport activity connected to Japan’s state of emergency declaration, we estimated the exiguous deaths from road injuries in each week from January to September 2020 by 47 prefectures.

</sec><sec>
<title>Methods</title>
To estimate the expected weekly number of deaths from road injuries, a quasi-Poisson regression was applied to daily traffic fatalities data obtained from Traffic Accident Research and Data Analysis, Japan. We set two thresholds, point estimate and lower bound of the two-sided 95% prediction interval, for exiguous deaths, and report the range of differences between the observed number of deaths and each of these thresholds as exiguous deaths.

</sec><sec>
<title>Results</title>
Since January 2020, in a few weeks the observed deaths from road injuries fell below the 95% lower bound, such as April 6–12 (exiguous deaths 5–21, percent deficit 2.82–38.14), May 4–10 (8–23, 21.05–43.01), July 20–26 (12–29, 30.77–51.53), and August 3–9 (3–20, 7.32–34.41). However, those less than the 95% lower bound were also observed in weeks in the previous years.

</sec><sec>
<title>Conclusions</title>
The number of road traffic fatalities during the COVID-19 pandemic in Japan has decreased slightly, but not significantly, in several weeks compared with the average year. This suggests that the relatively small changes in excess all-cause mortality observed in Japan during the COVID-19 pandemic could not be explained simply by an offsetting reduction in traffic deaths. Considering a variety of other indirect effects, evaluating an independent, unbiased measure of COVID-19-related mortality burden could provide insight into the design of future broad-based infectious disease counter-measures and offer lessons to other countries.

</sec>

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Digitization of the approach to food and nutrition respecting individual health values

Shuhei Nomura, Hiroaki Miyata

Nutrition Reviews (Oxford University Press (OUP)) 78 ( Supplement_3 ) 46 - 48 2020.11

Lead author, Accepted, ISSN 0029-6643

<title>Abstract</title>
Japan’s aging population and increasing medical costs threaten the sustainability of its healthcare system. Society 5.0, Japan’s growth strategy, calls for a paradigm shift in healthcare based on digital technology. Health is a topic of great public concern, and diet and nutrition are at the heart of health. Many different values are used to define health, and Society 5.0 focuses on creating personalized values for different styles of eating and health. Health is already at the core of global business, and Japan, which is ahead of the rest of the world in its super-aging society, has a unique opportunity to be the first to create new business solutions for diet and nutrition.

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The herbivore’s dilemma: Trends in and factors associated with heterosexual relationship status and interest in romantic relationships among young adults in Japan—Analysis of national surveys, 1987–2015

Cyrus Ghaznavi, Haruka Sakamoto, Shuhei Nomura, Anna Kubota, Daisuke Yoneoka, Kenji Shibuya, Peter Ueda

PLOS ONE (Public Library of Science (PLoS)) 15 ( 11 ) e0241571 - e0241571 2020.11

Accepted

<sec id="sec001">
<title>Background</title>
It has been suggested that an increasing proportion of young adults in Japan have lost interest in romantic relationships, a phenomenon termed “herbivorization”. We assessed trends in heterosexual relationship status and self-reported interest in heterosexual romantic relationships in nationally representative data.

</sec>
<sec id="sec002">
<title>Methods</title>
We used data from seven rounds of the National Fertility Survey (1987–2015) and included adults aged 18–39 years (18–34 years in the 1987 survey; sample size 11,683–17,675). Current heterosexual relationship status (married; unmarried but in a relationship; single) was estimated by sex, age group and survey year, with singles further categorized into those reporting interest vs. no interest in heterosexual romantic relationships. Information about same-sex relationships were not available.

</sec>
<sec id="sec003">
<title>Results</title>
Between 1992 and 2015, the age-standardized proportion of 18-39-year-old Japanese adults who were single had increased steadily, from 27.4 to 40.7% among women and from 40.3 to 50.8% among men. This increase was largely driven by decreases in the proportion of married women aged 25–39 years and men aged 30–39 years, while those in a relationship had increased only slightly for women and remained stable for men. By 2015, the proportion of single women was 30.2% in those aged 30–34 years and 24.4% in those aged 35–39 years. The corresponding numbers for men were 39.3% and 32.4%. Around half of the singles (21.4% of all women and 25.1% of all men aged 18–39 years) reported that they had no interest in heterosexual romantic relationships. Single women and men who reported no interest in romantic relationships had lower income and educational levels and were less likely to have regular employment compared to those who reported such an interest.

</sec>
<sec id="sec004">
<title>Conclusions</title>
In this analysis of heterosexual relationships in nationally representative data from Japan, singlehood among young adults had steadily increased over the last three decades. In 2015 around one in four women and one in three men in their thirties were unmarried and not in a heterosexual relationship. Half of the singles reported no interest in romantic relationships and these women and men had lower income and educational levels and were less likely to have regular employment.

</sec>

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Five insights from the Global Burden of Disease Study 2019

GBD 2019 Viewpoint Collaborators

The Lancet (Elsevier BV) 396 ( 10258 ) 1135 - 1159 2020.10

Accepted, ISSN 0140-6736

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 provides a rules-based synthesis of the available evidence on levels and trends in health outcomes, a diverse set of risk factors, and health system responses. GBD 2019 covered 204 countries and territories, as well as first administrative level disaggregations for 22 countries, from 1990 to 2019. Because GBD is highly standardised and comprehensive, spanning both fatal and non-fatal outcomes, and uses a mutually exclusive and collectively exhaustive list of hierarchical disease and injury causes, the study provides a powerful basis for detailed and broad insights on global health trends and emerging challenges. GBD 2019 incorporates data from 281 586 sources and provides more than 3.5 billion estimates of health outcome and health system measures of interest for global, national, and subnational policy dialogue. All GBD estimates are publicly available and adhere to the Guidelines on Accurate and Transparent Health Estimate Reporting. From this vast amount of information, five key insights that are important for health, social, and economic development strategies have been distilled. These insights are subject to the many limitations outlined in each of the component GBD capstone papers.

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Large-scale epidemiological monitoring of the COVID-19 epidemic in Tokyo

Daisuke Yoneoka, Yuta Tanoue, Takayuki Kawashima, Shuhei Nomura, Shoi Shi, Akifumi Eguchi, Keisuke Ejima, Toshibumi Taniguchi, Haruka Sakamoto, Hiroyuki Kunishima, Stuart Gilmour, Hiroshi Nishiura, Hiroaki Miyata

The Lancet Regional Health - Western Pacific (Elsevier BV) 3 100016 - 100016 2020.10

Accepted, ISSN 2666-6065

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Global burden of 87 risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019

GBD 2019 Risk Factors Collaborators

The Lancet (Elsevier BV) 396 ( 10258 ) 1223 - 1249 2020.10

Accepted, ISSN 0140-6736

Background Rigorous analysis of levels and trends in exposure to leading risk factors and quantification of their effect on human health are important to identify where public health is making progress and in which cases current efforts are inadequate. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 provides a standardised and comprehensive assessment of the magnitude of risk factor exposure, relative risk, and attributable burden of disease.Methods GBD 2019 estimated attributable mortality, years of life lost (YLLs), years of life lived with disability (YLDs), and disability-adjusted life-years (DALYs) for 87 risk factors and combinations of risk factors, at the global level, regionally, and for 204 countries and territories. GBD uses a hierarchical list of risk factors so that specific risk factors (eg, sodium intake), and related aggregates (eg, diet quality), are both evaluated. This method has six analytical steps. (1) We included 560 risk-outcome pairs that met criteria for convincing or probable evidence on the basis of research studies. 12 risk-outcome pairs included in GBD 2017 no longer met inclusion criteria and 47 risk-outcome pairs for risks already included in GBD 2017 were added based on new evidence. (2) Relative risks were estimated as a function of exposure based on published systematic reviews, 81 systematic reviews done for GBD 2019, and meta-regression. (3) Levels of exposure in each age-sex-location-year included in the study were estimated based on all available data sources using spatiotemporal Gaussian process regression, DisMod-MR 2.1, a Bayesian meta-regression method, or alternative methods. (4) We determined, from published trials or cohort studies, the level of exposure associated with minimum risk, called the theoretical minimum risk exposure level. (5) Attributable deaths, YLLs, YLDs, and DALYs were computed by multiplying population attributable fractions (PAFs) by the relevant outcome quantity for each age-sex-location-year. (6) PAFs and attributable burden for combinations of risk factors were estimated taking into account mediation of different risk factors through other risk factors. Across all six analytical steps, 30 652 distinct data sources were used in the analysis. Uncertainty in each step of the analysis was propagated into the final estimates of attributable burden. Exposure levels for dichotomous, polytomous, and continuous risk factors were summarised with use of the summary exposure value to facilitate comparisons over time, across location, and across risks. Because the entire time series from 1990 to 2019 has been re-estimated with use of consistent data and methods, these results supersede previously published GBD estimates of attributable burden.Findings The largest declines in risk exposure from 2010 to 2019 were among a set of risks that are strongly linked to social and economic development, including household air pollution; unsafe water, sanitation, and handwashing; and child growth failure. Global declines also occurred for tobacco smoking and lead exposure. The largest increases in risk exposure were for ambient particulate matter pollution, drug use, high fasting plasma glucose, and high body-mass index. In 2019, the leading Level 2 risk factor globally for attributable deaths was high systolic blood pressure, which accounted for 10.8 million (95% uncertainty interval [UI] 9.51-12.1) deaths (19.2% [16.9-21.3] of all deaths in 2019), followed by tobacco (smoked, second-hand, and chewing), which accounted for 8.71 million (8.12-9.31) deaths (15.4% [14.6-16.2] of all deaths in 2019). The leading Level 2 risk factor for attributable DALYs globally in 2019 was child and maternal malnutrition, which largely affects health in the youngest age groups and accounted for 295 million (253-350) DALYs (11.6% [10.3-13.1] of all global DALYs that year). The risk factor burden varied considerably in 2019 between age groups and locations. Among children aged 0-9 years, the three leading detailed risk factors for attributable DALYs were all related to malnutrition. Iron deficiency was the leading risk factor for those aged 10-24 years, alcohol use for those aged 25-49 years, and high systolic blood pressure for those aged 50-74 years and 75 years and older.Interpretation Overall, the record for reducing exposure to harmful risks over the past three decades is poor. Success with reducing smoking and lead exposure through regulatory policy might point the way for a stronger role for public policy on other risks in addition to continued efforts to provide information on risk factor harm to the general public. Copyright (C) 2020 The Author(s). Published by Elsevier Ltd.

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Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019

GBD 2019 Diseases and Injuries Collaborators

The Lancet (Elsevier BV) 396 ( 10258 ) 1204 - 1222 2020.10

Accepted, ISSN 0140-6736

Background In an era of shifting global agendas and expanded emphasis on non-communicable diseases and injuries along with communicable diseases, sound evidence on trends by cause at the national level is essential. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) provides a systematic scientific assessment of published, publicly available, and contributed data on incidence, prevalence, and mortality for a mutually exclusive and collectively exhaustive list of diseases and injuries.Methods GBD estimates incidence, prevalence, mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) due to 369 diseases and injuries, for two sexes, and for 204 countries and territories. Input data were extracted from censuses, household surveys, civil registration and vital statistics, disease registries, health service use, air pollution monitors, satellite imaging, disease notifications, and other sources. Cause-specific death rates and cause fractions were calculated using the Cause of Death Ensemble model and spatiotemporal Gaussian process regression. Cause-specific deaths were adjusted to match the total all-cause deaths calculated as part of the GBD population, fertility, and mortality estimates. Deaths were multiplied by standard life expectancy at each age to calculate YLLs. A Bayesian meta-regression modelling tool, DisMod-MR 2.1, was used to ensure consistency between incidence, prevalence, remission, excess mortality, and cause-specific mortality for most causes. Prevalence estimates were multiplied by disability weights for mutually exclusive sequelae of diseases and injuries to calculate YLDs. We considered results in the context of the Socio-demographic Index (SDI), a composite indicator of income per capita, years of schooling, and fertility rate in females younger than 25 years. Uncertainty intervals (UIs) were generated for every metric using the 25th and 975th ordered 1000 draw values of the posterior distribution.Findings Global health has steadily improved over the past 30 years as measured by age-standardised DALY rates. After taking into account population growth and ageing, the absolute number of DALYs has remained stable. Since 2010, the pace of decline in global age-standardised DALY rates has accelerated in age groups younger than 50 years compared with the 1990-2010 time period, with the greatest annualised rate of decline occurring in the 0-9-year age group. Six infectious diseases were among the top ten causes of DALYs in children younger than 10 years in 2019: lower respiratory infections (ranked second), diarrhoeal diseases (third), malaria (fifth), meningitis (sixth), whooping cough (ninth), and sexually transmitted infections (which, in this age group, is fully accounted for by congenital syphilis; ranked tenth). In adolescents aged 10-24 years, three injury causes were among the top causes of DALYs: road injuries (ranked first), self-harm (third), and interpersonal violence (fifth). Five of the causes that were in the top ten for ages 10-24 years were also in the top ten in the 25-49-year age group: road injuries (ranked first), HIV/AIDS (second), low back pain (fourth), headache disorders (fifth), and depressive disorders (sixth). In 2019, ischaemic heart disease and stroke were the top-ranked causes of DALYs in both the 50-74-year and 75-years-and-older age groups. Since 1990, there has been a marked shift towards a greater proportion of burden due to YLDs from non-communicable diseases and injuries. In 2019, there were 11 countries where non-communicable disease and injury YLDs constituted more than half of all disease burden. Decreases in age-standardised DALY rates have accelerated over the past decade in countries at the lower end of the SDI range, while improvements have started to stagnate or even reverse in countries with higher SDI.Interpretation As disability becomes an increasingly large component of disease burden and a larger component of health expenditure, greater research and development investment is needed to identify new, more effective intervention strategies. With a rapidly ageing global population, the demands on health services to deal with disabling outcomes, which increase with age, will require policy makers to anticipate these changes. The mix of universal and more geographically specific influences on health reinforces the need for regular reporting on population health in detail and by underlying cause to help decision makers to identify success stories of disease control to emulate, as well as opportunities to improve. Copyright (C) 2020 The Author(s). Published by Elsevier Ltd.

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Global age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950–2019: a comprehensive demographic analysis for the Global Burden of Disease Study 2019

GBD 2019 Demographics Collaborators

The Lancet (Elsevier BV) 396 ( 10258 ) 1160 - 1203 2020.10

Accepted, ISSN 0140-6736

Background Accurate and up-to-date assessment of demographic metrics is crucial for understanding a wide range of social, economic, and public health issues that affect populations worldwide. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 produced updated and comprehensive demographic assessments of the key indicators of fertility, mortality, migration, and population for 204 countries and territories and selected subnational locations from 1950 to 2019.Methods 8078 country-years of vital registration and sample registration data, 938 surveys, 349 censuses, and 238 other sources were identified and used to estimate age-specific fertility. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate age-specific fertility rates for 5-year age groups between ages 15 and 49 years. With extensions to age groups 10-14 and 50-54 years, the total fertility rate (TFR) was then aggregated using the estimated age-specific fertility between ages 10 and 54 years. 7417 sources were used for under-5 mortality estimation and 7355 for adult mortality. ST-GPR was used to synthesise data sources after correction for known biases. Adult mortality was measured as the probability of death between ages 15 and 60 years based on vital registration, sample registration, and sibling histories, and was also estimated using ST-GPR. HIV-free life tables were then estimated using estimates of under-5 and adult mortality rates using a relational model life table system created for GBD, which closely tracks observed age-specific mortality rates from complete vital registration when available. Independent estimates of HIV-specific mortality generated by an epidemiological analysis of HIV prevalence surveys and antenatal clinic serosurveillance and other sources were incorporated into the estimates in countries with large epidemics. Annual and single-year age estimates of net migration and population for each country and territory were generated using a Bayesian hierarchical cohort component model that analysed estimated age-specific fertility and mortality rates along with 1250 censuses and 747 population registry years. We classified location-years into seven categories on the basis of the natural rate of increase in population (calculated by subtracting the crude death rate from the crude birth rate) and the net migration rate. We computed healthy life expectancy (HALE) using years lived with disability (YLDs) per capita, life tables, and standard demographic methods. Uncertainty was propagated throughout the demographic estimation process, including fertility, mortality, and population, with 1000 draw-level estimates produced for each metric.Findings The global TFR decreased from 2.72 (95% uncertainty interval [UI] 2.66-2.79) in 2000 to 2.31 (2.17-2.46) in 2019. Global annual livebirths increased from 134.5 million (131.5-137.8) in 2000 to a peak of 139.6 million (133.0-146.9) in 2016. Global livebirths then declined to 135.3 million (127.2-144.1) in 2019. Of the 204 countries and territories included in this study, in 2019, 102 had a TFR lower than 2.1, which is considered a good approximation of replacement-level fertility. All countries in sub-Saharan Africa had TFRs above replacement level in 2019 and accounted for 27.1% (95% UI 26.4-27.8) of global livebirths. Global life expectancy at birth increased from 67.2 years (95% UI 66.8-67.6) in 2000 to 73.5 years (72.8-74.3) in 2019. The total number of deaths increased from 50.7 million (49.5-51.9) in 2000 to 56.5 million (53.7-59.2) in 2019. Under-5 deaths declined from 9.6 million (9.1-10.3) in 2000 to 5.0 million (4.3-6.0) in 2019. Global population increased by 25.7%, from 6.2 billion (6.0-6.3) in 2000 to 7.7 billion (7.5-8.0) in 2019. In 2019, 34 countries had negative natural rates of increase; in 17 of these, the population declined because immigration was not sufficient to counteract the negative rate of decline. Globally, HALE increased from 58.6 years (56.1-60.8) in 2000 to 63.5 years (60.8-66.1) in 2019. HALE increased in 202 of 204 countries and territories between 2000 and 2019.Interpretation Over the past 20 years, fertility rates have been dropping steadily and life expectancy has been increasing, with few exceptions. Much of this change follows historical patterns linking social and economic determinants, such as those captured by the GBD Socio-demographic Index, with demographic outcomes. More recently, several countries have experienced a combination of low fertility and stagnating improvement in mortality rates, pushing more populations into the late stages of the demographic transition. Tracking demographic change and the emergence of new patterns will be essential for global health monitoring. Copyright (C) 2020 The Author(s). Published by Elsevier Ltd.

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Trend change of the transmission route of COVID-19–related symptoms in Japan

A. Eguchi, D. Yoneoka, S. Shi, Y. Tanoue, T. Kawashima, S. Nomura, K. Matsuura, K. Makiyama, K. Ejima, S. Gilmour, H. Nishiura, H. Miyata

Public Health (Elsevier BV) 187 157 - 160 2020.10

ISSN 0033-3506

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Effect and cost-effectiveness of national gastric cancer screening in Japan: a microsimulation modeling study.

Hsi-Lan Huang, Chi Yan Leung, Eiko Saito, Kota Katanoda, Chin Hur, Chung Yin Kong, Shuhei Nomura, Kenji Shibuya

BMC medicine 18 ( 1 ) 257 - 257 2020.09

Accepted

BACKGROUND: A national endoscopic screening program for gastric cancer was rolled out in Japan in 2015. We used a microsimulation model to estimate the cost-effectiveness of current screening guidelines and alternative screening strategies in Japan. METHODS: We developed a microsimulation model that simulated a virtual population corresponding to the Japanese population in risk factor profile and life expectancy. We evaluated 15 endoscopic screening scenarios with various starting ages, stopping ages, and screening intervals. The primary outcomes were quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratio. Cost-effective screening strategies were determined using a willingness-to-pay threshold of $50,000 per QALY gained. One-way sensitivity and probabilistic sensitivity analyses were done to explore model uncertainty. RESULTS: Using the threshold of $50,000 per QALY, a triennial screening program for individuals aged 50 to 75 years was the cost-effective strategy, with an incremental cost-effectiveness ratio of $45,665. Compared with no endoscopic screening, this strategy is predicted to prevent 63% of gastric cancer mortality and confer 27.2 QALYs gained per 1000 individuals over a lifetime period. Current screening guidelines were not on the cost-effectiveness efficient frontier. The results were robust on one-way sensitivity analyses and probabilistic sensitivity analysis. CONCLUSIONS: This modeling study suggests that the endoscopic screening program in Japan would be cost-effective when implemented between age 50 and 75 years, with the screening repeated every 3 years. These findings underscore the need for further evaluation of the current gastric cancer screening recommendations.

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Inequalities and risk factors analysis in prevalence and management of hypertension in India and Nepal: a national and subnational study.

Santosh Kumar Rauniyar, Md Mizanur Rahman, Md Shafiur Rahman, Sarah Krull Abe, Shuhei Nomura, Kenji Shibuya

BMC public health 20 ( 1 ) 1341 - 1341 2020.09

Accepted

BACKGROUND: Hypertension is one of the leading risk factors for cardiovascular diseases in India and Nepal. Socio-economic disparity in these two countries has created wide gap in management of hypertension. However, inequalities in prevalence and management (awareness, treatment, and control) of hypertension is poorly assessed. This study analyzes the risk factors associated with prevalence and management of hypertension in India and Nepal and assesses the wealth-and education-based inequalities in them. METHODS: This study used data from the Demographic and Health Survey; a cross-sectional survey conducted between January 2015 to December 2016 in India and June 2016 to January 2017 in Nepal. A total of 787,713 individuals in India and 14,454 individuals in Nepal aged between 15 and 49 years were included in the study. Respondents were classified as being hypertensive if their systolic blood pressure (SBP) readings were at least 140 mmHg or diastolic blood pressure (DBP) readings were at least 90 mmHg, or if they reported currently taking anti-hypertensive medication. Multilevel logistic regression models with random intercepts at household-and community-levels were used to identify the risk factors associated with prevalence and management of hypertension. For inequality assessment, slope index and relative index of inequalities in prevalence and management of hypertension were estimated. RESULTS: Overall prevalence of hypertension in India and Nepal were 11.4% (95% confidence interval (CI), 11.4-11.5) and 19.6% (95% CI, 18.9-20.2), respectively. Less than one-third of the hypertensive population received treatment and below 20% among them had their blood pressure controlled. In both countries, wealth-and education-based inequalities in awareness, treatment, and control of hypertension were significantly high in urban and rural areas. CONCLUSION: Wealth- and education-based inequalities in prevalence and management of hypertension were high among different socio-economic groups at national and sub-national levels. Tailored strategies are required to effectively manage hypertension in different regions by considering socio-economic and demographic factors.

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Forecasting disability-adjusted life years for chronic diseases: reference and alternative scenarios of salt intake for 2017–2040 in Japan

Shuhei Nomura, Daisuke Yoneoka, Shiori Tanaka, Aya Ishizuka, Peter Ueda, Keiji Nakamura, Hisayuki Uneyama, Naoki Hayashi, Kenji Shibuya

BMC Public Health (Springer Science and Business Media LLC) 20 ( 1 ) 1475 - 1475 2020.09

Accepted

<title>Abstract</title>
<sec>
<title>Background</title>
In Japan, a high-sodium diet is the most important dietary risk factor and is known to cause a range of health problems. This study aimed to forecast Japan’s disability-adjusted life year (DALYs) for chronic diseases that would be associated with high-sodium diet in different future scenarios of salt intake. We modelled DALY forecast and alternative future scenarios of salt intake for cardiovascular diseases (CVDs), chronic kidney diseases (CKDs), and stomach cancer (SC) from 2017 to 2040.

</sec>
<sec>
<title>Methods</title>
We developed a three-component model of disease-specific DALYs: a component on the changes in major behavioural and metabolic risk predictors including salt intake; a component on the income per person, educational attainment, and total fertility rate under 25 years; and an autoregressive integrated moving average model to capture the unexplained component correlated over time. Data on risk predictors were obtained from Japan’s National Health and Nutrition Surveys and from the Global Burden of Disease Study 2017. To generate a reference forecast of disease-specific DALY rates for 2017–2040, we modelled the three diseases using the data for 1990–2016. Additionally, we generated better, moderate, and worse scenarios to evaluate the impact of change in salt intake on the DALY rate for the diseases.

</sec>
<sec>
<title>Results</title>
In our reference forecast, the DALY rates across all ages were predicted to be stable for CVDs, continuously increasing for CKDs, and continuously decreasing for SC. Meanwhile, the age group-specific DALY rates for these three diseases were forecasted to decrease, with some exceptions. Except for the ≥70 age group, there were remarkable differences in DALY rates between scenarios, with the best scenario having the lowest DALY rates in 2040 for SC. This represents a wide scope of future trajectories by 2040 with a potential for tremendous decrease in SC burden.

</sec>
<sec>
<title>Conclusions</title>
The gap between scenarios provides some quantification of the range of policy impacts on future trajectories of salt intake. Even though we do not yet know the policy mix used to achieve these scenarios, the result that there can be differences between scenarios means that policies today can have a significant impact on the future DALYs.

</sec>

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Timeliness of routine vaccination among children and determinants associated with age-appropriate vaccination in Mongolia

Santosh Kumar Rauniyar, Enkhtuya Munkhbat, Peter Ueda, Daisuke Yoneoka, Kenji Shibuya, Shuhei Nomura

Heliyon (Elsevier {BV}) 6 ( 9 ) e04898 2020.09

Accepted

Introduction: Routine vaccination at the recommended age is crucial to minimize the risk of acquiring vaccine preventable diseases. This study aimed to assess the proportion of children receiving routine immunization at the recommended age and determinants of timely (age-appropriate) vaccination in Mongolia. Material and method: A total of 879 eligible children aged 12-23 months were included in this study. We investigated age-appropriate administration of Bacillus Calmette-Guerin vaccine (BCG); hepatitis B vaccine (Hep B); oral polio vaccine (OPV); pentavalent vaccine; and measles, mumps, and rubella vaccine (MMR) using Kaplan-Meier method. Multilevel logistic regression with random intercept at cluster level was used to assess the determinants of age-appropriate vaccination. Results: Overall, the crude vaccination coverage for routine vaccinations were above 90% for all vaccines except MMR1 which was 86.0% (95% CI, 83.6-88.2). While the first dose of almost all the vaccines given at birth; BCG, Hep B, and OPV0, were administered in a timely manner, a substantial proportion of second and third doses of these vaccines were not given in a timely manner with age-appropriate vaccination coverage ranging from 35.9% (32.8-39.1%) for MMR1 to 67.7% (64.5-70.7%) for OPV1 respectively. Factors associated with age-appropriate administration of the investigated vaccines included socio-economic status of household, religion of household heads, area of residence, owning mobile phone, and season of childbirth. For instance, children belonging to households from richer wealth quintile had higher possibilities of getting age-appropriate OPV1-OPV3, PE1-PE3 and MMR1 vaccines compared to those from the poorest household wealth quintile. Conclusion: Our findings suggest that the commonly used indicator 'crude vaccination coverage' could be supplemented by 'age-appropriate vaccination' to help to identify gaps in timely vaccinations and stimulate interventions in Mongolia. Factors such as household wealth quintile, place of residence and religion associated with timely vaccination in our study could be considered to promote effective intervention aiming to improve adequate vaccination coverage.

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Early SNS-Based Monitoring System for the COVID-19 Outbreak in Japan: A Population-Level Observational Study.

Daisuke Yoneoka, Takayuki Kawashima, Yuta Tanoue, Shuhei Nomura, Keisuke Ejima, Shoi Shi, Akifumi Eguchi, Toshibumi Taniguchi, Haruka Sakamoto, Hiroyuki Kunishima, Stuart Gilmour, Hiroshi Nishiura, Hiroaki Miyata

Journal of epidemiology 30 ( 8 ) 362 - 370 2020.08

Accepted

BACKGROUND: The World Health Organization declared the novel coronavirus outbreak (COVID-19) to be a pandemic on March 11, 2020. Large-scale monitoring for capturing the current epidemiological situation of COVID-19 in Japan would improve preparation for and prevention of a massive outbreak. METHODS: A chatbot-based healthcare system named COOPERA (COvid-19: Operation for Personalized Empowerment to Render smart prevention And care seeking) was developed using the LINE app to evaluate the current Japanese epidemiological situation. LINE users could participate in the system either though a QR code page in the prefectures' websites or a banner at the top of the LINE app screen. COOPERA asked participants questions regarding personal information, preventive actions, and non-specific symptoms related to COVID-19 and their duration. We calculated daily cross correlation functions between the reported number of infected cases confirmed using polymerase chain reaction and the symptom-positive group captured by COOPERA. RESULTS: We analyzed 206,218 participants from three prefectures reported between March 5 and 30, 2020. The mean age of participants was 44.2 (standard deviation, 13.2) years. No symptoms were reported by 96.93% of participants, but there was a significantly positive correlation between the reported number of COVID-19 cases and self-reported fevers, suggesting that massive monitoring of fever might help to estimate the scale of the COVID-19 epidemic in real time. CONCLUSIONS: COOPERA is the first real-time system being used to monitor trends in COVID-19 in Japan and provides useful insights to assist political decisions to tackle the epidemic.

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Time to Reconsider Diverse Ways of Working in Japan to Promote Social Distancing Measures against the COVID-19

Shuhei Nomura, Daisuke Yoneoka, Yuta Tanoue, Takayuki Kawashima, Shoi Shi, Akifumi Eguchi, Hiroaki Miyata

Journal of Urban Health 97 ( 4 ) 457 - 460 2020.08

Accepted, ISSN 1099-3460

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An assessment of self-reported COVID-19 related symptoms of 227,898 users of a social networking service in Japan: Has the regional risk changed after the declaration of the state of emergency?

Shuhei Nomura, Daisuke Yoneoka, Shoi Shi, Yuta Tanoue, Takayuki Kawashima, Akifumi Eguchi, Kentaro Matsuura, Koji Makiyama, Keisuke Ejima, Toshibumi Taniguchi, Haruka Sakamoto, Hiroyuki Kunishima, Stuart Gilmour, Hiroshi Nishiura, Hiroaki Miyata

The Lancet Regional Health - Western Pacific (Elsevier BV) 1 100011 - 100011 2020.08

Accepted, ISSN 2666-6065

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Travel restrictions and sars-cov-2 transmission: An effective distance approach to estimate impact

Shoi Shi, Shiori Tanaka, Ryo Ueno, Stuart Gilmour, Yuta Tanoue, Takayuki Kawashima, Shuhei Nomura, Akifumi Eguchi, Hiroaki Miyata, Daisuke Yoneoka

Bulletin of the World Health Organization 98 ( 8 ) 518 - 529 2020.08

Accepted, ISSN 0042-9686

© 2020, World Health Organization. All rights reserved. Objective To estimate the effect of airline travel restrictions on the risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) importation. Methods We extracted passenger volume data for the entire global airline network, as well as the dates of the implementation of travel restrictions and the observation of the first case of coronavirus disease (COVID-19) in each country or territory, from publicly available sources. We calculated effective distance between every airport and the city of Wuhan, China. We modelled the risk of SARS-CoV-2 importation by estimating survival probability, expressing median time of importation as a function of effective distance. We calculated the relative change in importation risk under three different hypothetical scenarios that all resulted in different passenger volumes. Findings We identified 28 countries with imported cases of COVID-19 as at 26 February 2020. The arrival time of the virus at these countries ranged from 39 to 80 days since identification of the first case in Wuhan. Our analysis of relative change in risk indicated that strategies of reducing global passenger volume and imposing travel restrictions at a further 10 hub airports would be equally effective in reducing the risk of importation of SARS-CoV-2; however, this reduction is very limited with a close-to-zero median relative change in risk. Conclusion The hypothetical variations in observed travel restrictions were not sufficient to prevent the global spread of SARS-CoV-2; further research should also consider travel by land and sea. Our study highlights the importance of strengthening local capacities for disease monitoring and control.

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Contributions of information and communications technology to future health systems and Universal Health Coverage: application of Japan’s experiences

Shuhei Nomura, Vera Siesjö, Göran Tomson, Wiebke Mohr, Eriko Fukuchi, Kenji Shibuya, Viroj Tangcharoensathien, Hiroaki Miyata

Health Research Policy and Systems (Springer Science and Business Media {LLC}) 18 ( 1 ) 2020.06

ISSN 1478-4505

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Cancer incidence attributable to tuberculosis in 2015: global, regional, and national estimates.

Chi Yan Leung, Hsi-Lan Huang, Md Mizanur Rahman, Shuhei Nomura, Sarah Krull Abe, Eiko Saito, Kenji Shibuya

BMC cancer 20 ( 1 ) 412 - 412 2020.05

Accepted

BACKGROUND: Tuberculosis is associated with increased risk of cancer. However, the impact of tuberculosis on global cancer burden is unknown. METHODS: We performed random-effects meta-analyses and meta-regressions of studies reporting the association between tuberculosis and cancer risks by searching PubMed, Web of Science, Embase, Cochrane library, and CINAHL from inception to 1 June 2019. Population attributable fractions (PAFs) of cancer incidence attributable to tuberculosis were calculated using relative risks from our meta-analyses and tuberculosis prevalence data from Global Health Data Exchange by age, sex, and country. The study has been registered with PROSPERO (CRD42016050691). RESULTS: Fourty nine studies with 52,480 cancer cases met pre-specified inclusion criteria. Tuberculosis was associated with head and neck cancer (RR 2.64[95% CI 2.00-3.48]), hepatobiliary cancer (2.43[1.82-3.25]), Hodgkin's lymphoma (2.19[1.62-2.97]), lung cancer (1.69[1.46-1.95]), gastrointestinal cancer (1.62[1.26-2.08]), non-Hodgkin's lymphoma (1.61[1.34-1.94]), pancreatic cancer (1.58[1.28-1.96]), leukaemia (1.55[1.25-1.93]), kidney and bladder cancer (1.54[1.21-1.97]), and ovarian cancer (1.43[1.04-1.97]). We estimated that 2.33%(1.14-3.81) or 381,035(187145-623,404) of global cancer incidences in 2015 were attributable to tuberculosis. The PAFs varied by Socio-demographic Index (SDI)-ranging from 1.28% (0.57-2.31%) in the high-SDI countries to 3.51% (1.84-5.42%) in the middle-SDI countries. Individually, China and India accounted for 47% of all tuberculosis-related cancer cases. CONCLUSIONS: Tuberculosis is associated with increased risk of cancer at ten sites. The burden of tuberculosis attributable cancer skewed towards lower resource countries. Research priorities are to better understand regional disparities and underlying mechanism linking tuberculosis and cancer development.

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Mental health of family, friends, and co-workers of COVID-19 patients in Japan.

Yuta Tanoue, Shuhei Nomura, Daisuke Yoneoka, Takayuki Kawashima, Akifumi Eguchi, Shoi Shi, Nahoko Harada, Hiroaki Miyata

Psychiatry research (Elsevier BV) 291 113067 - 113067 2020.05

Accepted, ISSN 0165-1781

As the coronavirus disease 2019 (COVID-19) pandemic rages on, the mental health of both the infected and non-infected is a rising concern. We used administrative survey data (16402 responses in the last two weeks) using a chatbot on LINE, the most popular social networking service (SNS) in Japan, to show that people with COVID-19 patients in a close setting had higher psychological distress level than those without. We believe that the results indicate an urgent need to prioritize the establishment and implementation of mental health and psychosocial support tailored to family, close relatives, and friends of COVID-19 patients.

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Tracking Japan's development assistance for health, 2012-2016.

Shuhei Nomura, Haruka Sakamoto, Maaya Kita Sugai, Haruyo Nakamura, Keiko Maruyama-Sakurai, Sangnim Lee, Aya Ishizuka, Kenji Shibuya

Globalization and health 16 ( 1 ) 32 - 32 2020.04

Lead author

BACKGROUND: Development assistance for health (DAH) is one of the most important means for Japan to promote diplomacy with developing countries and contribute to the international community. This study, for the first time, estimated the gross disbursement of Japan's DAH from 2012 to 2016 and clarified its flows, including source, aid type, channel, target region, and target health focus area. METHODS: Data on Japan Tracker, the first data platform of Japan's DAH, were used. The DAH definition was based on the Organisation for Economic Co-operation and Development's (OECD) sector classification. Regarding core funding to non-health-specific multilateral agencies, we estimated DAH and its flows based on the OECD methodology for calculating imputed multilateral official development assistance (ODA). RESULTS: Japan's DAH was estimated at 1472.94 (2012), 823.15 (2013), 832.06 (2014), 701.98 (2015), and 894.57 million USD (2016) in constant prices of 2016. Multilateral agencies received the largest DAH share of 44.96-57.01% in these periods, followed by bilateral grants (34.59-53.08%) and bilateral loans (1.96-15.04%). Ministry of Foreign Affairs (MOFA) was the largest contributors to the DAH (76.26-82.68%), followed by Ministry of Finance (MOF) (10.86-16.25%). Japan's DAH was most heavily distributed in the African region with 41.64-53.48% share. The channel through which the most DAH went was Global Fund to Fight AIDS, Tuberculosis, and Malaria (20.04-34.89%). Between 2012 and 2016, approximately 70% was allocated to primary health care and the rest to health system strengthening. CONCLUSIONS: With many major high-level health related meetings ahead, coming years will play a powerful opportunity to reevaluate DAH and shape the future of DAH for Japan. We hope that the results of this study will enhance the social debate for and contribute to the implementation of Japan's DAH with a more efficient and effective strategy.

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Associations between parental socioeconomic position and health-seeking behaviour for diarrhoea and acute respiratory infection among under-5 children in Myanmar: a cross-sectional study.

Kaung Suu Lwin, Shuhei Nomura, Daisuke Yoneoka, Peter Ueda, Sarah Krull Abe, Kenji Shibuya

BMJ open 10 ( 3 ) e032039 2020.03

Accepted

OBJECTIVES: To examine the associations of parental social and economic position with health-seeking behaviour for diarrhoea and acute respiratory infection (ARI) among under-5 children in Myanmar and explore potential underlying mechanisms. DESIGN: A cross-sectional study. SETTING: A secondary dataset from the nationwide 2015-2016 Myanmar Demographic and Health Survey (MDHS). PARTICIPANTS: All under-5 children in the sampled households with reported symptoms of diarrhoea and ARI during the 2-week period preceding the MDHS survey interview. PRIMARY AND SECONDARY OUTCOME MEASURES: Four parental health-seeking behaviours: 'seeking treatment', 'formal health provider', 'public provider' and 'private provider' were considered. Social and economic positions were determined by confirmatory factor analysis. Multilevel logistic regressions were employed to examine the associations of social and economic positions with health-seeking behaviours for diarrhoea and ARI. Mediation analyses were conducted to explore potential underlying mechanisms in these associations. RESULTS: Of the 4099 under-5 children from the sampled households in MDHS, 427 (10.4%) with diarrhoea and 131 (3.2%) with ARI were considered for the analyses. For diarrhoea, social position was positively associated with seeking treatment and private provider use (adjusted OR: 1.60 (95% CIs: 1.07 to 2.38) and 1.83 (1.00 to 3.34), respectively). Economic position was positively associated with private provider use for diarrhoea (1.57 (1.07 to 2.30)). Negative associations were observed between social and economic positions with public provider use for diarrhoea (0.55 (0.30 to 0.99) and 0.64 (0.43 to 0.94), respectively). Social position had more influence than economic position on parental health-seeking behaviour for children with diarrhoea. No evidence for a significant association of social and economic position with health-seeking for ARI was observed. CONCLUSIONS: Social and economic positions were possible determinants of health-seeking behaviour for diarrhoea among children; and social position had more influence than economic position. The results of this study may contribute to improve relevant interventions for diarrhoea and ARI among children in Myanmar.

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Impact of travel restrictions on importation of novel coronavirus infection: An effective distance approach

Shoi Shi, Shiori Tanaka, Ryo Ueno, Stuart Gilmour, Yuta Tanoue, Takayuki Kawashima, Shuhei Nomura, Hiroaki Miyata, Daisuke Yoneoka

Bulletin of the World Health Organization 2020.03

Accepted

Implementing a sustainable health insurance system in Cambodia: a study protocol for developing and validating an efficient household income-level assessment model for equitable premium collection.

Haruyo Nakamura, Floriano Amimo, Siyan Yi, Sovannary Tuot, Tomoya Yoshida, Makoto Tobe, Shuhei Nomura

International journal for equity in health 19 ( 1 ) 17 - 17 2020.01

Accepted

BACKGROUND: As elsewhere in low- and middle-income countries, due to limited fiscal resources, universal health coverage (UHC) remains a challenge in Cambodia. Since 2016, the National Social Security Fund (NSSF) has implemented a social health insurance scheme with a contributory approach for formal sector workers. However, informal sector workers and dependents of formal sector workers are still not covered by this insurance because it is difficult to set an optimal amount of contribution for such individuals as their income levels are inestimable. The present study aims to develop and validate an efficient household income-level assessment model for Cambodia. We aim to help the country implement a financially sustainable social health insurance system in which the insured can pay contributions according to their ability. METHODS: This study will use nationally representative data collected by the Cambodia Socio-Economic Survey (CSES), covering the period from 2009 to 2019, and involving a total of 50,016 households. We will employ elastic net regression analysis, with per capita disposable income based on purchasing power parity as the dependent variable, and individual and community-level socioeconomic and demographic characteristics as independent variables. These analyses aim to create efficient income-level assessment models for health insurance contribution estimation. To fully capture socioeconomic heterogeneity, sub-group analyses will be conducted to develop separate income-level assessment models for urban and rural areas, as well as for each province. DISCUSSION: This research will help Cambodia implement a sustainable social health insurance system by collecting optimal amount of contributions from each socioeconomic group of the society. Incorporation of this approach into existing NSSF schemes will enhance the country's current efforts to prevent impoverishing health expenditure and to achieve UHC.

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The trajectories of local food avoidance after the Fukushima Daiichi nuclear plant disaster: A five-year prospective cohort study

Yoshitake Takebayashi, Michio Murakami, Shuhei Nomura, Tomoyoshi Oikawa, MasaharuTsubokura

International Journal of Disaster Risk Reduction 46 101513 2020.01

Assessing the quality of cause of death data in six high-income countries: Australia, Canada, Denmark, Germany, Japan and Switzerland.

Lene Mikkelsen, Kim Moesgaard Iburg, Tim Adair, Thomas Fürst, Michael Hegnauer, Elena von der Lippe, Lauren Moran, Shuhei Nomura, Haruka Sakamoto, Kenji Shibuya, Annelene Wengler, Stephanie Willbond, Patricia Wood, Alan D Lopez

International journal of public health 65 ( 1 ) 17 - 28 2020.01

Accepted

OBJECTIVES: To assess the policy utility of national cause of death (COD) data of six high-income countries with highly developed health information systems. METHODS: National COD data sets from Australia, Canada, Denmark, Germany, Japan and Switzerland for 2015 or 2016 were assessed by applying the ANACONDA software tool. Levels, patterns and distributions of unusable and insufficiently specified "garbage" codes were analysed. RESULTS: The average proportion of unusable COD was 18% across the six countries, ranging from 14% in Australia and Canada to 25% in Japan. Insufficiently specified codes accounted for a further 8% of deaths, on average, varying from 6% in Switzerland to 11% in Japan. The most commonly used garbage codes were Other ill-defined and unspecified deaths (R99), Heart failure (I50.9) and Senility (R54). CONCLUSIONS: COD certification errors are common, even in countries with very advanced health information systems, greatly reducing the policy value of mortality data. All countries should routinely provide certification training for hospital interns and raise awareness among doctors of their public health responsibility to certify deaths correctly and usefully for public health policy.

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Reducing childhood malnutrition in Bangladesh: the importance of addressing socio-economic inequalities.

Md Rashedul Islam, Md Shafiur Rahman, Md Mahfuzur Rahman, Shuhei Nomura, Angela de Silva, Pulani Lanerolle, Jenny Jung, Md Mizanur Rahman

Public health nutrition 23 ( 1 ) 72 - 82 2020.01

Accepted, ISSN 1368-9800

OBJECTIVE: To obtain projections of the prevalence of childhood malnutrition indicators up to 2030 and to analyse the changes of wealth-based inequality in malnutrition indicators and the degree of contribution of socio-economic determinants to the inequities in malnutrition indicators in Bangladesh. Additionally, to identify the risk factors of childhood malnutrition. DESIGN: Cross-sectional study. A Bayesian linear regression model was used to estimate trends and projections of malnutrition. For equity analysis, slope index, relative index and decomposition in concentration index were used. Multilevel logistic models were used to identify risk factors of malnutrition. SETTING: Household surveys in Bangladesh from 1996 to 2014. PARTICIPANTS: Children under the age of 5 years. RESULTS: A decreasing trend was observed for all malnutrition indices. In 1990, predicted prevalence of stunting, wasting and underweight was 55·0, 15·9 and 61·8 %, respectively. By 2030, prevalence is projected to reduce to 28·8 % for stunting, 12·3 % for wasting and 17·4 % for underweight. Prevalence of stunting, wasting and underweight were 34·3, 6·9 and 32·8 percentage points lower in the richest households than the poorest households. Contribution of the wealth index to child malnutrition increased over time and the largest contribution of pro-poor inequity was explained by wealth index. Being an underweight mother, parents with a lower level of education and poorer households were the key risk factors for stunting and underweight. CONCLUSIONS: Our findings show an evidence-based need for targeted interventions to improve education and household income-generating activities among poor households to reduce inequalities and reduce the burden of child malnutrition in Bangladesh.

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Limited alignment of publicly competitive disease funding with disease burden in Japan.

Shuhei Nomura, Daisuke Yoneoka, Shiori Tanaka, Ryoko Makuuchi, Haruka Sakamoto, Aya Ishizuka, Haruyo Nakamura, Anna Kubota, Kenji Shibuya

PloS one 15 ( 2 ) e0228542 2020

Accepted

OBJECTIVE: The need to align investments in health research and development (R&D) with public health needs is one of the most important public health challenges in Japan. We examined the alignment of disease-specific publicly competitive R&D funding to the disease burden in the country. METHODS: We analyzed publicly available data on competitive public funding for health in 2015 and 2016 and compared it to disability-adjusted life year (DALYs) in 2016, which were obtained from the Global Burden of Disease (GBD) 2017 study. Their alignment was assessed as a percentage distribution among 22 GBD disease groups. Funding was allocated to the 22 disease groups based on natural language processing, using textual information such as project title and abstract for each research project, while considering for the frequency of information. RESULTS: Total publicly competitive funding in health R&D in 2015 and 2016 reached 344.1 billion JPY (about 3.0 billion USD) for 32,204 awarded projects. About 49.5% of the funding was classifiable for disease-specific projects. Five GDB disease groups were significantly and relatively well-funded compared to their contributions to Japan's DALY, including neglected tropical diseases and malaria (funding vs DALY = 1.7% vs 0.0%, p<0.01) and neoplasms (28.5% vs 19.2%, p<0.001). In contrast, four GDB disease groups were significantly under-funded, including cardiovascular diseases (8.0% vs 14.8%, p<0.001) and musculoskeletal disorders (1.0% vs 11.9%, p<0.001). These percentages do not include unclassifiable funding. CONCLUSIONS: While caution is necessary as this study was not able to consider public in-house funding and the methodological uncertainties could not be ruled out, the analysis may provide a snapshot of the limited alignment between publicly competitive disease-specific funding and the disease burden in the country. The results call for greater management over the allocation of scarce resources on health R&D. DALYs will serve as a crucial, but not the only, consideration in aligning Japan's research priorities with the public health needs. In addition, the algorithms for natural language processing used in this study require continued efforts to improve accuracy.

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Low dose of external exposure among returnees to former evacuation areas: a cross-sectional all-municipality joint study following the 2011 Fukushima Daiichi nuclear power plant incident.

Shuhei Nomura, Michio Murakami, Wataru Naito, Tetsuo Yasutaka, Toyoaki Sawano, Masaharu Tsubokura

Journal of radiological protection : official journal of the Society for Radiological Protection 40 ( 1 ) 1 - 18 2019.12

Accepted, ISSN 0952-4746

There is little information on the radiation dose levels of returnees to areas once designated as legal no-go zones, after evacuation orders were lifted subsequent to the 2011 Fukushima Daiichi nuclear power plant incident. This study used individual radiation dosimeter monitoring and a location history survey to conduct the most recent dose assessment of external exposure among returnees to former no-go zones. We specifically determined correlation and agreement between external doses and the air dose rate in residential areas and quantified both uncertainty and population variability of the observed data using Monte Carlo (MC) simulation methods. A total of 239 voluntary participants across ten municipalities were analysed; their representativeness of all affected municipal populations was confirmed in terms of air dose rate distribution in residential areas. We found that individual doses were statistically significantly correlated with the air dose rate based on government airborne monitoring. This implies that airborne monitoring can provide sufficient information for understanding dose levels among such returnees. The MC simulations demonstrated that the mean of the annual dose in 2019 (including natural background doses) was 0.93 (95% uncertainty interval 0.53-1.76) mSv, with limited variation between municipalities. As of 2019, this implies that doses from external exposure were very low among returnees and would be associated with a very low likelihood of physical effects according to current scientific consensus. However, these results should be taken with caution due to several study limitations, including selection and participation biases. Regardless, its findings will enhance societal debates about how both individual-dose and government airborne monitoring practices should operate in the future and how the government can improve the public outlook for radiation doses in incident-affected areas.

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A Comparative Survival Analysis Between Evacuees and Nonevacuees Among Dialysis Patients in Fukushima Prefecture After Japan's 2011 Fukushima Nuclear Incident.

Shuhei Nomura, Yukie Matsuzaki, Yuko Sato, Jyunko Takasaki, Yuki Sonoda, Hiroaki Shimmura, Yuko Kodama

Disaster medicine and public health preparedness 13 ( 5-6 ) 898 - 904 2019.12

Accepted, ISSN 1935-7893

OBJECTIVE: There has been little research on the health consequences of evacuation in the disaster context. A comparative analysis of survival between evacuated and nonevacuated hospital dialysis patients was conducted following Japan's Fukushima Dai-ichi nuclear power plant incident, which occurred on March 11, 2011. METHODS: The study included 554 patients (mean age: 70.9) receiving dialysis therapy at one of the Tokiwakai Group hospitals-all of which are located in and around Iwaki City, approximately 50 km from the Fukushima nuclear plant-as of the incident date. The patients' survival after the incident was tracked until March 3, 2017. Significant differences in mortality rates between postincident evacuees and nonevacuees were tested using the Bayesian survival analysis with Weibull multivariate regression. RESULTS: Out of 554 dialysis patients, 418 (75.5%) were evacuated after the incident. The postincident mortality rate (adjusted for covariates) of evacuees was not statistically significantly different from that of nonevacuees. The hazard ratio was 1.17 (95% credible intervals: 0.77-1.74). CONCLUSIONS: If performed in a well-planned manner with satisfactory arrangements for appropriate selection of evacuees and their transportation, evacuation could be a reasonable option, which might save more lives of vulnerable people.

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Radiation doses and decontamination effects in Minamisoma city: airborne and individual monitoring after the Fukushima nuclear accident.

Michio Murakami, Shuhei Nomura, Masaharu Tsubokura, Yoshitake Takebayashi, Kana Yamamoto, Tomoyoshi Oikawa

Journal of radiological protection : official journal of the Society for Radiological Protection 39 ( 4 ) N27-N35 - N35 2019.10

Accepted, ISSN 0952-4746

After the Fukushima accident, airborne monitoring was implemented to measure airborne radiation. We examined the relationships between airborne and individual radiation monitoring and clarified the use of airborne monitoring to evaluate the effects of decontamination on residents' received doses. We used the air dose rate data from four airborne monitors conducted between 2013 and 2016, and the dose data from four individual monitors (in which a total of 18 392 adults and 3650 children participated), conducted in Minamisoma City during the same period. We examined the Pearson correlation coefficients between the airborne and individual monitoring data and estimated exposure ratios (ERs; ratios of individual dose to air dose rates) among adults and children. We also estimated the effects of decontamination on residents' doses based on airborne monitoring data, adjusting this for timing and dosing through propensity score matching, which were then compared to individual monitoring data. There were significant correlations between airborne and individual monitoring doses among adults and children, and more than 80% of residents showed a good estimation-observation agreement within a factor of two. The median of ERs was 0.304 and 0.250 among adults and children, respectively. There was a significant difference between the two. Effects of decontamination on residents' doses estimated from airborne monitoring were significantly lower than those estimated from individual monitoring. These findings suggest that airborne monitoring can be used to estimate representative radiation doses within residential areas. It may be a useful tool for enhancing communication among stakeholders and supporting individual and policy decisions; however, it is less sensitive for evaluating individual effects of decontamination than individual monitoring. Combined use of airborne and individual monitoring also showed a lower median of ERs in children than in adults and in a Japanese government's model, possibly due to prioritised decontamination for children and differences between their behavioral patterns.

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Risk factors and regional variations of malnutrition among children under 5 in Myanmar: cross-sectional analyses at national and subnational levels.

Hnin Thiri Khaing, Shuhei Nomura, Daisuke Yoneoka, Peter Ueda, Kenji Shibuya

BMJ open 9 ( 9 ) e030894 2019.09

Accepted

OBJECTIVE: The levels, distributions of child malnutrition and its potential risk factors are not very well known in Myanmar. The objectives included in this study were: to estimate the current national and subnational prevalence of four types of malnutrition (stunting, wasting, underweight and overweight) among children under 5 in Myanmar; to identify potential risk factors associated with each type of malnutrition and to investigate how the identified risk factors' distributions explained the regional disparities in malnutrition prevalence. DESIGN/METHODS: Data from the Myanmar Demographic and Health Survey 2015-2016 were used to estimate the prevalence of four types of malnutrition at both national and subnational levels (15 regions). Logistic regression models were applied to examine the association between each type of malnutrition and its risk factors, including child's factors, parental social status and household conditions. The risk factor-adjusted prevalence of the malnutrition was estimated at the subnational level based on the estimated parameters from the regression models. RESULTS: The national prevalence of stunting, wasting, underweight and overweight in children under 5 was estimated to be 29.1% (95% CI 27.7% to 30.6%), 6.8% (6.0% to 7.6%), 18.3% (17.0% to 19.5%) and 1.5% (1.1% to 1.9%), respectively. Substantial regional variations in the prevalence of each type of malnutrition were observed. Several risk factors of each type of malnutrition were identified, including low birth weight (LBW) and inadequate maternal nutritional status. Except for overweight, regional variations largely persisted even after adjustment for the risk factors investigated. CONCLUSION: The prevalence of malnutrition among children under 5 is still high in Myanmar, most commonly stunting. Targeted interventions aimed at prevention of LBW, improving the maternal nutritional status, in addition to other sociodemographic conditions should be encouraged urgently. Further research is necessary to investigate the potential sources of regional variation in prevalence of malnutrition among children under 5 in the country.

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Breast Cancer Provider Interval Length in Fukushima, Japan, After the 2011 Triple Disaster: A Long-Term Retrospective Study.

Akihiko Ozaki, Shuhei Nomura, Claire Leppold, Masaharu Tsubokura, Toyoaki Sawano, Manabu Tsukada, Tomohiro Morita, Tetsuya Tanimoto, Shigehira Saji, Shigeaki Kato, Kazue Yamaoka, Yoshinori Nakata, Hiromichi Ohira

Clinical breast cancer 20 ( 2 ) e127-e150 2019.09

Accepted

BACKGROUND: Minimizing the interval from symptom onset to treatment commencement is essential for a favorable outcome among breast cancer (BC) patients. This study examined whether provider interval (time elapsed from first consultation to treatment initiation) lengthened among BC patients after Japan's 2011 earthquake, tsunami, and nuclear disaster in Fukushima. Factors associated with the length of postdisaster interval and whether the interval was associated with BC stage were also investigated. PATIENTS AND METHODS: So-so District (study site) was an area damaged by the 2011 disasters. Data of all BC patients who made their first medical consultation and received initial treatment at the core medical institutions in the area 5 years before or after the disaster were extracted from patient medical records. We used several regression approaches to fulfill our study objectives. RESULTS: We included 263 (140 predisaster and 123 postdisaster) patients. After adjustment for covariates, the interval did not significantly change after the disaster compared to before the disaster. Those with 4 or 5 cohabiting family members experienced a shorter interval after the disaster than those with 0 or 1 cohabiting family members (relative length, 0.47; 95% confidence interval, 0.28-0.78). Those with an interval of > 60 days had lower odds of stage III or IV cancer after the disaster than those with an interval of < 30 days (odds ratio, 0.09; 95% confidence interval, 0.01-0.84). CONCLUSION: Overall, provider interval did not lengthen after the disaster. However, those with fewer cohabiting family members might have experienced a longer total interval. Cancer stage may not necessarily reflect the influence of interval on patient outcome.

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Impact of decontamination on individual radiation doses from external exposure among residents of Minamisoma City after the 2011 Fukushima Daiichi nuclear power plant incident in Japan: a retrospective observational study.

Masaharu Tsubokura, Michio Murakami, Yoshitake Takebayashi, Shuhei Nomura, Kyoko Ono, Akihiko Ozaki, Toyoaki Sawano, Yurie Kobashi, Tomoyoshi Oikawa

Journal of radiological protection : official journal of the Society for Radiological Protection 39 ( 3 ) 854 - 871 2019.09

Accepted, ISSN 0952-4746

Following the Fukushima incident, radiation doses from external exposure accounted for the majority of the total doses. Although countermeasures are being implemented, with the aim of reducing radiation exposure, little information is available on the effects of decontamination on individual doses among the residents of radioactively contaminated areas. To evaluate the effectiveness of the decontamination measures in reducing individual doses, and to examine the influence of the timing of decontamination and the district, data were analysed for 18 392 adults and 3 650 children in Minamisoma City, Fukushima, who participated in a voluntary screening programme using individual radiation dosimeters (Glass Badge) between June 2013 and September 2016. The dose reduction rates (DRR) were calculated for one year by comparing the first and last three-month measurement results between areas with and without decontamination. Using a regression approach and Monte Carlo simulation, the dose reduction rate by decontamination eliminating the effect of physical decay (DRRd') was also estimated as a function of the timing of the decontamination and the dose at the time of starting the decontamination. The annual DRR in areas with decontamination for both adults and children were significantly higher than those in areas without decontamination, depending on the timing of decontamination: 31%-36% for 2013-14 for adults in decontamination areas and 33%-35% for children in decontamination areas, compared to 12%-23% and 13%-23% for adults and children in areas without decontamination, respectively. There was a positive correlation between DRRd' and individual doses, and DRRd' was estimated at 30%-40% for adults and children with doses of 3 mSv y-1 in 2013 and 2014. This study demonstrated that decontamination does lower individual doses from external exposure. The higher the dose at the time of starting the decontamination, the greater the dose reduction rate by decontamination, regardless of the timing of the decontamination. Our study confirms that decontamination was useful for high-dose areas in the later phases of the incident.

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Internal exposure risk due to radiocesium and the consuming behaviour of local foodstuffs among pregnant women in Minamisoma City near the Fukushima nuclear power plant: a retrospective observational study.

Kana Yamamoto, Shuhei Nomura, Masaharu Tsubokura, Michio Murakami, Akihiko Ozaki, Claire Leppold, Toyoaki Sawano, Morihito Takita, Shigeaki Kato, Yukio Kanazawa, Hiroshi Anbe

BMJ open 9 ( 7 ) e023654 2019.07

Accepted

OBJECTIVES: This study aimed to evaluate the internal cesium (Cs) level among pregnant women in Minamisoma City (the area straddling the evacuation zones) over a 5-year period after Japan's 2011 Fukushima nuclear accident and assess the status and transition of their food-acquiring preferences during this period. DESIGN: A retrospective observational study of a screening along with a questionnaire survey. SETTING: This study was conducted in an obstetrics and gynaecology service in Minamisoma City in Fukushima, Japan. PARTICIPANTS: Participants included pregnant women who applied for the voluntary internal radiation exposure screening programme. PRIMARY AND SECONDARY OUTCOME MEASURES: Internal radiation exposure was evaluated using the whole-body counter (WBC) in the screening programme. Data from a food acquisition preference questionnaire administered to the participants were analysed and compared across the 5-year period after adjusting for covariates. RESULTS: Overall, 804 screening programmes were conducted with 579 participants during the study period. All participants had internal contamination levels below the detection limit of the WBC unit (220 and 250 Bq/body for Cs-134 and Cs-137, respectively). Based on the most conservative assumption, their maximum annual effective doses by Cs-134 and Cs-137 together were estimated at 16 µSv/year. Contrary to limited internal contamination risks and counter-dose initiatives by the government, a considerable number of pregnant women were still concerned about consuming potentially contaminated local food products when purchasing them at supermarkets between 2012 (78.4%) and 2015 (75.0%). CONCLUSIONS: Health effects from post-accident internal radiation exposure were likely to be insignificant in pregnant women. National/local action is urgently needed to promote scientific understanding in pregnant women regarding limited internal exposure risks from local food products in the market. However, few mothers chose to participate in the internal radiation exposure screening programme, and thus, caution is required in interpreting the results of analyses.

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Long-term trends of hospital admissions among patients with cancer following the 2015 earthquake: a single institution observational study in Kathmandu, Nepal.

Anup Uprety, Akihiko Ozaki, Asaka Higuchi, Bikal Ghimire, Toyoaki Sawano, Kenji Tsuda, Shuhei Nomura, Claire Leppold, Masaharu Tsubokura, Tetsuya Tanimoto, Yogendra Prasad Singh

BMJ open 9 ( 6 ) e026746 2019.06

Accepted

OBJECTIVES: Little is known regarding how natural disasters affect patients with cancer in low-income and middle-income countries. The objective of the present study was to assess the impact of the 2015 Nepal earthquake on the admission of patients with cancer at a core medical institution in Kathmandu. DESIGN, SETTING AND PARTICIPANTS: We considered all 3520 cancer patient admissions to Tribhuvan University Teaching Hospital, from 25 April 2013 to 24 April 2017 (2 years before and 2 years after the earthquake). OUTCOME MEASURES: The number of cancer patient admissions was calculated for each month. Using a negative binomial model, we estimated the incidence rate ratio (IRR) for admission numbers each month after the earthquake compared with the pre-earthquake baseline and investigated chronological change. RESULTS: The total admission number in the first month after the earthquake was decreased compared with that of the predisaster baseline (IRR=0.66, 95% CI 0.43 to 1.00), which largely reflected decreased admissions of patients from outside of the most disaster-affected districts. From the second month, the admission number consistently exceeded the predisaster baseline for the remaining postdisaster period. In contrast to the month of the disaster, the continuation of increased admissions was most prominent among those from outside of the most affected districts. CONCLUSIONS: After a transient decrease immediately following the 2015 Nepal earthquake, there was a long-term increase in cancer patient admissions in a core hospital in Kathmandu. These changes were seen most prominently in patients from outside the most disaster affected areas.

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Low dose from external radiation among returning residents to the former evacuation zone in Minamisoma City, Fukushima Prefecture.

Shuhei Nomura, Tomoyoshi Oikawa, Masaharu Tsubokura

Journal of radiological protection : official journal of the Society for Radiological Protection 39 ( 2 ) 548 - 563 2019.06

Accepted, ISSN 0952-4746

After the 2011 Fukushima Daiichi nuclear power plant accident, evidence on the real-life conditions of returnees to areas once designated as legal no-go zones, including their radiation dose levels, is scarce. In the present study, using a radiation dosimeter and lifestyle survey, we evaluated the lifestyle characteristics and dose levels in 2017 from external exposure among those who returned to the no-go zones after the evacuation orders were lifted. A total of 112 returnees to Odaka district, Minamisoma City, Fukushima Prefecture, were considered and compared to 266 non-returnees. The proportion of participants with annual additional doses from external exposure above 1 mSv was 7.0% for returnees, and 7.3% and 4.2% for non-returnees living in other districts or outside of the city, respectively. Although caution is required given the very small sample sizes, this implies that as of 2017 doses from external exposure among returnees in Odaka were very low and by scientific consensus would be associated with a very low likelihood of physical effects. We also found that while returnees were older on average than non-returnees, they had similar life conditions (i.e. occupation and time spent outdoors). It should be particularly emphasised that the expected lifetime doses from the incident in addition to the natural background dose are a very small among returnees. This study contributes to enhancing societal debates and risk communication regarding how government can provide returnees with the support they need, improve their outlook for radiation doses, and continue to improve crucial infrastructure in former no-go zones so that communities can be rebuilt.

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Worsening Health Status among Evacuees: Analysis of Medical Expenditures after the 2011 Great East Japan Earthquake and Nuclear Disaster in Fukushima.

Makoto Hasegawa, Michio Murakami, Shuhei Nomura, Yoshitake Takebayashi, Masaharu Tsubokura

The Tohoku journal of experimental medicine 248 ( 2 ) 115 - 123 2019.06

Accepted, ISSN 0040-8727

After Fukushima disaster in 2011, the health status of the region's residents deteriorated. We analyzed the health status, care needs, and access to health services among evacuees and non-evacuees using healthcare expenditure (for self-employed and unemployed individuals aged < 75 years) and long-term care expenditure (mainly for individuals aged ≥ 65 years). Fukushima Prefecture was divided into four areas according to their evacuation status: non-EOAs (municipalities that did not include evacuation order areas (EOAs)); EOAs/non-EOAs (municipalities that included both EOAs and non-EOAs); short-term EOAs (municipalities where the EOA designation was lifted in most areas by fiscal year (FY) 2011); and long-term EOAs (municipalities where most EOA designations remained in place until the end of FY 2015). Increases in expenditure on healthcare and long-term care per capita in short-term and long-term EOAs were greater in FY 2015 than the average values in FYs 2008-2010. The increases in expenditure were higher in short-term and long-term EOAs than those in non-EOAs and EOAs/non-EOAs. The increases in dental health expenditure were attributed to enhanced accessibility to dental health facilities. Furthermore, the evacuations contributed to increases in healthcare and long-term care expenditure, independent of aging and improved accessibly to health facilities. Possible explanations for these increases include the poor health status of the evacuees following the evacuations, reduced availability of informal care provided by family members and neighbors, and reduced patient copayments. The findings highlight the necessity of health promotion among evacuees.

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Trends in heterosexual inexperience among young adults in Japan: analysis of national surveys, 1987-2015.

Cyrus Ghaznavi, Haruka Sakamoto, Daisuke Yoneoka, Shuhei Nomura, Kenji Shibuya, Peter Ueda

BMC public health 19 ( 1 ) 355 - 355 2019.04

Accepted, ISSN 1471-2458

BACKGROUND: It has been suggested that an increasing number of Japanese adults remain sexually inexperienced; however, no study has assessed this issue using nationally representative data. METHODS: We used data from seven rounds of the National Fertility Survey of Japan, 1987-2015, and included adults aged 18-39 years (18-34 years in the 1987 survey) in the analyses (sample size 11,553-17,850 [1987-2010]; response rate 70.0-92.5%). For each survey year, sex and age group, we estimated the age-adjusted prevalence of heterosexual inexperience, defined as reporting no experience of sexual intercourse with someone of the opposite sex. We used logistic regression, adjusted for age, to identify factors associated with heterosexual inexperience in the 2010 survey. Information about same-sex sexual experience was not available. RESULTS: Between 1992 and 2015, the age-standardized prevalence of heterosexual inexperience in adults aged 18-39 years increased from 21.7 to 24.6% for women (p-values for linear and quadratic trend < 0.05) and from 20.0 to 25.8% for men (p-values for trend < 0.05). Among those aged 30-34 years, the prevalence was 6.2% in 1987 and 11.9% in 2015 for women (p-values for trend ≥0.05) and 8.8% (1987) and 12.7% (2015) for men (p-values for trend ≥0.05). Among those aged 35-39 years, prevalence increased from 4.0% in 1992 to 8.9% in 2015 among women (p-values for trend < 0.05). The corresponding numbers for men in the same age group were 5.5 and 9.5%, respectively (p-values for trend ≥0.05). Among men aged 25-39 years, unemployment, temporary/part-time employment and lower income were associated with heterosexual inexperience. CONCLUSIONS: The proportion of young Japanese adults with no experience of heterosexual intercourse had increased in the past two decades. Among adults in their thirties, around one in ten had no heterosexual experience. Unemployment, temporary/part-time employment and low income were associated with heterosexual inexperience among men. Further research is needed on the factors contributing to and the potential public health and demographic implications of the high proportion of the Japanese population that remains sexually inexperienced well into adult age.

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JAPAN: EFFECTIVE SMOKEFREE LAWS URGENTLY NEEDED

Nomura Shuhei, Sakamoto Haruka

TOBACCO CONTROL 28 ( 2 ) 123 - 124 2019.03

Accepted, ISSN 0964-4563

Trends in comparative efficacy and safety of malaria control interventions for maternal and child health outcomes in Africa: a study protocol for a Bayesian network meta-regression exploring the effect of HIV and malaria endemicity spectrum.

Floriano Amimo, Troy D Moon, Anthony Magit, Jahit Sacarlal, Ben Lambert, Shuhei Nomura

BMJ open 9 ( 2 ) e024313 2019.02

Accepted, ISSN 2044-6055

INTRODUCTION: Unprecedented global efforts to prevent malaria morbidity and mortality in sub-Saharan Africa have saved hundreds of thousands of lives across the continent in the last two decades. This study aims to determine how the comparative efficacy and safety of available malaria control interventions intended to improve maternal and child health outcomes have changed over time considering the varied epidemiological contexts on the continent. METHODS: We will review all randomised controlled trials that investigated malaria control interventions in pregnant women in sub-Saharan Africa and were published between January 1980 and December 2018. We will subsequently use network meta-regression to estimate temporal trends in the relative and absolute efficacy and safety of Intermittent Preventive Treatments, Intermittent Screening and Treatments, Insecticide-treated bed nets, and their combinations, and predict their ranking according to their relative and absolute efficacy and safety over time. Our outcomes will include 12 maternal and 7 child mortality and morbidity outcomes, known to be associated with either malaria infection or control. We will use intention-to-treat analysis to derive our estimates and meta-regression to estimate temporal trends and the effect modification by HIV infection, malaria endemicity and Plasmodium falciparum resistance to sulfadoxine-pyrimethamine, while adjusting for multiple potential confounders via propensity score calibration. PROSPERO REGISTRATION NUMBER: CRD42018095138.

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Change of access to emergency care in a repopulated village after the 2011 Fukushima nuclear disaster: a retrospective observational study.

Yoshitaka Nishikawa, Masaharu Tsubokura, Yoshimitsu Takahashi, Shuhei Nomura, Akihiko Ozaki, Yuko Kimura, Tomohiro Morita, Toyoaki Sawano, Tomoyoshi Oikawa, Takeo Nakayama

BMJ open 9 ( 2 ) e023836 2019.02

Accepted, ISSN 2044-6055

OBJECTIVES: Sustaining emergency care access is of great concern. The aim of this study is to evaluate access to emergency care in a repopulated village following the 2011 Fukushima disaster. DESIGN: This research was a retrospective observational study. The primary outcome measure was total emergency medical services (EMS) time. A Bayesian time series analysis was performed to consider local time series trend and seasonality. SETTING: The residents in Kawauchi Village, Fukushima, Japan were forced to evacuate after the 2011 Fukushima disaster. As the radiation dose was an acceptable level, the residents began the process of repopulation in April 2012. PARTICIPANTS: This study included patients transported by EMS from January 2009 to October 2015. Patients transported during the evacuation period (from March 2011 to March 2012) were excluded. RESULTS: A total of 781 patients were transferred by EMS (281 patients before the disaster, 416 after repopulation and 84 during the evacuation period). A Bayesian time series analysis revealed an increase in total EMS time, from the first request call to arrival at a hospital of 21.85 min (95% credible interval 14.2-29.0, Bayesian one-sided tail-area probability p=0.001). After the disaster, 42.3% of patients were transported to a partner hospital. CONCLUSIONS: Total EMS time increased after repopulation of the area affected because of a massive number of hospital closures. Proactive partnerships would be a possible countermeasure in the affected areas after a major disaster.

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Does Japan's national nutrient-based dietary guideline improve lifestyle-related disease outcomes? A retrospective observational cross-sectional study.

Daisuke Yoneoka, Shuhei Nomura, Kayo Kurotani, Shiori Tanaka, Keiji Nakamura, Hisayuki Uneyama, Naoki Hayashi, Kenji Shibuya

PloS one 14 ( 10 ) e0224042 2019

Accepted

OBJECTIVE: The Japanese government has developed and promoted a national nutrient-based dietary guideline for preventing lifestyle-related chronic disease. However, its impact in a real-life setting has never been evaluated. We performed a critical appraisal of the guideline by examining the association between adherence to the guideline and lifestyle-related outcome indicators. METHODS: This is a retrospective observational cross-sectional study using nationally representative data on health and nutrition characteristics from the 2016 National Health and Nutrition Survey of Japan. We considered 3,861 participants aged ≥20 years, with evidence of low health risks of diabetes, hypertension, hyperlipidemia, and obesity. Five health outcome indicators (hemoglobin A1c (HbA1c), systolic blood pressure, diastolic blood pressure, high-density lipoprotein cholesterol, and body mass index), were employed. A summary score was developed to reflect adherence to the recommended intake of seven nutrients defined by the guideline, including proteins, fat, saturated fatty acid, carbohydrate, dietary fiber, sodium, and potassium. Multivariate quartile regression approaches were employed to examine the association between the adherence score and the health outcome indicators, adjusting for the covariates. RESULTS: Overall, the proportion of those who adhered to the guideline (adherence rate) for all seven nutrients was only 0.3%. There was considerable variation in the adherence rate between the different nutrients, from 24.2% to 61.8%. After adjustment for covariates, in most health outcome indicators, regardless of age category and quartile, there was no clear association between the guideline adherence score and indicators. CONCLUSIONS: There is plenty of scope for improving the guideline. Nutrient impact on health may not necessarily depend on the amount of each nutrient in the diet. The significance and contribution of synergies between nutrients and complex interactions within foods to health outcomes need to be explored in future guideline updates.

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Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980-2017: a systematic analysis for the Global Burden of Disease Study 2017

Collaborators, G. B. D. Causes of Death

Lancet 392 ( 10159 ) 2170 2018.11

Accepted, ISSN 0140-6736

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Global, regional, and national age-sex-specific mortality and life expectancy, 1950-2017: A systematic analysis for the Global Burden of Disease Study 2017

GBD 2017 Mortality Collaborators

The Lancet 392 ( 10159 ) 1684 - 1735 2018.11

Accepted, ISSN 0140-6736

© 2018 The Author(s). Background: Assessments of age-specifc mortality and life expectancy have been done by the UN Population Division, Department of Economics and Social Afairs (UNPOP), the United States Census Bureau, WHO, and as part of previous iterations of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD). Previous iterations of the GBD used population estimates from UNPOP, which were not derived in a way that was internally consistent with the estimates of the numbers of deaths in the GBD. The present iteration of the GBD, GBD 2017, improves on previous assessments and provides timely estimates of the mortality experience of populations globally. Methods: The GBD uses all available data to produce estimates of mortality rates between 1950 and 2017 for 23 age groups, both sexes, and 918 locations, including 195 countries and territories and subnational locations for 16 countries. Data used include vital registration systems, sample registration systems, household surveys (complete birth histories, summary birth histories, sibling histories), censuses (summary birth histories, household deaths), and Demographic Surveillance Sites. In total, this analysis used 8259 data sources. Estimates of the probability of death between birth and the age of 5 years and between ages 15 and 60 years are generated and then input into a model life table system to produce complete life tables for all locations and years. Fatal discontinuities and mortality due to HIV/AIDS are analysed separately and then incorporated into the estimation. We analyse the relationship between age-specifc mortality and development status using the Socio-demographic Index, a composite measure based on fertility under the age of 25 years, education, and income. There are four main methodological improvements in GBD 2017 compared with GBD 2016: 622 additional data sources have been incorporated; new estimates of population, generated by the GBD study, are used; statistical methods used in diferent components of the analysis have been further standardised and improved; and the analysis has been extended backwards in time by two decades to start in 1950. Findings: Globally, 18·7% (95% uncertainty interval 18·4-19·0) of deaths were registered in 1950 and that proportion has been steadily increasing since, with 58·8% (58·2-59·3) of all deaths being registered in 2015. At the global level, between 1950 and 2017, life expectancy increased from 48·1 years (46·5-49·6) to 70·5 years (70·1-70·8) for men and from 52·9 years (51·7-54·0) to 75·6 years (75·3-75·9) for women. Despite this overall progress, there remains substantial variation in life expectancy at birth in 2017, which ranges from 49·1 years (46·5-51·7) for men in the Central African Republic to 87·6 years (86·9-88·1) among women in Singapore. The greatest progress across age groups was for children younger than 5 years; under-5 mortality dropped from 216·0 deaths (196·3-238·1) per 1000 livebirths in 1950 to 38·9 deaths (35·6-42·83) per 1000 livebirths in 2017, with huge reductions across countries. Nevertheless, there were still 5·4 million (5·2-5·6) deaths among children younger than 5 years in the world in 2017. Progress has been less pronounced and more variable for adults, especially for adult males, who had stagnant or increasing mortality rates in several countries. The gap between male and female life expectancy between 1950 and 2017, while relatively stable at the global level, shows distinctive patterns across super-regions and has consistently been the largest in central Europe, eastern Europe, and central Asia, and smallest in south Asia. Performance was also variable across countries and time in observed mortality rates compared with those expected on the basis of development. Interpretation: This analysis of age-sex-specifc mortality shows that there are remarkably complex patterns in population mortality across countries. The fndings of this study highlight global successes, such as the large decline in under-5 mortality, which refects signifcant local, national, and global commitment and investment over several decades. However, they also bring attention to mortality patterns that are a cause for concern, particularly among adult men and, to a lesser extent, women, whose mortality rates have stagnated in many countries over the time period of this study, and in some cases are increasing.

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Global, regional, and national incidence, prevalence, and years lived with disability for 354 Diseases and Injuries for 195 countries and territories, 1990-2017: A systematic analysis for the Global Burden of Disease Study 2017

GBD 2017 Disease and Injury Incidence and Prevalence Collaborators

The Lancet 392 ( 10159 ) 1789 - 1858 2018.11

Accepted, ISSN 0140-6736

Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Background: The Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017) includes a comprehensive assessment of incidence, prevalence, and years lived with disability (YLDs) for 354 causes in 195 countries and territories from 1990 to 2017. Previous GBD studies have shown how the decline of mortality rates from 1990 to 2016 has led to an increase in life expectancy, an ageing global population, and an expansion of the non-fatal burden of disease and injury. These studies have also shown how a substantial portion of the world's population experiences non-fatal health loss with considerable heterogeneity among different causes, locations, ages, and sexes. Ongoing objectives of the GBD study include increasing the level of estimation detail, improving analytical strategies, and increasing the amount of high-quality data. Methods: We estimated incidence and prevalence for 354 diseases and injuries and 3484 sequelae. We used an updated and extensive body of literature studies, survey data, surveillance data, inpatient admission records, outpatient visit records, and health insurance claims, and additionally used results from cause of death models to inform estimates using a total of 68 781 data sources. Newly available clinical data from India, Iran, Japan, Jordan, Nepal, China, Brazil, Norway, and Italy were incorporated, as well as updated claims data from the USA and new claims data from Taiwan (province of China) and Singapore. We used DisMod-MR 2.1, a Bayesian meta-regression tool, as the main method of estimation, ensuring consistency between rates of incidence, prevalence, remission, and cause of death for each condition. YLDs were estimated as the product of a prevalence estimate and a disability weight for health states of each mutually exclusive sequela, adjusted for comorbidity. We updated the Socio-demographic Index (SDI), a summary development indicator of income per capita, years of schooling, and total fertility rate. Additionally, we calculated differences between male and female YLDs to identify divergent trends across sexes. GBD 2017 complies with the Guidelines for Accurate and Transparent Health Estimates Reporting. Findings: Globally, for females, the causes with the greatest age-standardised prevalence were oral disorders, headache disorders, and haemoglobinopathies and haemolytic anaemias in both 1990 and 2017. For males, the causes with the greatest age-standardised prevalence were oral disorders, headache disorders, and tuberculosis including latent tuberculosis infection in both 1990 and 2017. In terms of YLDs, low back pain, headache disorders, and dietary iron deficiency were the leading Level 3 causes of YLD counts in 1990, whereas low back pain, headache disorders, and depressive disorders were the leading causes in 2017 for both sexes combined. All-cause age-standardised YLD rates decreased by 3·9% (95% uncertainty interval [UI] 3·1-4·6) from 1990 to 2017; however, the all-age YLD rate increased by 7·2% (6·0-8·4) while the total sum of global YLDs increased from 562 million (421-723) to 853 million (642-1100). The increases for males and females were similar, with increases in all-age YLD rates of 7·9% (6·6-9·2) for males and 6·5% (5·4-7·7) for females. We found significant differences between males and females in terms of age-standardised prevalence estimates for multiple causes. The causes with the greatest relative differences between sexes in 2017 included substance use disorders (3018 cases [95% UI 2782-3252] per 100 000 in males vs 1400 [1279-1524] per 100 000 in females), transport injuries (3322 [3082-3583] vs 2336 [2154-2535]), and self-harm and interpersonal violence (3265 [2943-3630] vs 5643 [5057-6302]). Interpretation: Global all-cause age-standardised YLD rates have improved only slightly over a period spanning nearly three decades. However, the magnitude of the non-fatal disease burden has expanded globally, with increasing numbers of people who have a wide spectrum of conditions. A subset of conditions has remained globally pervasive since 1990, whereas other conditions have displayed more dynamic trends, with different ages, sexes, and geographies across the globe experiencing varying burdens and trends of health loss. This study emphasises how global improvements in premature mortality for select conditions have led to older populations with complex and potentially expensive diseases, yet also highlights global achievements in certain domains of disease and injury.

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Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990-2017: A systematic analysis for the Global Burden of Disease Study 2017

GBD 2017 Risk Factor Collaborators

The Lancet 392 ( 10159 ) 1923 - 1994 2018.11

Accepted, ISSN 0140-6736

© 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Background The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 comparative risk assessment (CRA) is a comprehensive approach to risk factor quantification that offers a useful tool for synthesising evidence on risks and risk-outcome associations. With each annual GBD study, we update the GBD CRA to incorporate improved methods, new risks and risk-outcome pairs, and new data on risk exposure levels and risk- outcome associations. Methods We used the CRA framework developed for previous iterations of GBD to estimate levels and trends in exposure, attributable deaths, and attributable disability-adjusted life-years (DALYs), by age group, sex, year, and location for 84 behavioural, environmental and occupational, and metabolic risks or groups of risks from 1990 to 2017. This study included 476 risk-outcome pairs that met the GBD study criteria for convincing or probable evidence of causation. We extracted relative risk and exposure estimates from 46 749 randomised controlled trials, cohort studies, household surveys, census data, satellite data, and other sources. We used statistical models to pool data, adjust for bias, and incorporate covariates. Using the counterfactual scenario of theoretical minimum risk exposure level (TMREL), we estimated the portion of deaths and DALYs that could be attributed to a given risk. We explored the relationship between development and risk exposure by modelling the relationship between the Socio-demographic Index (SDI) and risk-weighted exposure prevalence and estimated expected levels of exposure and risk-attributable burden by SDI. Finally, we explored temporal changes in risk-attributable DALYs by decomposing those changes into six main component drivers of change as follows: (1) population growth; (2) changes in population age structures; (3) changes in exposure to environmental and occupational risks; (4) changes in exposure to behavioural risks; (5) changes in exposure to metabolic risks; and (6) changes due to all other factors, approximated as the risk-deleted death and DALY rates, where the risk-deleted rate is the rate that would be observed had we reduced the exposure levels to the TMREL for all risk factors included in GBD 2017.

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Public Health Preparedness for and Response to Nuclear Disasters: An Editorial.

Shuhei Nomura, Michio Murakami

International journal of environmental research and public health 15 ( 11 ) 2018.11

Accepted, ISSN 1661-7827

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Bibliometric Study of Obstetrics Articles Published in the Journal of the American Medical Association, 1997-2016.

Kana Yamamoto, Akihiko Ozaki, Shuhei Nomura, Yuki Senoo, Izumi Yoshida, Yuto Maeda, Mutsuko Ohnishi, Tetsuya Tanimoto, Masahiro Kami

Cureus 10 ( 10 ) e3448 2018.10

Accepted, ISSN 2168-8184

Introduction A recent increase in cases of advanced maternal age in the US has been partly associated with a higher incidence of pregnancy-related complications and infertility. However, little is known on how such social changes may have influenced obstetrics articles published in high-impact medical journals subscribed by diverse physicians. The objective of this study is to elucidate the presence and trend of obstetrics investigations in high-profile medical journals. Material and methods This bibliometric study retrospectively analyzed original articles published in the Journal of the American Medical Association (JAMA) from 1997 to 2016. Two reviewers extracted obstetrics articles from PubMed, assessed whether to include specific articles, and categorized them by subtopic. Main outcomes measure was the annual number of original investigations in obstetrics divided by that of original investigations from all fields during the study period, expressed as a trend. Results A total of 3486 original investigations were published during the study period. Regarding obstetrics, 1989 articles were originally extracted from PubMed; after a two-step review process, 199 (10.0%) obstetrics-related original investigations remained. Among them, 134 (67.4%) were classified as pregnancy-related abnormalities or complications (non-infection). The proportion of obstetrics articles decreased during the first 10 years but increased in the last 10 years. The highest figures in the first 10 and last 10 years were 8.5% in 1999 and 9.4% in 2014, respectively, whereas the lowest was 1.4% in 2008. The proportion articles on pregnancy-associated complications or abnormalities (non-infection) steadily increased during the study period, that of articles on infertility increased, and that of articles on human immunodeficiency virus (HIV) infection steadily decreased. Conclusions The observed trend may suggest a changing interest in obstetrics investigations among general physicians in the last 20 years. What is particularly notable is a heightened presence of research on pregnancy-related complications and infertility, which may reflect an increasing frequency in advanced maternal age in the US.

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Progress towards universal health coverage in Myanmar: a national and subnational assessment.

Su Myat Han, Md Mizanur Rahman, Md Shafiur Rahman, Khin Thet Swe, Matthew Palmer, Haruka Sakamoto, Shuhei Nomura, Kenji Shibuya

The Lancet. Global health 6 ( 9 ) e989-e997 - e997 2018.09

Accepted, ISSN 2214-109X

BACKGROUND: Attainment of universal health coverage is a global health priority. The Myanmar Government has committed to attainment of universal health coverage by 2030, but progress so far has not been assessed. We aimed to estimate national and subnational health service coverage and financial risk protection. METHODS: We used nationally representative data from the Myanmar Demographic and Health Survey (2016) and the Integrated Household Living Condition Assessment (2010) to examine 26 health service indicators and explored the incidence of catastrophic health payment and impoverishment caused by out-of-pocket payments. We used logistic regression models of inequalities in, and risk factors for, indicators of universal health coverage. FINDINGS: Nationally, the coverage of health service indicators ranged from 18·4% (95% CI 14·9-21·9) to 96·2% (95·9-96·5). Coverage of most health services indicators was below the universal health coverage target of 80%. 14·6% (95% CI 13·9-15·3) of households that used health services faced catastrophic health-care payments. 2·0% (95% CI 1·7-2·3) of non-poor households became poor because of out-of-pocket payments for health. Health service coverage and financial risk protection varied substantially by region. Although the richest quintiles had better access to health services than the poorest quintiles, they also had a higher incidence of financial catastrophe as a result of payments for health care. Of the indicators included in the study, coverage of adequate sanitation, no indoor use of solid fuels, at least four antenatal care visits, postnatal care for mothers, skilled birth attendance, and institutional delivery were the most inequitable by wealth quintile. INTERPRETATION: Attainment of universal health coverage in Myanmar in the immediate future will be very challenging as a result of the low health service coverage, high financial risk, and inequalities in access to care. Health service coverage and financial risk protection for vulnerable, disadvantaged populations should be prioritised. FUNDING: Japanese Ministry of Health, Labour and Welfare, Ministry of Education, Culture, Sports, Science and Technology of Japan.

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The Great East Japan Earthquake, Tsunamis, and Fukushima Daiichi Nuclear Power Plant Disaster: Lessons for Evidence Integration from a WADEM 2017 Presentation and Panel Discussion.

Claire Leppold, Sae Ochi, Shuhei Nomura, Virginia Murray

Prehospital and disaster medicine 33 ( 4 ) 424 - 427 2018.08

Accepted, ISSN 1049-023X

In April 2017, some of the health impacts of the 2011 Great East Japan Earthquake, tsunamis, and resultant Fukushima Daiichi nuclear power plant disaster (Okuma, Fukushima Prefecture, Japan) were presented at the 19th Congress of the World Association for Disaster and Emergency Medicine (WADEM; Madison, Wisconsin USA) in Toronto, Canada. A panel discussion was then opened by asking audience members about their experiences in their own countries, and how they would suggest taking steps to reach the goals of the Sendai Framework for Disaster Risk Reduction 2015-2030. This paper summarizes the presentation and panel discussion, with a particular focus on the common problems identified in understanding and reducing health risks from disasters in multiple countries, such as the ethical and practical difficulties in decision making on evacuating vulnerable populations that arose similarly during the Fukushima nuclear disaster in 2011 and Hurricane Ike's approach to Galveston (Texas USA) in 2008. This paper also highlights the need for greater integration of research, for example through increased review and collation of evidence from different disaster settings to identify common problems and possible solutions, which was identified in this panel session as a precursor to fulfilling the goals of the Sendai Framework.Leppold C, Ochi S, Nomura S, Murray V. The Great East Japan Earthquake, tsunamis, and Fukushima Daiichi nuclear power plant disaster: lessons for evidence integration from a WADEM 2017 presentation and panel discussion. Prehosp Disaster Med. 2018;33(4):424-427.

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Balancing the risk of the evacuation and sheltering-in-place options: a survival study following Japan's 2011 Fukushima nuclear incident.

Yuki Shimada, Shuhei Nomura, Akihiko Ozaki, Asaka Higuchi, Arinobu Hori, Yuki Sonoda, Kana Yamamoto, Izumi Yoshida, Masaharu Tsubokura

BMJ open 8 ( 7 ) e021482 2018.07

Accepted, ISSN 2044-6055

OBJECTIVE: The decision to evacuate or shelter-in-place is fundamental to emergency response, especially for a vulnerable population. While an elevated risk of mortality due to a hasty, unplanned evacuation has been well documented, there is little research on and knowledge about the health consequences of sheltering-in-place in disaster contexts. We compared hospital mortality in patients who sheltered-in-place (non-evacuees) after the incident with the baseline preincident mortality and articulated postincident circumstances of the hospital while sheltering-in-place. PARTICIPANTS: We considered all 484 patients admitted to Takano Hospital (located 22 km South of the Fukushima Daiichi nuclear power plant) from 1 January 2008 to 31 December 2016. METHODS: Significant differences in mortality rates between preincident baseline and three postincident groups (evacuees, non-evacuees (our major interest) and new admittees) were tested using the Bayesian survival analysis with Weibull multivariate regression and survival probability using the Kaplan-Meier product limit method. All the analyses were separately performed by the internal and psychiatry department. RESULTS: After adjusting for covariates, non-evacuees in the internal department had a significantly higher mortality risk with an HR of 1.57 (95% credible intervals 1.11 to 2.18) than the baseline preincident. Of them, most deaths occurred within the first 100 days of the incident. No significant increase in mortality risk was identified in evacuees and new admittees postincident in the department, which were adjusted for covariates. In contrast, for the psychiatry department, statistical difference in mortality risk was not identified in any groups. CONCLUSIONS: The mortality risk of sheltering-in-place in a harsh environment might be comparable to those in an unplanned evacuation. If sheltering-in-place with sufficient resources is not guaranteed, evacuation could be a reasonable option, which might save more lives of vulnerable people if performed in a well-planned manner with satisfactory arrangements for appropriate transportation and places to safely evacuate.

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Automatic anatomical classification of esophagogastroduodenoscopy images using deep convolutional neural networks.

Hirotoshi Takiyama, Tsuyoshi Ozawa, Soichiro Ishihara, Mitsuhiro Fujishiro, Satoki Shichijo, Shuhei Nomura, Motoi Miura, Tomohiro Tada

Scientific reports 8 ( 1 ) 7497 - 7497 2018.05

Accepted, ISSN 2045-2322

The use of convolutional neural networks (CNNs) has dramatically advanced our ability to recognize images with machine learning methods. We aimed to construct a CNN that could recognize the anatomical location of esophagogastroduodenoscopy (EGD) images in an appropriate manner. A CNN-based diagnostic program was constructed based on GoogLeNet architecture, and was trained with 27,335 EGD images that were categorized into four major anatomical locations (larynx, esophagus, stomach and duodenum) and three subsequent sub-classifications for stomach images (upper, middle, and lower regions). The performance of the CNN was evaluated in an independent validation set of 17,081 EGD images by drawing receiver operating characteristics (ROC) curves and calculating the area under the curves (AUCs). ROC curves showed high performance of the trained CNN to classify the anatomical location of EGD images with AUCs of 1.00 for larynx and esophagus images, and 0.99 for stomach and duodenum images. Furthermore, the trained CNN could recognize specific anatomical locations within the stomach, with AUCs of 0.99 for the upper, middle, and lower stomach. In conclusion, the trained CNN showed robust performance in its ability to recognize the anatomical location of EGD images, highlighting its significant potential for future application as a computer-aided EGD diagnostic system.

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Call for a new epidemiological approach to disaster response.

Michio Murakami, Shuhei Nomura, Masaharu Tsubokura

Journal of epidemiology and community health 72 ( 4 ) 267 - 268 2018.04

Accepted, ISSN 0143-005X

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Causes and risk factors for singleton stillbirth in Japan: Analysis of a nationwide perinatal database, 2013-2014.

Rei Haruyama, Stuart Gilmour, Erika Ota, Sarah K Abe, Md Mizanur Rahman, Shuhei Nomura, Naoyuki Miyasaka, Kenji Shibuya

Scientific reports 8 ( 1 ) 4117 - 4117 2018.03

Accepted, ISSN 2045-2322

Over 80% of perinatal mortality in Japan is due to stillbirths after 22 weeks of gestation, with one in 300 families experiencing fetal loss every year. This study aimed to assess causes and risk factors for singleton stillbirth in Japan. A retrospective cross-sectional study was conducted using the Japan Society of Obstetrics and Gynecology Perinatal Database from January 2013 to December 2014. A total of 379,211 births including 2,133 stillbirths were analyzed. Causes of death were classified into eight categories. A multi-level Poisson regression model was used to assess the relationship between stillbirth and key covariates. Causes of death were unknown in 25-40% of stillbirths across gestational age. Placental abnormality accounted for the largest proportion of known causes, followed by umbilical cord abnormality. Stillbirth risk was increased among small-for-gestational-age infants (adjusted relative risk [ARR]: 3.78, 95% confidence interval [CI]: 3.31-4.32) and nulliparous women (ARR: 1.19, 95% CI: 1.05-1.35). Maternal underweight, pregnancy-induced hypertension and oligohydramnios showed a protective effect. Our finding suggests that stillbirths occurring among women with known complications are likely already being prevented. Further reduction in stillbirths must target small-sized fetuses and nulliparous women. Improved recording of the causal pathways of stillbirths is also needed.

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Comparison of external doses between radio-contaminated areas and areas with high natural terrestrial background using the individual dosimeter 'D-shuttle' 75 months after the Fukushima Daiichi nuclear power plant accident.

Masaharu Tsubokura, Shuhei Nomura, Izumi Yoshida, Toyoaki Sawano, Makoto Miyazaki, Satoru Tomita, Oikawa Tomoyoshi, Masami Watanabe

Journal of radiological protection : official journal of the Society for Radiological Protection 38 ( 1 ) 273 - 285 2018.03

Accepted, ISSN 0952-4746

After the Fukushima Daiichi nuclear power plant accident, the air dose gradually decreases every year due to the physical decay of radioactive materials and environmental changes, as well as countermeasures. However, there is little information on personal behavioural patterns and individual dose from external exposure among the inhabitants around the nuclear power plant. To evaluate the dose from external exposure in Minamisoma city, and compare the differences with outside Fukushima Prefecture, we started the external dose assessment project in cooperation with city officials in Minamisoma and three other cities in Japan where the natural terrestrial background radiation level is relatively high. In these four cities, external dose was measured every hour for two weeks using an individual electronic dosimeter D-shuttle. The places of activity of participants were recorded every hour to compare and evaluate the dose from external exposure, and to clarify whether there is a difference in the exposure dose by behaviour. The annual effective doses from external exposure for 100 participants from four municipalities ranged from 0.566 to 1.295 with a mean value of 0.784 mSv, which was below the level where it is necessary to initiate further remedial actions. Mean external dose in Minamisoma city (0.820 mSv/year) was comparable to those in municipalities with a relatively high natural radiation background in Japan (0.793, 0.806, and 0.718 mSv/year in Fukuyama, Nanto, and Tajimi, respectively). The time spent at home and in the workplace accounted for most of the time of the participants, and this also contributed to the majority of the total dose from external exposure. The amount of exposure at times other than while at home or in the workplace was very small regardless of the indoor or outdoor location in the city. For future dose reduction and radiation protection, continuous dosimetry and countermeasures at home and in the workplace are important for individuals who present high values.

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Demographic transition and factors associated with remaining in place after the 2011 Fukushima nuclear disaster and related evacuation orders.

Tomohiro Morita, Shuhei Nomura, Tomoyuki Furutani, Claire Leppold, Masaharu Tsubokura, Akihiko Ozaki, Sae Ochi, Masahiro Kami, Shigeaki Kato, Tomoyoshi Oikawa

PloS one 13 ( 3 ) e0194134 2018

Accepted, ISSN 1932-6203

INTRODUCTION: Demographic changes as a result of evacuation in the acute phase of the 2011 Fukushima nuclear disaster are not well evaluated. We estimated post-disaster demographic transitions in Minamisoma City-located 14-38 km north of the nuclear plant-in the first month of the disaster; and identified demographic factors associated with the population remaining in the affected areas. MATERIALS AND METHODS: We extracted data from the evacuation behavior survey administered to participants in the city between July 11, 2011 and April 30, 2013. Using mathematical models, we estimated the total population in the city after the disaster according to sex, age group, and administrative divisions of the city. To investigate factors associated with the population remaining in place after the disaster, a probit regression model was employed, taking into account sex, age, pre-disaster dwelling area, and household composition. RESULTS: The overall population decline in Minamisoma City peaked 11 days after the disaster, when the population reached 7,107 people-11% of the pre-disaster level. The remaining population levels differed by area: 1.1% for mandatory evacuation zone, 12.5% for indoor sheltering zone, and 12.6% for other areas of the city. Based on multiple regression analyses, higher odds for remaining in place were observed among men (odds ratio 1.72 [95% confidence intervals 1.64-1.85]) than women; among people aged 40-64 years (1.40 [1.24-1.58]) than those aged 75 years or older; and among those living with the elderly, aged 70 years or older (1.18 [1.09-1.27]) or those living alone (1.71 [1.50-1.94]) than among those who were not. DISCUSSION: Despite the evacuation order, some residents of mandatory evacuation zones remained in place, signaling the need for preparation to respond to their post-disaster needs. Indoor sheltering instructions may have accelerated voluntary evacuation, and this demonstrates the need for preventing potentially disorganized evacuation in future nuclear events.

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Assessment of medium-term cardiovascular disease risk after Japan's 2011 Fukushima Daiichi nuclear accident: a retrospective analysis.

Haruka Toda, Shuhei Nomura, Stuart Gilmour, Masaharu Tsubokura, Tomoyoshi Oikawa, Kiwon Lee, Grace Y Kiyabu, Kenji Shibuya

BMJ open 7 ( 12 ) e018502 2017.12

Accepted, ISSN 2044-6055

OBJECTIVE: To assess the medium-term indirect impact of the 2011 Fukushima Daiichi nuclear accident on cardiovascular disease (CVD) risks and to identify whether risk factors for CVD changed after the accident. PARTICIPANTS: Residents aged 40 years and over participating in annual public health check-ups from 2009 to 2012, administered by Minamisoma city, located about 10 to 40 km from the Fukushima Daiichi nuclear plant. METHODS: The sex-specific Framingham CVD risk score was considered as the outcome measure and was compared before (2009-2010) and after the accident (2011-2012). A multivariate regression analysis was employed to evaluate risk factors for CVD. RESULTS: Data from 563 individuals (60.2% women) aged 40 to 74 years who participated in the check-ups throughout the study period was analysed. After adjusting for covariates, no statistically significant change was identified in the CVD risk score postaccident in both sexes, which may suggest no obvious medium-term health impact of the Fukushima nuclear accident on CVD risk. The risk factors for CVD and their magnitude and direction (positive/negative) did not change after the accident. CONCLUSIONS: There was no obvious increase in CVD risks in Minamisoma city, which may indicate successful management of health risks associated with CVD in the study sample.

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Application of Convolutional Neural Networks in the Diagnosis of Helicobacter pylori Infection Based on Endoscopic Images.

Satoki Shichijo, Shuhei Nomura, Kazuharu Aoyama, Yoshitaka Nishikawa, Motoi Miura, Takahide Shinagawa, Hirotoshi Takiyama, Tetsuya Tanimoto, Soichiro Ishihara, Keigo Matsuo, Tomohiro Tada

EBioMedicine (ELSEVIER SCIENCE BV) 25 106 - 111 2017.11

Accepted, ISSN 2352-3964

BACKGROUND AND AIMS: The role of artificial intelligence in the diagnosis of Helicobacter pylori gastritis based on endoscopic images has not been evaluated. We constructed a convolutional neural network (CNN), and evaluated its ability to diagnose H. pylori infection. METHODS: A 22-layer, deep CNN was pre-trained and fine-tuned on a dataset of 32,208 images either positive or negative for H. pylori (first CNN). Another CNN was trained using images classified according to 8 anatomical locations (secondary CNN). A separate test data set (11,481 images from 397 patients) was evaluated by the CNN, and 23 endoscopists, independently. RESULTS: The sensitivity, specificity, accuracy, and diagnostic time were 81.9%, 83.4%, 83.1%, and 198s, respectively, for the first CNN, and 88.9%, 87.4%, 87.7%, and 194s, respectively, for the secondary CNN. These values for the 23 endoscopists were 79.0%, 83.2%, 82.4%, and 230±65min (85.2%, 89.3%, 88.6%, and 253±92min by 6 board-certified endoscopists), respectively. The secondary CNN had a significantly higher accuracy than endoscopists (by 5.3%; 95% CI, 0.3-10.2). CONCLUSION: H. pylori gastritis could be diagnosed based on endoscopic images using CNN with higher accuracy and in a considerably shorter time compared to manual diagnosis by endoscopists.

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Decontamination Work and the Long-term Increase in Hospital Visits for Hymenoptera Stings Following the Fukushima Nuclear Disaster.

Akihiko Ozaki, Takeru Yokota, Shuhei Nomura, Masaharu Tsubokura, Claire Leppold, Tetsuya Tanimoto, Toru Miura, Kana Yamamoto, Toyoaki Sawano, Manabu Tsukada, Masahiro Kami, Yukio Kanazawa, Hiromichi Ohira

Disaster medicine and public health preparedness (CAMBRIDGE UNIV PRESS) 11 ( 5 ) 545 - 551 2017.10

Accepted, ISSN 1935-7893

OBJECTIVE: Animals, including arthropods, are one health threat that can be affected by disasters. This institution-based study aimed to assess trends in Hymenoptera stings following the 2011 Fukushima nuclear disaster. METHODS: We reviewed the medical records of patients with hymenopteran stings who visited Minamisoma Municipal General Hospital, located 23 km from Fukushima Daiichi Nuclear Power Plant, from March 2005 to March 2016. Patient and sting characteristics of post-disaster patients were examined, and the annual incidence of hospital visits for hymenopteran stings was compared with the pre-disaster baseline, calculating an incidence rate ratio (IRR) for each year. RESULTS: We identified 152 pre-disaster patients (2005-2011) and 222 post-disaster patients (2011-2016). In the post-disaster period, 160 males (72.1%) were identified, with a median age of 59 years (range: 2-89 years). A total of 45 patients (20.3%) were decontamination workers. Post-disaster increases were found in the IRR for hymenopteran stings, peaking first in 2011 (IRR: 2.8; 95% confidence interval [CI]: 1.9-4.2) and later in 2014 (IRR: 3.2; 95% CI: 2.4-4.3) and 2015 (IRR 3.3; 95% CI: 2.5-4.4). CONCLUSIONS: Long-term increases were found in the IRR of hospital visits for hymenopteran stings in an institution affected by the Fukushima nuclear disaster. Decontamination workers appear to have been particularly affected by this phenomenon. Better disaster field worker monitoring and education about potential environmental health hazards may help to identify and prevent worker exposure to insect stings and other vectors in these settings. (Disaster Med Public Health Preparedness. 2017;11:545-551).

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Excess mortality due to indirect health effects of the 2011 triple disaster in Fukushima, Japan: a retrospective observational study.

Tomohiro Morita, Shuhei Nomura, Masaharu Tsubokura, Claire Leppold, Stuart Gilmour, Sae Ochi, Akihiko Ozaki, Yuki Shimada, Kana Yamamoto, Manami Inoue, Shigeaki Kato, Kenji Shibuya, Masahiro Kami

Journal of epidemiology and community health (BMJ PUBLISHING GROUP) 71 ( 10 ) 974 - 980 2017.10

Accepted, ISSN 0143-005X

BACKGROUND: Evidence on the indirect health impacts of disasters is limited. We assessed the excess mortality risk associated with the indirect health impacts of the 2011 triple disaster (earthquake, tsunami and nuclear disaster) in Fukushima, Japan. METHODS: The mortality rates in Soma and Minamisoma cities in Fukushima from 2006 to 2015 were calculated using vital statistics and resident registrations. We investigated the excess mortality risk, defined as the increased mortality risk between postdisaster and predisaster after excluding direct deaths attributed to the physical force of the disaster. Multivariate Poisson regression models were used to estimate the relative risk (RR) of mortality after adjusting for city, age and year. RESULTS: There were 6163 and 6125 predisaster and postdisaster deaths, respectively. The postdisaster mortality risk was significantly higher in the first month following the disaster (March 2011) than in the same month during the predisaster period (March 2006-2010). RRs among men and women were 2.64 (95% CI 2.16 to 3.24) and 2.46 (95% CI 1.99 to 3.03), respectively, demonstrating excess mortality risk due to the indirect health effects of the disaster. Age-specific subgroup analyses revealed a significantly higher mortality risk in women aged ≥85 years in the third month of the disaster compared with predisaster baseline, with an RR (95% CI) of 1.73 (1.23 to 2.44). CONCLUSIONS: Indirect health impacts are most severe in the first month of the disaster. Early public health support, especially for the elderly, can be an important factor for reducing the indirect health effects of a disaster.

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Population health and regional variations of disease burden in Japan, 1990-2015: a systematic subnational analysis for the Global Burden of Disease Study 2015.

Shuhei Nomura, Haruka Sakamoto, Scott Glenn, Yusuke Tsugawa, Sarah K Abe, Md M Rahman, Jonathan C Brown, Satoshi Ezoe, Christina Fitzmaurice, Tsuyoshi Inokuchi, Nicholas J Kassebaum, Norito Kawakami, Yosuke Kita, Naoki Kondo, Stephen S Lim, Satoshi Maruyama, Hiroaki Miyata, Meghan D Mooney, Mohsen Naghavi, Tomoko Onoda, Erika Ota, Yuji Otake, Gregory A Roth, Eiko Saito, Takahiro Tabuchi, Yohsuke Takasaki, Tadayuki Tanimura, Manami Uechi, Theo Vos, Haidong Wang, Manami Inoue, Christopher J L Murray, Kenji Shibuya

Lancet (London, England) (ELSEVIER SCIENCE INC) 390 ( 10101 ) 1521 - 1538 2017.09

Accepted, ISSN 0140-6736

BACKGROUND: Japan has entered the era of super-ageing and advanced health transition, which is increasingly putting pressure on the sustainability of its health system. The level and pace of this health transition might vary across regions within Japan and concern is growing about increasing regional variations in disease burden. The Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) provides a comprehensive, comparable framework. We used data from GBD 2015 with the aim to quantify the burden of disease and injuries, and to attribute risk factors in Japan at a subnational, prefecture-level. METHODS: We used data from GBD 2015 for 315 causes and 79 risk factors of death, disease, and injury incidence and prevalence to measure the burden of diseases and injuries in Japan and in the 47 Japanese prefectures from 1990 to 2015. We extracted data from GBD 2015 to assess mortality, causes of death, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), life expectancy, and healthy life expectancy (HALE) in Japan and its 47 prefectures. We split extracted data by prefecture and applied GBD methods to generate estimates of burden, and attributable burden due to known risk factors. We examined the prefecture-level relationships of common health system inputs (eg, health expenditure and workforces) to the GBD outputs in 2015 to address underlying determinants of regional health variations. FINDINGS: Life expectancy at birth in Japan increased by 4·2 years from 79·0 years (95% uncertainty interval [UI] 79·0 to 79·0) to 83·2 years (83·1 to 83·2) between 1990 and 2015. However, the gaps between prefectures with the lowest and highest life expectancies and HALE have widened, from 2·5 to 3·1 years and from 2·3 to 2·7 years, respectively, from 1990 to 2015. Although overall age-standardised death rates decreased by 29·0% (28·7 to 29·3) from 1990 to 2015, the rates of mortality decline in this period substantially varied across the prefectures, ranging from -32·4% (-34·8 to -30·0) to -22·0% (-20·4 to -20·1). During the same time period, the rate of age-standardised DALYs was reduced overall by 19·8% (17·9 to 22·0). The reduction in rates of age-standardised YLDs was very small by 3·5% (2·6 to 4·3). The pace of reduction in mortality and DALYs in many leading causes has largely levelled off since 2005. Known risk factors accounted for 34·5% (32·4 to 36·9) of DALYs; the two leading behavioural risk factors were unhealthy diets and tobacco smoking in 2015. The common health system inputs were not associated with age-standardised death and DALY rates in 2015. INTERPRETATION: Japan has been successful overall in reducing mortality and disability from most major diseases. However, progress has slowed down and health variations between prefectures is growing. In view of the limited association between the prefecture-level health system inputs and health outcomes, the potential sources of regional variations, including subnational health system performance, urgently need assessment. FUNDING: Bill & Melinda Gates Foundation, Japan Ministry of Education, Science, Sports and Culture, Japan Ministry of Health, Labour and Welfare, AXA CR Fixed Income Fund and AXA Research Fund.

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Towards a Long-Term Strategy for Voluntary-Based Internal Radiation Contamination Monitoring: Representativeness of the Monitoring Results in Fukushima, Japan.

Shuhei Nomura, Masaharu Tsubokura, Michio Murakami, Kyoko Ono, Yoshitaka Nishikawa, Tomoyoshi Oikawa

International journal of environmental research and public health 14 ( 6 ) 2017.06

Accepted, ISSN 1661-7827

Following Japan's 2011 Fukushima nuclear incident, voluntary participation, rather than mandatory, was adopted as the default scenario for individual radiation monitoring. We evaluated the representativeness of the internal monitoring results from voluntary participants in Minamisoma City, which is located 10-40 km from the Fukushima nuclear plant. Of approximately 70,000 individuals who were residing in Minamisoma City before the incident, a total of 19,263 residents (aged ≥21 years) participated in the monitoring from 1 October 2011 to 31 March 2015. Based on regression projection techniques with the available data obtained from the voluntary participants, the modeled probabilities of radiocesium (Cs) detection in October 2011 for Cs-137 and Cs-134 were 66.9% and 52.9%, respectively, which declined dramatically within a year following the incident. The rate of decline had stagnated since mid-2012, and the probability was close to zero after mid-2014. Sufficient agreement between the modeled probabilities of Cs detection (for the whole population) versus the measured Cs levels (for voluntary participants) was observed, except for Cs-134 in October 2011, indicating that the voluntary monitoring participant group was a good representative sample. Our findings affirmed the clinical importance of voluntary-based monitoring as a screening and dose-assessment tool in a post-nuclear incident. Our study informs societal decision-making regarding the long-term maintenance of the monitoring program under the current low exposure levels.

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Breast cancer patient delay in Fukushima, Japan following the 2011 triple disaster: a long-term retrospective study.

Akihiko Ozaki, Shuhei Nomura, Claire Leppold, Masaharu Tsubokura, Tetsuya Tanimoto, Takeru Yokota, Shigehira Saji, Toyoaki Sawano, Manabu Tsukada, Tomohiro Morita, Sae Ochi, Shigeaki Kato, Masahiro Kami, Tsuyoshi Nemoto, Yukio Kanazawa, Hiromichi Ohira

BMC cancer (BIOMED CENTRAL LTD) 17 ( 1 ) 423 - 423 2017.06

Accepted, ISSN 1471-2407

BACKGROUND: Little information is available concerning how patient delay may be affected by mass disasters. The main objectives of the present study are to identify whether there was a post-disaster increase in the risk of experiencing patient delay among breast cancer patients in an area affected by the 2011 triple disaster in Fukushima, Japan, and to elucidate factors associated with post-disaster patient delay. Sociodemographic factors (age, employment status, cohabitant status and evacuation status), health characteristics, and health access- and disaster-related factors were specifically considered. METHODS: Records of symptomatic breast cancer patients diagnosed from 2005 to 2016 were retrospectively reviewed to calculate risk ratios (RRs) for patient delay in every year post-disaster compared with the pre-disaster baseline. Total and excessive patient delays were respectively defined as three months or more and twelve months or more from symptom recognition to first medical consultation. Logistic regression analysis was conducted for pre- and post-disaster patient delay in order to reveal any factors potentially associated with patient delay, and changes after the disaster. RESULTS: Two hundred nineteen breast cancer patients (122 pre-disaster and 97 post-disaster) were included. After adjustments for age, significant post-disaster increases in RRs of experiencing both total (RR: 1.66, 95% Confidence Interval (CI): 1.02-2.70, p < 0.05) and excessive patient delay (RR: 4.49, 95% CI: 1.73-11.65, p < 0.01) were observed. The RRs for total patient delay peaked in the fourth year post-disaster, and significant increases in the risk of excessive patient delay were observed in the second, fourth, and fifth years post-disaster, with more than five times the risk observed pre-disaster. A family history of any cancer was the only factor significantly associated with total patient delay post-disaster (odds ratio: 0.38, 95% CI: 0.15-0.95, p < 0.05), while there were no variables associated with delay pre-disaster. CONCLUSIONS: The triple disaster in Fukushima appears to have led to an increased risk of patient delay among breast cancer patients, and this trend has continued for five years following the disaster.

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Birth Outcomes after the Fukushima Daiichi Nuclear Power Plant Disaster: A Long-Term Retrospective Study.

Claire Leppold, Shuhei Nomura, Toyoaki Sawano, Akihiko Ozaki, Masaharu Tsubokura, Sarah Hill, Yukio Kanazawa, Hiroshi Anbe

International journal of environmental research and public health 14 ( 5 ) 2017.05

Accepted, ISSN 1661-7827

Changes in population birth outcomes, including increases in low birthweight or preterm births, have been documented after natural and manmade disasters. However, information is limited following the 2011 Fukushima Daiichi Nuclear Power Plant Disaster. In this study, we assessed whether there were long-term changes in birth outcomes post-disaster, compared to pre-disaster data, and whether residential area and food purchasing patterns, as proxy measurements of evacuation and radiation-related anxiety, were associated with post-disaster birth outcomes. Maternal and perinatal data were retrospectively collected for all live singleton births at a public hospital, located 23 km from the power plant, from 2008 to 2015. Proportions of low birthweight (<2500 g at birth) and preterm births (<37 weeks gestation at birth) were compared pre- and post-disaster, and regression models were conducted to assess for associations between these outcomes and evacuation and food avoidance. A total of 1101 live singleton births were included. There were no increased proportions of low birthweight or preterm births in any year after the disaster (merged post-disaster risk ratio of low birthweight birth: 0.98, 95% confidence interval (CI): 0.64-1.51; and preterm birth: 0.68, 95% CI: 0.38-1.21). No significant associations between birth outcomes and residential area or food purchasing patterns were identified, after adjustment for covariates. In conclusion, no changes in birth outcomes were found in this institution-based investigation after the Fukushima disaster. Further research is needed on the pathways that may exacerbate or reduce disaster effects on maternal and perinatal health.

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Towards a Long-Term Strategy for Voluntary-Based Internal Radiation Contamination Monitoring: A Population-Level Analysis of Monitoring Prevalence and Factors Associated with Monitoring Participation Behavior in Fukushima, Japan.

Shuhei Nomura, Masaharu Tsubokura, Akihiko Ozaki, Michio Murakami, Susan Hodgson, Marta Blangiardo, Yoshitaka Nishikawa, Tomohiro Morita, Tomoyoshi Oikawa

International journal of environmental research and public health 14 ( 4 ) 2017.04

Accepted, ISSN 1661-7827

Following Japan's 2011 Fukushima nuclear incident, we assessed voluntary-based monitoring behavior in Minamisoma City-located 10-40 km from the Fukushima nuclear plant-to inform future monitoring strategies. The monitoring in Minamisoma included occasional free of charge internal-radiation-exposure measurements. Out of around 70,000 individuals residing in the city before the incident, a total of 45,788 residents (female: 52.1%) aged ≥21 were evaluated. The monitoring prevalence in 2011-2012 was only 30.2%, and this decreased to 17.9% in 2013-2014. Regression analyses were performed to estimate factors associated with the monitoring prevalence and participation behavior. The results show that, in comparison with the age cohort of 21-30 years, the cohort of 71-80 and ≥81 years demonstrated significantly lower monitoring prevalence; female residents had higher monitoring prevalence than male residents; those who were living in evacuation zones at the time of the incident had higher monitoring prevalence than those who lived outside any of the evacuation zones; for those living outside Fukushima and neighboring Prefectures post-incident monitoring prevalence decreased significantly in 2013-2014. Our findings inform the discussion on the concepts of radiation risk perception and accessibility to monitoring and societal decision-making regarding the maintenance of the monitoring program with low monitoring prevalence. We also stress the possibility that the monitoring can work both to check that internal contamination levels are within acceptable limits, and as a risk communication tool, alleviating individuals' concern and anxiety over radiation contamination.

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Additional risk of diabetes exceeds the increased risk of cancer caused by radiation exposure after the Fukushima disaster.

Michio Murakami, Masaharu Tsubokura, Kyoko Ono, Shuhei Nomura, Tomoyoshi Oikawa

PloS one (PUBLIC LIBRARY SCIENCE) 12 ( 9 ) e0185259 2017

Accepted, ISSN 1932-6203

The 2011 Fukushima disaster led to increases in multiple risks (e.g., lifestyle diseases and radiation exposure) and fear among the public. Here, we assessed the additional risks of cancer caused by radiation and diabetes related to the disaster and the cost-effectiveness of countermeasures against these conditions. Our study included residents of the cities of Minamisoma and Soma (10-40 km and 35-50 km north of the Fukushima Daiichi (N° 1) Nuclear Power Station, respectively). We used the loss of life expectancy (LLE) as an indicator to compare risks between radiation exposure and diabetes. We also estimated the cost-effectiveness of radiation-related countermeasures, including restricted food distribution, decontamination, and whole-body counter tests and interventions. Metformin therapy was selected as a representative management for diabetes. The diabetes-related LLEs among residents were 4.1 (95% confidence interval: 1.4-6.8) ×10-2 years for the whole population and 8.0 (2.7-13.2) ×10-2 years for 40s to 70s in a scenario that considered the additional incidence of diabetes during the first 10 years. The cancer-related LLEs caused by lifetime exposure to radiation were 0.69 (2.5-97.5 percentile: 0.61-0.79) ×10-2 years for the whole population and 0.24 (0.20-0.29) ×10-2 years for 40s to 70s. The diabetes-related LLEs among residents in the above-mentioned scenario were 5.9-fold and 33-fold higher than those attributed to average radiation among the whole population and among the 40s to 70s age groups, respectively. The costs per life-years saved of the radiation countermeasures (i.e., restricted food distribution, decontamination, and whole-body counter tests and interventions) were >1 to >4 orders of magnitude higher than those of general heath checkups and conventional management for diabetes. Our findings indicate that countermeasures to mitigate diabetes are warranted. Policy-makers' and individuals' understanding of multiple risks after any disaster will be essential to saving the lives of victims.

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Degarelix treatment is compatible with diabetes and antithrombotic therapy in patients with prostate cancer.

Suguru Tokiwa, Hiroaki Shimmura, Shuhei Nomura, Ryota Watanabe, Minoru Kurita, Naoto Yoshida, Kaori Yamashita, Yoshitaka Nishikawa, Alexander Kouzmenko, Shigeaki Kato

Research and reports in urology 9 225 - 232 2017

Accepted, ISSN 2253-2447

Introduction: Therapeutically induced androgen deficiency (AD) is a standard treatment for patients with prostate cancer, but it is often associated with various adverse effects (AEs) that may lead to discontinuation. Some AEs may depend on the patient's health condition, while others may be due to complications of the drug delivery method. Degarelix is a gonadotropin-releasing hormone (GnRH) antagonist widely used for the treatment of androgen-dependent prostate cancer. This study aimed to ascertain the following: 1) the compatibility of degarelix treatment with diabetes and 2) any specific causal associations of degarelix injections with increased blood clotting and antithrombotic therapy requirements. Patients and methods: The medical records of 162 patients with prostate cancer who had undergone degarelix treatment were retrospectively examined. The association of a medical history of diabetes and anticoagulant co-treatment with degarelix treatment discontinuation was analyzed statistically. Results: Rapid and significant decreases in prostate-specific antigen (PSA) levels during the course of degarelix treatment were detected for patients with prostate cancer regardless of clinical state. During the 27 months of treatment, 68 subjects (48%) ceased degarelix treatment, owing to several reasons, mainly financial issues. Among these subjects, 19 had diabetes, while 35 were treated with antithrombotics. Extensive statistical analysis indicated that there were no causal associations between degarelix treatment discontinuation and preexisting diabetes or antithrombotic therapy. Conclusion: Our study suggests that preexisting diabetes and antithrombotic therapy were not significant factors for the discontinuation of degarelix treatment in patients with prostate cancer.

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Individual external doses below the lowest reference level of 1 mSv per year five years after the 2011 Fukushima nuclear accident among all children in Soma City, Fukushima: A retrospective observational study.

Masaharu Tsubokura, Michio Murakami, Shuhei Nomura, Tomohiro Morita, Yoshitaka Nishikawa, Claire Leppold, Shigeaki Kato, Masahiro Kami

PloS one (PUBLIC LIBRARY SCIENCE) 12 ( 2 ) e0172305 2017

Accepted, ISSN 1932-6203

After the 2011 Fukushima Daiichi nuclear power plant accident, little information has been available on individual doses from external exposure among residents living in radioactively contaminated areas near the nuclear plant; in the present study we evaluated yearly changes in the doses from external exposure after the accident and the effects of decontamination on external exposure. This study considered all children less than 16 years of age in Soma City, Fukushima who participated in annual voluntary external exposure screening programs during the five years after the accident (n = 5,363). In total, 14,405 screening results were collected. The median participant age was eight years. The geometric mean levels of annual additional doses from external exposure attributable to the Fukushima accident, decreased each year: 0.60 mSv (range: not detectable (ND)-4.29 mSv), 0.37 mSv (range: ND-3.61 mSv), 0.22 mSv (range: ND-1.44 mSv), 0.20 mSv (range: ND-1.87 mSv), and 0.17 mSv (range: ND-0.85 mSv) in 2011, 2012, 2013, 2014, and 2015, respectively. The proportion of residents with annual additional doses from external exposure of more than 1 mSv dropped from 15.6% in 2011 to zero in 2015. Doses from external exposure decreased more rapidly than those estimated from only physical decay, even in areas without decontamination (which were halved in 395 days from November 15, 2011), presumably due to the weathering effects. While the ratios of geometric mean doses immediately after decontamination to before were slightly lower than those during the same time in areas without decontamination, annual additional doses reduced by decontamination were small (0.04-0.24 mSv in the year of immediately after decontamination was completed). The results of this study showed that the levels of external exposure among Soma residents less than 16 years of age decreased during the five years after the Fukushima Daiichi nuclear power plant accident. Decontamination had only limited and temporal effects on reducing individual external doses.

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Non-communicable diseases in decontamination workers in areas affected by the Fukushima nuclear disaster: a retrospective observational study.

Toyoaki Sawano, Masaharu Tsubokura, Akihiko Ozaki, Claire Leppold, Shuhei Nomura, Yuki Shimada, Sae Ochi, Manabu Tsukada, Tsuyoshi Nemoto, Shigeaki Kato, Yukio Kanazawa, Hiromichi Ohira

BMJ open 6 ( 12 ) e013885 2016.12

Accepted, ISSN 2044-6055

OBJECTIVES: To assess the prevalence of non-communicable diseases (NCDs), and whether NCDs were treated or not, among hospitalised decontamination workers who moved to radio-contaminated areas after Japan's 2011 Fukushima Daiichi Nuclear Power Plant disaster. METHODS: We retrospectively extracted records of decontamination workers admitted to Minamisoma Municipal General Hospital between 1 June 2012 and 31 August 2015, from hospital records. We investigated the incidence of underlying NCDs such as hypertension, dyslipidaemia and diabetes among the decontamination workers, and their treatment status, in addition to the reasons for their hospital admission. RESULTS: A total of 113 decontamination workers were admitted to the hospital (112 male patients, median age of 54 years (age range: 18-69 years)). In terms of the demographics of underlying NCDs in this population, 57 of 72 hypertensive patients (79.2%), 37 of 45 dyslipidaemic patients (82.2%) and 18 of 27 hyperglycaemic patients (66.7%) had not been treated for their NCDs before admission to the hospital. CONCLUSIONS: A high burden of underlying NCDs was found in hospitalised decontamination workers in Fukushima. Managing underlying diseases such as hypertension, hyperlipidaemia and diabetes mellitus is essential among this population.

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Assessment of Nutritional Status of Iodine Through Urinary Iodine Screening Among Local Children and Adolescents After the Fukushima Daiichi Nuclear Power Plant Accident.

Masaharu Tsubokura, Shuhei Nomura, Hajime Watanobe, Yoshitaka Nishikawa, Chiaki Suzuki, Sae Ochi, Claire Leppold, Hirokatsu Kinoshita, Shigeaki Kato, Yasutoshi Saito

Thyroid : official journal of the American Thyroid Association 26 ( 12 ) 1778 - 1785 2016.12

Accepted, ISSN 1050-7256

BACKGROUND: Iodine deficiency is an important modifier of the risk of thyroid cancer following irradiation. However, little information is available on the prevalence of iodine deficiency in Fukushima and its surroundings after the Fukushima Daiichi nuclear power plant accident that occurred in March 2011. METHODS: In order to assess urinary iodine concentrations (UIC) and the prevalence of iodine deficiency and to elucidate any associations between demographic characteristics and UIC levels among children and adolescents aged ≤18 years at the time of the accident in Fukushima Prefecture and its surroundings, the data on voluntary UIC testing conducted by Hirata Central Hospital, Fukushima, were evaluated. RESULTS: A total of 4410 children and adolescents with a median age of 10 years at examination underwent UIC testing between October 2012 and October 2015. Calculated for all the participants, the median UIC level was 204 μg/L (range 25-21,100 μg/L). There were 133 (3.0%), 732 (16.6%), and 1472 (33.4%) participants with UIC levels of <50, <100, or ≥300 μg/L, respectively. Based on the World Health Organization criteria for nutritional iodine status, no participants were severely iodine deficient (<20 μg/L), but 16.6% of the population were mildly (50-100 μg/L) or moderately (20-50 μg/L) iodine deficient. While no significant difference in UIC was noted between those who did and did not increase dietary iodine intake after the accident (p = 0.93), there were significant differences by year (p < 0.01), school level (p < 0.001), and residential area at the time of the accident (p < 0.001). CONCLUSIONS: This study demonstrates that the children and adolescents examined had a sufficient amount of iodine during the period 1.5-4.5 years after the nuclear accident. In addition to the differences in the scale and the countermeasures undertaken between the Fukushima and Chernobyl accidents, differences in dietary iodine intake might have played an additional role in resulting in the reportedly different radiation doses to the thyroid between the two nuclear accidents.

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Factors affecting dilation force in balloon dilation of severe esophageal strictures: an experiment using an artificial stricture model.

Yoshitaka Nishikawa, Hirokazu Higuchi, Osamu Kikuchi, Yasumasa Ezoe, Ikuo Aoyama, Atsushi Yamada, Masataka Kanki, Shuhei Nomura, Motoo Nomura, Takahiro Horimatsu, Manabu Muto

Surgical endoscopy 30 ( 10 ) 4315 - 20 2016.10

Accepted, ISSN 0930-2794

BACKGROUND: The multidiameter balloon catheter is used widely for severe esophageal stricture dilation. However, the relationships between inflation pressure, balloon size, and radial dilation force at the stricture site have not been examined fully. METHODS: We performed an experiment using phantom models to investigate the relationships between inflation pressure, balloon size, and radial dilation force. The balloon dilation procedure was performed for each stricture model using three sizes of balloon: 10-11-12, 12-13.5-15, and 15-16.5-18 mm. RESULTS: A positive association between inflation pressure and dilation force was observed for each balloon size. In balloons inflated by targeting the same diameter, the dilation force was higher for smaller balloons than for larger balloons. An inverse association between stricture size and dilation force was observed in the 12-13.5-15 mm balloon (3 vs 5 mm, P = .002; 5 vs 7 mm, P < .001). CONCLUSIONS: We found relationships between inflation pressure, balloon size, severity of strictures, and dilation force. To perform safe and effective esophageal balloon dilation, the inflation pressure and balloon size should be selected after considering the stricture size and target diameter.

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Impacts of the 2011 Fukushima nuclear accident on emergency medical service times in Soma District, Japan: a retrospective observational study.

Tomohiro Morita, Masaharu Tsubokura, Tomoyuki Furutani, Shuhei Nomura, Sae Ochi, Claire Leppold, Kazuhiro Takahara, Yuki Shimada, Sho Fujioka, Masahiro Kami, Shigeaki Kato, Tomoyoshi Oikawa

BMJ open 6 ( 9 ) e013205 2016.09

Accepted, ISSN 2044-6055

OBJECTIVE: To assess the influence of the 3.11 triple disaster (earthquake, tsunami and nuclear accident) on the emergency medical service (EMS) system in Fukushima. METHODS: Total EMS time (from EMS call to arrival at a hospital) was assessed in the EMS system of Soma district, located 10-40 km north of the nuclear plant, from 11 March to 31 December 2011. We defined the affected period as when total EMS time was significantly extended after the disasters compared with the historical control data from 1 January 2009 to 10 March 2011. To identify risk factors associated with the extension of total EMS time after the disasters, we investigated trends in 3 time segments of total EMS time; response time, defined as time from an EMS call to arrival at the location, on-scene time, defined as time from arrival at the location to departure, and transport time, defined as time from departure from the location to arrival at a hospital. RESULTS: For the affected period from week 0 to week 11, the median total EMS time was 36 (IQR 27-52) minutes, while that in the predisaster control period was 31 (IQR 24-40) min. The percentage of transports exceeding 60 min in total EMS time increased from 8.2% (584/7087) in the control period to 22.2% (151/679) in the affected period. Among the 3 time segments, there was the most change in transport time (standardised mean difference: 0.41 vs 0.13-0.17). CONCLUSIONS: EMS transport was significantly delayed for ∼3 months, from week 1 to 11 after the 3.11 triple disaster. This delay may be attributed to malfunctioning emergency hospitals after the triple disaster.

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School restrictions on outdoor activities and weight status in adolescent children after Japan's 2011 Fukushima Nuclear Power Plant disaster: a mid-term to long-term retrospective analysis.

Shuhei Nomura, Marta Blangiardo, Masaharu Tsubokura, Sae Ochi, Susan Hodgson

BMJ open 6 ( 9 ) e013145 2016.09

Accepted, ISSN 2044-6055

OBJECTIVE: Radiation fears following Japan's 2011 Fukushima nuclear disaster affected levels of physical activity in local children. We assessed the postdisaster versus predisaster weight status in school children and evaluated to what extent school restrictions on outdoor activities that were intended to reduce radiation exposure risk affected child weight. PARTICIPANTS: We considered children aged 13-15 years from 4 of the 5 secondary schools in Soma City (n=1030, 99.1% of all children in the city), located in 35-50 km from the Fukushima nuclear plant, postdisaster (2012 and 2015) and predisaster (2010). METHODS: Weight status, in terms of body mass index (BMI), percentage of overweight (POW) and incidence of obesity and underweight (defined as a POW ≥20% and ≤-20%, respectively) were examined and compared predisaster and postdisaster using regression models. We also constructed models to assess the impact of school restrictions on outdoor activity on weight status. RESULTS: After adjustment for covariates, a slight decrease in mean BMI and POW was detected in females in 2012 (-0.37, 95% CI -0.68 to -0.06; and -1.97, 95% CI -3.57 to -0.36, respectively). For male children, obesity incidence increased in 2012 (OR for obesity: 1.45, 95% CI 1.02 to 2.08). Compared with predisaster weight status, no significant weight change was identified in 2015 in either males or females. School restrictions on outdoor activities were not significantly associated with weight status. CONCLUSIONS: 4 years following the disaster, weight status has recovered to the predisaster levels for males and females; however, a slight decrease in weight in females and a slight increase in risk of obesity were observed in males 1 year following the disaster. Our findings could be used to guide actions taken during the early phase of a radiological disaster to manage the postdisaster health risks in adolescent children.

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Sociodemographic patterning of long-term diabetes mellitus control following Japan's 3.11 triple disaster: a retrospective cohort study.

Claire Leppold, Masaharu Tsubokura, Akihiko Ozaki, Shuhei Nomura, Yuki Shimada, Tomohiro Morita, Sae Ochi, Tetsuya Tanimoto, Masahiro Kami, Yukio Kanazawa, Tomoyoshi Oikawa, Sarah Hill

BMJ open 6 ( 7 ) e011455 2016.07

Accepted, ISSN 2044-6055

OBJECTIVE: To assess the sociodemographic patterning of changes in glycaemic control of patients with diabetes affected by the 2011 triple disaster in Japan (earthquake, tsunami and nuclear accident). METHODS: A retrospective cohort study was undertaken with 404 patients with diabetes at a public hospital in Minamisoma City, Fukushima Prefecture. Glycated haemoglobin (HbA1c) levels were measured in 2010, 2011 and 2012 to capture changes in glycaemic control postdisaster. Age, sex, urban/rural residency, evacuation status and medication use were also assessed. RESULTS: There was an overall deterioration in glycaemic control after the disaster, with the mean HbA1c rising from 6.77% in 2010 to 6.90% in 2012 (National Glycohemoglobin Standardization Program, NGSP). Rural residency was associated with a lower likelihood of deteriorating control (OR 0.34, 95% CI 0.13 to 0.84), compared with urban residency. Older age (OR 0.95, 95% CI 0.91 to 0.98) was also slightly protective against increased HbA1c. Evacuation and sex were not significant predictors. CONCLUSIONS: Patients with diabetes who were affected by Japan's triple disaster experienced a deterioration in their glycaemic control following the disasters. The extent of this deterioration was mediated by sociodemographic factors, with rural residence and older age protective against the effects of the disaster on glycaemic control. These results may be indicative of underlying social determinants of health in rural Japan.

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Estimated association between dwelling soil contamination and internal radiation contamination levels after the 2011 Fukushima Daiichi nuclear accident in Japan.

Masaharu Tsubokura, Shuhei Nomura, Kikugoro Sakaihara, Shigeaki Kato, Claire Leppold, Tomoyuki Furutani, Tomohiro Morita, Tomoyoshi Oikawa, Yukio Kanazawa

BMJ open 6 ( 6 ) e010970 2016.06

Accepted, ISSN 2044-6055

OBJECTIVES: Measurement of soil contamination levels has been considered a feasible method for dose estimation of internal radiation exposure following the Chernobyl disaster by means of aggregate transfer factors; however, it is still unclear whether the estimation of internal contamination based on soil contamination levels is universally valid or incident specific. METHODS: To address this issue, we evaluated relationships between in vivo and soil cesium-137 (Cs-137) contamination using data on internal contamination levels among Minamisoma (10-40 km north from the Fukushima Daiichi nuclear power plant), Fukushima residents 2-3 years following the disaster, and constructed three models for statistical analysis based on continuous and categorical (equal intervals and quantiles) soil contamination levels. RESULTS: A total of 7987 people with a mean age of 55.4 years underwent screening of in vivo Cs-137 whole-body counting. A statistically significant association was noted between internal and continuous Cs-137 soil contamination levels (model 1, p value <0.001), although the association was slight (relative risk (RR): 1.03 per 10 kBq/m(2) increase in soil contamination). Analysis of categorical soil contamination levels showed statistical (but not clinical) significance only in relatively higher soil contamination levels (model 2: Cs-137 levels above 100 kBq/m(2) compared to those <25 kBq/m(2), RR=1.75, p value <0.01; model 3: levels above 63 kBq/m(2) compared to those <11 kBq/m(2), RR=1.45, p value <0.05). CONCLUSIONS: Low levels of internal and soil contamination were not associated, and only loose/small associations were observed in areas with slightly higher levels of soil contamination in Fukushima, representing a clear difference from the strong associations found in post-disaster Chernobyl. These results indicate that soil contamination levels generally do not contribute to the internal contamination of residents in Fukushima; thus, individual measurements are essential for the precise evaluation of chronic internal radiation contamination.

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Social determinants of mid- to long-term disaster impacts on health: A systematic review

Shuhei Nomura, Alexander J. Q. Parsons, Mayo Hirabayashi, Ryo Kinoshita, Yi Liao, Susan Hodgson

INTERNATIONAL JOURNAL OF DISASTER RISK REDUCTION (ELSEVIER SCIENCE BV) 16 53 - 67 2016.06

Accepted, ISSN 2212-4209

Disasters cause a wide range of health impacts. Although there remains a need to understand and improve acute disaster management, a stronger understanding of how health is affected in the medium and longer term is also required to inform the design and delivery of measures to manage post-disaster health risks, and to guide actions taken before and during events which will also lead to reduction in health impact. Social determinants exert a powerful influence on different elements of risk, principally vulnerability, exposure and capacity, and thus, on people's health. As disaster health data and research has tended to focus on the short-term health impacts, no systematic assessment of the social determinants of the mid- to long-term health impacts of disasters has been identified. We assessed the chronic health impacts of disasters and explored the potential socioeconomic determinants of health impact through a systematic review. Our findings, based on 28 studies, highlighted that regardless of health outcomes and event types, the influence of disasters on chronic heath persists beyond the initial disaster period, affecting people's health for months to years. Using the World Health Organization's conceptual framework for the social determinants of health, we identified a total of 35 themes across the three conceptual domains (determinants related to the socioeconomic and political context, structural determinants, and intermediate determinants) as potentially influencing disaster impact. Investment to tackle modifiable underlying determinants could aid disaster risk management, improve medium and long-term health outcomes from disasters, and build community resilience. (C) 2016 Elsevier Ltd. All rights reserved.

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An evaluation of early countermeasures to reduce the risk of internal radiation exposure after the Fukushima nuclear incident in Japan.

Shuhei Nomura, Masaharu Tsubokura, Stuart Gilmour, Ryugo S Hayano, Yuni N Watanabe, Masahiro Kami, Yukio Kanazawa, Tomoyoshi Oikawa

Health policy and planning 31 ( 4 ) 425 - 33 2016.05

Accepted, ISSN 0268-1080

After a radiation-release incident, intake of radionuclides in the initial stage immediately following the incident may be the major contributor to total internal radiation exposure for individuals in affected areas. However, evaluation of early internal contamination risk is greatly lacking. This study assessed the relationship between initial stage evacuation/indoor sheltering and internal radiation contamination levels 4 months after the 2011 Fukushima nuclear incident in Japan and estimated potential pathways of the contamination. The study population comprised 525 participants in the internal radiation screening program at Minamisoma Municipal General Hospital, 23 km north of the Fukushima nuclear plant. The analysed dataset included the results of a screening performed in July 2011, 4 months after the incident, and of a questionnaire on early-incident response behaviours, such as sheltering indoors and evacuations, completed by participants. Association between such early countermeasures and internal contamination levels of cesium-134 were assessed using Tobit multiple regression analyses. Our study shows that individuals who evacuated to areas outside Fukushima Prefecture had similar contamination levels of cesium-134 to individuals who stayed in Fukushima (relative risk: 0.86; 95% confidence interval: 0.74-0.99). Time spent outdoors had no significant relationship with contamination levels. The effects of inhalation from radiological plumes released from the nuclear plant on total internal radiation contamination might be so low as to be undetectable by the whole-body counting unit used to examine participants. Given the apparent limited effectiveness of evacuation and indoor sheltering on internal contamination, the decision to implement such early responses to a radiation-release incident should be made by carefully balancing their potential benefits and health risks.

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Protecting human security: proposals for the G7 Ise-Shima Summit in Japan

Kenji Shibuya, Shuhei Nomura, Hiromasa Okayasu, Satoshi Ezoe, Seigo Hara, Yuriko Hara, Takashi Izutsu, Takuma Kato, Shunsuke Mabuchi, Yujiro Maeda, Yuki Murakami, Hiroko Nishimoto, Tomoko Ono, Kayoko Shioda, Atsushi Sorita, Amina Sugimoto, Kazuo Tase, Akihito Watabe, Anne Smith, Sarah K. Abe, Stuart Gilmour, Lawrence O. Gostin, Gavin Yamey, Marco Schaeferhoff, Elina M. Suzuki, Jessica Kraus, Takashi Oshio, Reiko Hayashi, Naoki Kondo, Koichiro Shiba, Hideo Yasunaga, Yusuke Sasabuchi, Yohsuke Takasaki, Naoki Akahane, Shingo Kasahara, Munehito Machida, Satoshi Maruyama, Shuushou Okada, Tadayuki Tanimura, Tomohiko Sugishita, Ikuo Takizawa, Maki Ozawa, Yoshiharu Yoneyama, Hidechika Akashi, Chiaki Miyoshi, Hitoshi Murakami, Toshiro Kumakawa, Satoko Horii, Kenichiro Taneda, Hideaki Shiroyama, Yasushi Katsuma, Makiko Matsuo, Sayako Kanamori, Chiaki Sato, Kayo Yasuda, Jonas Kemp, B. T. Slingsby, Kei Katsuno, Bumpei Tamamura, Keizo Takemi, Hideki Hashimoto, Michael R. Reich

LANCET (ELSEVIER SCIENCE INC) 387 ( 10033 ) 2155 - 2162 2016.05

Accepted, ISSN 0140-6736

In today's highly globalised world, protecting human security is a core challenge for political leaders who are simultaneously dealing with terrorism, refugee and migration crises, disease epidemics, and climate change. Promoting universal health coverage (UHC) will help prevent another disease outbreak similar to the recent Ebola outbreak in west Africa, and create robust health systems, capable of withstanding future shocks. Robust health systems, in turn, are the prerequisites for achieving UHC. We propose three areas for global health action by the G7 countries at their meeting in Japan in May, 2016, to protect human security around the world: restructuring of the global health architecture so that it enables preparedness and responses to health emergencies; development of platforms to share best practices and harness shared learning about the resilience and sustainability of health systems; and strengthening of coordination and financing for research and development and system innovations for global health security. Rather than creating new funding or organisations, global leaders should reorganise current financing structures and institutions so that they work more effectively and efficiently. By making smart investments, countries will improve their capacity to monitor, track, review, and assess health system performance and accountability, and thereby be better prepared for future global health shocks.

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Postnuclear disaster evacuation and chronic health in adults in Fukushima, Japan: a long-term retrospective analysis.

Shuhei Nomura, Marta Blangiardo, Masaharu Tsubokura, Akihiko Ozaki, Tomohiro Morita, Susan Hodgson

BMJ open 6 ( 2 ) e010080 2016.02

Accepted, ISSN 2044-6055

OBJECTIVE: Japan's 2011 Fukushima Daiichi Nuclear Power Plant incident required the evacuation of over a million people, creating a large displaced population with potentially increased vulnerability in terms of chronic health conditions. We assessed the long-term impact of evacuation on diabetes, hyperlipidaemia and hypertension. PARTICIPANTS: We considered participants in annual public health check-ups from 2008 to 2014, administrated by Minamisoma City and Soma City, located about 10-50 km from the Fukushima nuclear plant. METHODS: Disease risks, measured in terms of pre-incident and post-incident relative risks, were examined and compared between evacuees and non-evacuees/temporary-evacuees. We also constructed logistic regression models to assess the impact of evacuation on the disease risks adjusted for covariates. RESULTS: Data from a total of 6406 individuals aged 40-74 years who participated in the check-ups both at baseline (2008-2010) and in one or more post-incident years were analysed. Regardless of evacuation, significant post-incident increases in risk were observed for diabetes and hyperlipidaemia (relative risk: 1.27-1.60 and 1.12-1.30, respectively, depending on evacuation status and post-incident year). After adjustment for covariates, the increase in hyperlipidaemia was significantly greater among evacuees than among non-evacuees/temporary-evacuees (OR 1.18, 95% CI 1.06 to 1.32, p<0.01). CONCLUSIONS: The singularity of this study is that evacuation following the Fukushima disaster was found to be associated with a small increase in long-term hyperlipidaemia risk in adults. Our findings help identify discussion points on disaster planning, including preparedness, response and recovery measures, applicable to future disasters requiring mass evacuation.

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Living in Contaminated Radioactive Areas Is Not an Acute Risk Factor for Noncommunicable Disease Development: A Retrospective Observational Study.

Takeaki Ishii, Masaharu Tsubokura, Sae Ochi, Shigeaki Kato, Amina Sugimoto, Shuhei Nomura, Yoshitaka Nishikawa, Masahiro Kami, Kenji Shibuya, Yasutoshi Saito, Yukihide Iwamoto, Hidekiyo Tachiya

Disaster medicine and public health preparedness 10 ( 1 ) 34 - 7 2016.02

Accepted, ISSN 1935-7893

OBJECTIVE: Although much attention is now being paid to the health risks associated with nuclear disasters, reliable information is lacking. We retrospectively evaluated the health effects of living in highly contaminated radioactive areas in Japan. METHODS: The health evaluation was conducted in Tamano district, Fukushima prefecture, in 2011 and 2012. The surface deposition density of cesium in Tamano was 600 to 1000 kBq/m2 shortly after the Fukushima nuclear accident. Clinical parameters included body mass index, blood pressure, and laboratory examinations for blood cell counts, glucose levels, and lipid profiles. A screening program for internal and external exposure was also implemented. RESULTS: One hundred fifty-five residents participated in the health evaluation. Significant decreases in average body mass index and blood pressure were observed from 2011 to 2012. Annual internal exposure levels did not exceeded 1 mSv in any participants. The levels of external exposure ranged from 1.3 to 4.3 mSv/y measured in the first test period but decreased to 0.8 to 3.6 mSv/y in the second test period. CONCLUSIONS: These findings suggest that inhabiting nuclear contaminated areas is not always associated with short-term health deterioration and that radiation exposure can be controlled within safety limitations.

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Dependence of radiation dose on the behavioral patterns among school children: a retrospective analysis 18 to 20 months following the 2011 Fukushima nuclear incident in Japan.

Shuhei Nomura, Masaharu Tsubokura, Tomoyuki Furutani, Ryugo S Hayano, Masahiro Kami, Yukio Kanazawa, Tomoyoshi Oikawa

Journal of radiation research 57 ( 1 ) 1 - 8 2016.01

Accepted, ISSN 0449-3060

After radioactive incidents, the exposure risk in daily activities among children is a major public concern. However, there are limited methods available for evaluation of this risk, which is essential to future health risk management. To this end, this study assessed the relationship between behavioral patterns of school children and radiation exposure for a period of 18-20 months following the 2011 Fukushima nuclear incident. The assessed population comprised 520 school children from Minamisoma city, located 20 km north of the nuclear plant. Data for the doses were obtained using individual dosimeters and from results of a behavior survey administered by the City Office. The mean value of the doses in the study period was 0.34 mSv, with a standard deviation of 0.14 mSv, indicating an annual dose of ∼1.36 mSv, which includes doses from natural sources. Our results showed that behavior with respect to outdoor activities had no statistically significant relationship to the dose. A 0.1 μSv/h increase in the air dose rate at home was associated with a 10% increase in the dose; however, a 0.01 μSv/h increase in the air dose rate on the school grounds was associated with a 2% increase in the dose. This study indicates that the air contamination levels at the places where children spend most of their day are the significant predictors of the dose, as opposed to the levels at those outdoor locations in which short periods of time spent.

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Post-nuclear disaster evacuation and survival amongst elderly people in Fukushima: A comparative analysis between evacuees and non-evacuees.

Shuhei Nomura, Marta Blangiardo, Masaharu Tsubokura, Yoshitaka Nishikawa, Stuart Gilmour, Masahiro Kami, Susan Hodgson

Preventive medicine 82 77 - 82 2016.01

Accepted, ISSN 0091-7435

BACKGROUND: Considering the health impacts of evacuation is fundamental to disaster planning especially for vulnerable elderly populations; however, evacuation-related mortality risks have not been well-investigated. We conducted an analysis to compare survival of evacuated and non-evacuated residents of elderly care facilities, following the Great East Japan Earthquake and subsequent Fukushima Dai-ichi nuclear power plant incident on 11th March 2011. OBJECTIVE: To assess associations between evacuation and mortality after the Fukushima nuclear incident; and to present discussion points on disaster planning, with reference to vulnerable elderly populations. METHODS: The study population comprised 1,215 residents admitted to seven elderly care facilities located 20-40km from the nuclear plant in the five years before the incident. Demographic and clinical characteristics were obtained from medical records. Evacuation histories were tracked until mid 2013. Main outcome measures are hazard ratios in evacuees versus non-evacuees using random-effects Cox proportional hazards models, and pre- and post-disaster survival probabilities and relative mortality incidence. RESULTS: Experiencing the disasters did not have a significant influence on mortality (hazard ratio 1.10, 95% confidence interval: 0.84-1.43). Evacuation was associated with 1.82 times higher mortality (95% confidence interval: 1.22-2.70) after adjusting for confounders, with the initial evacuation from the original facility associated with 3.37 times higher mortality risk (95% confidence interval: 1.66-6.81) than non evacuation. CONCLUSIONS: The government should consider updating its requirements for emergency planning for elderly facilities and ensure that, in a disaster setting, these facilities have the capacity and support to shelter in place for at least sufficient time to adequately prepare initial evacuation.

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Overview of health impacts caused by the Fukushima nuclear disaster and our opportunity to 'Build Back Better'

Sae Ochi, Shigeaki Kato, Claire Leppold, Toyoaki Sawano, Shuhei Nomura, Tomohiro Morita, Masaharu Tsubokura, Tomoyoshi Oikawa, Ryuzaburo Shineha

Proceedings of the 6th International Disaster and Risk Conference: Integrative Risk Management - Towards Resilient Cities, IDRC Davos 2016 (Global Risk Forum (GRF)) 481 - 484 2016

Compliance with the proper use of an individual radiation dosimeter among children and the effects of improper use on the measured dose: a retrospective study 18-20 months following Japan's 2011 Fukushima nuclear incident.

Shuhei Nomura, Masaharu Tsubokura, Ryugo Hayano, Daisuke Yoneoka, Akihiko Ozaki, Yuki Shimada, Tomoyuki Furutani, Yukio Kanazawa, Tomoyoshi Oikawa

BMJ open 5 ( 12 ) e009555 2015.12

Accepted, ISSN 2044-6055

OBJECTIVES: To identify profiles of children who did not properly use individual radiation dosimeters following Japan's 2011 Fukushima nuclear incident, and to assess how much error is generated by improper dosimeter use. PARTICIPANTS: The participants in this study comprised 1637 school children who participated in the external radiation exposure screening programme administrated by Minamisoma City (located 20-30 km from the Fukushima nuclear plant) between 18 and 20 months after the Fukushima incident. METHODS: We assessed the factors associated with improper use (non-use) of the dosimeters at specific time periods during the day (school commuting hours, at school, at home, outdoors and at bedtime) using logistic regression analyses. Ratios of the measured dose to regression estimates of the 'expected' dose (referred to as an error due to non-use) were also examined. RESULTS: Only 119 children (7.3%) used the dosimeters properly in all time periods. This low rate was attributed primarily to non-use when children were in the home and outdoors, rather than at school. School level, air dose rate at home, gender, membership in outdoor sports clubs and time spent outdoors on weekends, were significantly associated with improper use, after adjustment for covariates. Data from children who did not wear the dosimeters to school and outdoors had statistically significant (but clinically insignificant) errors (ratio: 1.13, p<0.01; and 0.97, p<0.05, respectively), whereas improper use of the dosimeters at school, at home and at bedtime did not generate significant errors. CONCLUSIONS: Well-targeted rigorous instructions on the use of the dosimeter are required, with particular focus on time periods other than school hours. However, given the small dose error due to the improper use of the dosimeters, even if the dosimeters are improperly used, solid evaluation of the radiation exposure may be possible with some accuracy.

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Whole body counter assessment of internal radiocontamination in patients with end-stage renal disease living in areas affected by the Fukushima Daiichi nuclear power plant disaster: a retrospective observational study.

Hiroaki Shimmura, Masaharu Tsubokura, Shigeaki Kato, Junichi Akiyama, Shuhei Nomura, Jinichi Mori, Tetsuya Tanimoto, Koichiro Abe, Shuji Sakai, Hiroshi Kawaguchi, Michio Tokiwa

BMJ open 5 ( 12 ) e009745 2015.12

Accepted, ISSN 2044-6055

OBJECTIVE: To assess internal radiocontamination of patients with end-stage renal disease (ESRD) who were regularly taking haemodialysis (HD) and living in areas affected by the crippled Fukushima Daiichi nuclear plant after the Great East Japan earthquake on 11 March 2011. METHODS: Internal radiocontamination in 111 patients with ESRD regularly taking HD at Jyoban Hospital in Iwaki city, Fukushima from July 2012 to November 2012 was assessed with a whole body counter (WBC). The maximum annual effective dose was calculated from the detected Cs-137 levels. Interviews concerning patient dietary preferences and outdoor activities were also conducted. RESULTS: Among the 111 patients tested, internal radiocontamination with Cs-137 was detected in two participants, but the levels were marginal and just exceeded the detection limit (250 Bq/body). The tentatively calculated maximum annual effective dose ranged from 0.008 to 0.009 mSv/year, which is far below the 1 mSv/year limit set by the government of Japan. Relative to 238 non-ESRD participants, patients with ERSD had significantly more opportunities to consume locally grown produce that was not distributed to the market (p<0.01). However, the percentage of patients with ESRD with detectable Cs (1.8%) was lower than that for non-ESRD participants (3.8%), although this difference was not significant (p=0.51). CONCLUSIONS: These findings suggest that internal radiocontamination levels and the calculated annual additional effective doses were negligible for patients with ESRD taking HD in areas affected by the crippled Fukushima nuclear plant. Although HD is suggested to promote Cs-137 excretion, continuous inspection of locally grown produce together with WBC screening for radiocontamination should be continued for patients with ESRD regularly taking HD.

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Long-Term Changes in Stroke-Related Hospital Admissions After the Fukushima Triple Disaster.

Stuart Gilmour, Amina Sugimoto, Shuhei Nomura, Tomoyoshi Oikawa

Journal of the American Geriatrics Society 63 ( 11 ) 2425 - 6 2015.11

Accepted, ISSN 0002-8614

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Emergency medical service delay following Japan's 2011 Fukushima nuclear disaster

MORITA Tomohiro, TSUBOKURA Masaharu, FURUTANI Tomoyuki, OCHI Sae, KATO Shigeaki, TSUBOKURA Seiji, KAMI Masahiro, TSUBOKURA Seiji, SHIMADA Yuki, FUJIOKA Masaru, OIKAWA Tomoyoshi, NOMURA Shuhei, TAKAHARA Kazuhiro

日本救急医学会雑誌 ((一社)日本救急医学会) 26 ( 8 ) 353 - 353 2015.08

Accepted, ISSN 0915-924X

Comparison between direct measurements and modeled estimates of external radiation exposure among school children 18 to 30 months after the Fukushima nuclear accident in Japan.

Shuhei Nomura, Masaharu Tsubokura, Ryugo Hayano, Tomoyuki Furutani, Daisuke Yoneoka, Masahiro Kami, Yukio Kanazawa, Tomoyoshi Oikawa

Environmental science & technology 49 ( 2 ) 1009 - 16 2015.01

Accepted, ISSN 0013-936X

After a major radioactive incident, accurate dose reconstruction is important for evaluating health risks and appropriate radiation protection policies. After the 2011 Japan Fukushima nuclear incident, we assessed the level of agreement between the modeled and directly measured dose and estimated the uncertainties. The study population comprised 520 school children from Minamisoma city, located 20 km north of the nuclear plant. The annual dose 18–30 months after the incident was assessed using two approaches: estimation using the model proposed by the Japanese government and direct measurement by radiation dosemeters. The ratio of the average of modeled and measured doses was 3.0 (standard deviation (SD): 2.0). The reduction coefficient, an index for radiation attenuation properties, was 0.3 (SD: 0.1) on average, whereas the value used in the government model was 0.6. After adjusting for covariates, the coefficient had a significant negative correlation with the air dose rate in the dwelling location (p < 0.001), indicating that stronger building shielding effects are valuable in areas with higher air contamination levels. The present study demonstrated that some overestimation may have been related to uncertainties in radiation reduction effects, and that the air contamination level might provide a more important indicator of these effects.

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Absence of internal radiation contamination by radioactive cesium among children affected by the Fukushima Daiichi nuclear power plant disaster.

Masaharu Tsubokura, Shigeaki Kato, Shuhei Nomura, Tomohiro Morita, Amina Sugimoto, Stuart Gilmour, Masahiro Kami, Tomoyoshi Oikawa, Yukio Kanazawa

Health physics 108 ( 1 ) 39 - 43 2015.01

Accepted, ISSN 0017-9078

Chronic internal radiation contamination accounts for a substantial fraction of long-term cumulative radiation exposure among residents in radiation-contaminated areas. However, little information is available on ongoing chronic internal radiation contamination among residents near the crippled Fukushima Daiichi nuclear power plant. Using a whole body counter, internal radiation contamination levels among elementary and middle school students who commute to 22 schools located within Minamisoma city were assessed between May and July 2013 (26 to 28 mo after the disaster). Of 3,299 elementary and middle school students in the city, 3,255 individuals (98%) were screened through school health check-ups. Not a single student was detected with internal radiation contamination due to radioactive cesium. The study found no risk of chronic internal radiation exposure among residents near the crippled nuclear power plant. Current food inspection by local governments, volunteers, and farmers has been functioning well within Fukushima prefecture. However, food management by screening suspected contamination along with whole body counter screening are key public health interventions and should be continued to avoid further internal radiation exposure in radiation-contaminated areas.

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An assessment of the characteristics and quality of diagnostic accuracy studies for positron emission tomography conducted in Japan: a systematic review.

Shuhei Nomura, Akinori Hisashige, Daisuke Yoneoka, Mikiko Kanda, Karin Miyamoto, Miwako Segawa, Erika Ota, Kenji Shibuya

EJNMMI research 5 6 - 6 2015

Accepted, ISSN 2191-219X

BACKGROUND: Systematic evaluations of the diagnostic accuracy of positron emission tomography (PET) imaging have been widely conducted in many countries. Although Japan's total number of PET units is the second highest in the world, very limited effort has been made to systematically assess the methodological quality of PET studies in Japan. We performed a systematic review to assess the characteristics and quality of PET diagnostic accuracy studies conducted in Japan and to analyze the factors related to their quality. METHODS: All PET studies conducted in Japan were identified using MEDLINE and the Japan Medical Abstract Society Database. The characteristics of the Japanese studies were examined and their methodological quality evaluated by the standardized quality assessment of diagnostic accuracy studies (QUADAS) tool. We compared the quality of studies indexed in MEDLINE with non-indexed studies, followed by a comparison of the studies' conclusions with those of international health technology assessment (HTA) reports. RESULTS: A total of 138 studies were identified. Half of them were not indexed in MEDLINE. The mean quality score of the Japanese studies was 6.7 and the proportion of high-quality studies (with a quality score higher than 8) was 32.6%. A significant difference was observed in several quality items between MEDLINE-indexed and non-indexed studies, although there was no difference in total quality score. Three variables (i.e., target diseases, publication year, and study type) were identified as factors related to the quality of the studies. Conclusions of Japanese studies relating to several target diseases were relatively consistent with international assessments. CONCLUSIONS: Although a considerable number of diagnostic accuracy studies of PET have been conducted in Japan, a substantial proportion of high-quality studies were not indexed in international databases. High-quality Japanese studies, therefore, should be searched using Japanese databases and assessed by systematic reviews and HTA conducted internationally.

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Assessment of the Annual Additional Effective Doses amongst Minamisoma Children during the Second Year after the Fukushima Daiichi Nuclear Power Plant Disaster.

Masaharu Tsubokura, Shigeaki Kato, Tomohiro Morita, Shuhei Nomura, Masahiro Kami, Kikugoro Sakaihara, Tatsuo Hanai, Tomoyoshi Oikawa, Yukio Kanazawa

PloS one 10 ( 6 ) e0129114 2015

Accepted, ISSN 1932-6203

An assessment of the external and internal radiation exposure levels, which includes calculation of effective doses from chronic radiation exposure and assessment of long-term radiation-related health risks, has become mandatory for residents living near the nuclear power plant in Fukushima, Japan. Data for all primary and secondary children in Minamisoma who participated in both external and internal screening programs were employed to assess the annual additional effective dose acquired due to the Fukushima Daiichi nuclear power plant disaster. In total, 881 children took part in both internal and external radiation exposure screening programs between 1st April 2012 to 31st March 2013. The level of additional effective doses ranged from 0.025 to 3.49 mSv/year with the median of 0.70 mSv/year. While 99.7% of the children (n = 878) were not detected with internal contamination, 90.3% of the additional effective doses was the result of external radiation exposure. This finding is relatively consistent with the doses estimated by the United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR). The present study showed that the level of annual additional effective doses among children in Minamisoma has been low, even after the inter-individual differences were taken into account. The dose from internal radiation exposure was negligible presumably due to the success of contaminated food control.

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Managing Type 2 Diabetes Mellitus through Periodical Hospital Visits in the Aftermath of the Great East Japan Earthquake Disaster: A Retrospective Case Series.

Yoshitaka Nishikawa, Yuji Fukuda, Masaharu Tsubokura, Shigeaki Kato, Shuhei Nomura, Yasutoshi Saito

PloS one 10 ( 5 ) e0125632 2015

Accepted, ISSN 1932-6203

AIMS: To assess the impact of the Great East Japan Earthquake Disaster on daily diabetes practice and to determine the feasibility of controlling type 2 diabetes mellitus in an outpatient department. METHODS: We retrospectively reviewed the data on disaster-affected patients with type 2 diabetes who periodically attended outpatient department of Soma Central Hospital. There were 767 patients with type 2 diabetes mellitus in total. The primary outcome measure was the change in HbA1c. RESULTS: HbA1c levels of 58 patients with periodical hospital visits did not deteriorate after the disasters. Moreover, there observed no significant difference in the mean of HbA1c levels among all age and sex throughout the year. While several changes in diabetes medication usage occurred, DPP4-inhibitor was the only oral diabetic agent that increased in frequency (+60%). CONCLUSIONS: Patients with type 2 diabetes who were managed with periodical hospital visits did not show significant deterioration in HbA1c levels.

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Was the Risk from Nursing-Home Evacuation after the Fukushima Accident Higher than the Radiation Risk?

Michio Murakami, Kyoko Ono, Masaharu Tsubokura, Shuhei Nomura, Tomoyoshi Oikawa, Tosihiro Oka, Masahiro Kami, Taikan Oki

PloS one 10 ( 9 ) e0137906 2015

Accepted, ISSN 1932-6203

After the 2011 accident at the Fukushima Daiichi nuclear power plant, nursing-home residents and staff were evacuated voluntarily from damaged areas to avoid radiation exposure. Unfortunately, the evacuation resulted in increased mortalities among nursing home residents. We assessed the risk trade-off between evacuation and radiation for 191 residents and 184 staff at three nursing homes by using the same detriment indicator, namely loss of life expectancy (LLE), under four scenarios, i.e. "rapid evacuation (in accordance with the actual situation; i.e. evacuation on 22 March)," "deliberate evacuation (i.e. evacuation on 20 June)," "20-mSv exposure," and "100-mSv exposure." The LLE from evacuation-related mortality among nursing home residents was assessed with survival probability data from nursing homes in the city of Minamisoma and the city of Soma. The LLE from radiation mortality was calculated from the estimated age-specific mortality rates from leukemia and all solid cancers based on the additional effective doses and the survival probabilities. The total LLE of residents due to evacuation-related risks in rapid evacuation was 11,000 persons-d-much higher than the total LLEs of residents and staff due to radiation in the other scenarios (27, 1100, and 5800 persons-d for deliberate evacuation, 20 mSv-exposure, and 100 mSv-exposure, respectively). The latitude for reducing evacuation risks among nursing home residents is surprisingly large. Evacuation regulation and planning should therefore be well balanced with the trade-offs against radiation risks. This is the first quantitative assessment of the risk trade-off between radiation exposure and evacuation after a nuclear power plant accident.

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Whole-body counter survey results 4 months after the Fukushima Dai-ichi NPP accident in Minamisoma City, Fukushima.

Ryugo S Hayano, Yuni N Watanabe, Shuhei Nomura, Tsuyoshi Nemoto, Masaharu Tsubokura, Tatsuo Hanai, Yuki Kumemoto, Satoshi Kowata, Tomoyoshi Oikawa, Yukio Kanazawa

Journal of radiological protection : official journal of the Society for Radiological Protection (IOP PUBLISHING LTD) 34 ( 4 ) 787 - 99 2014.12

Accepted, ISSN 0952-4746

Using the first WBC unit installed in Fukushima Prefecture after the accident, the radiocesium body burdens of 566 high-risk residents of Minamisoma city were measured in July 2011 at the Minamisoma Municipal General Hospital. The analysis of the data was challenging because this chair-type, WBC unit, did not have sufficient shielding against background gamma rays and methods had to be developed to reliably compensate for the body-attenuated background radiation. Fortunately, data for repeated tests of hospital staff members using both the chair-type and well-shielded FASTSCAN WBC units, installed in September 2011, were available and could be used to check the validity of the analysis. The CEDs of all subjects, estimated under the assumption of acute inhalation in March 2011, were found to be less than 1 mSv.

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Assessment of the risk of medium-term internal contamination in Minamisoma City, Fukushima, Japan, after the Fukushima Dai-ichi nuclear accident.

Amina Sugimoto, Stuart Gilmour, Masaharu Tsubokura, Shuhei Nomura, Masahiro Kami, Tomoyoshi Oikawa, Yukio Kanazawa, Kenji Shibuya

Environmental health perspectives (US DEPT HEALTH HUMAN SCIENCES PUBLIC HEALTH SCIENCE) 122 ( 6 ) 587 - 93 2014.06

Accepted, ISSN 0091-6765

BACKGROUND: The Fukushima Dai-ichi nuclear disaster, the first level-7 major nuclear disaster since Chernobyl, raised concerns about the future health consequences of exposure to and intake of radionuclides. Factors determining the risk and level of internal radiation contamination after a nuclear accident, which are a key to understanding and improving current nuclear disaster management, are not well studied. OBJECTIVE: We investigated both the prevalence and level of internal contamination in residents of Minamisoma, and identified factors determining the risk and levels of contamination. METHODS: We implemented a program assessing internal radiation contamination using a whole body counter (WBC) measurement and a questionnaire survey in Minamisoma, between October 2011 and March 2012. RESULTS: Approximately 20% of the city's population (8,829 individuals) participated in the WBC measurement for internal contamination, of which 94% responded to the questionnaire. The proportion of participants with detectable internal contamination was 40% in adults and 9% in children. The level of internal contamination ranged from 2.3 to 196.5 Bq/kg (median, 11.3 Bq/kg). Tobit regression analysis identified two main risk factors: more time spent outdoors, and intake of potentially contaminated foods and water. CONCLUSIONS: Our findings suggest that, with sensible and reasonable precautions, people may be able to live continuously in radiation-affected areas with limited contamination risk. To enable this, nuclear disaster response should strictly enforce food and water controls and disseminate evidence-based and up-to-date information about avoidable contamination risks.

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Detection of 131I in a patient with thyroid cancer by internal radiation exposure screening using a whole-body counter in Fukushima.

Masaharu Tsubokura, Shuhei Nomura, Takeaki Ishii, Masahiro Kami, Shigeaki Kato

Clinical nuclear medicine (LIPPINCOTT WILLIAMS & WILKINS) 39 ( 3 ) 281 - 2 2014.03

Accepted, ISSN 0363-9762

We have been performing a systematic screening using a whole-body counter of internal radiation exposure in the affected areas by the Fukushima Daiichi nuclear incident. This case suggests 2 important points regarding the thyroid internal exposure screening immediately after a nuclear disaster. First, clinicians should recognize the possibility of overestimation of I exposure during the initial checkups of thyroid internal exposure if a detailed history of treatment by radioisotopes is not obtained. Second, in vivo measurements should be taken immediately after the disaster because all of the radioactive iodine generated after the disaster disappears within a few months.

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The immediate physical and mental health crisis in residents proximal to the evacuation zone after Japan's nuclear disaster: an observational pilot study.

Masaharu Tsubokura, Kazuo Hara, Tomoko Matsumura, Amina Sugimoto, Shuhei Nomura, Masamitsu Hinata, Kenji Shibuya, Masahiro Kami

Disaster medicine and public health preparedness (CAMBRIDGE UNIV PRESS) 8 ( 1 ) 30 - 6 2014.02

Accepted, ISSN 1935-7893

OBJECTIVE: The 2011 earthquake and Fukushima nuclear disaster in Japan have had devastating effects on residents near the damaged nuclear power plant, but quantifying its effect on their health has been difficult. METHODS: Among the 564 residents of Iitate Village and Soma City who enrolled in this study, we evaluated the changes of clinical parameters in 155 participants who underwent annual health evaluations in the previous year and after the earthquake. Psychological distress was also measured by using patient health questionnaire 9 (PHQ-9). RESULTS: Participants (median age, 64 years) showed significant post-disaster increases in body weight, body mass index, systolic and diastolic blood pressure, blood glucose levels, and triglyceride levels. PHQ-9 scores of 10 or greater were found in 12% of the subjects, indicating that a substantial number had major depression. CONCLUSIONS: The findings in this study showed substantial deterioration in clinical parameters related to lifestyle diseases and the presence of general psychological distress among residents living near the damaged nuclear power plant after the Fukushima Daiichi disaster. In addition to controlling the levels of radiation exposure, aggressive management of immediate physical and mental health crisis for residents may be necessary in future nuclear accidents.

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Are Japanese randomized controlled trials up to the task? A systematic review.

Daisuke Yoneoka, Akinori Hisashige, Erika Ota, Karin Miyamoto, Shuhei Nomura, Miwako Segawa, Stuart Gilmour, Kenji Shibuya

PloS one (PUBLIC LIBRARY SCIENCE) 9 ( 3 ) e90127 2014

Accepted, ISSN 1932-6203

OBJECTIVES: Despite increasing numbers of RCTs done in Japan, existing international databases fail to capture them, and detailed information on the quality of Japanese RCTs is still missing. This study assessed the characteristics and quality of Japanese RCTs and analyzed factors related to their quality. METHODS: All RCTs conducted in Japan, and published as original articles that assessed the effect of healthcare interventions on humans in 2010, were included. We excluded study protocols, conference abstracts, and comments. In addition, quasi-RCTs were excluded. Data were independently abstracted and assessed by two of the authors and disagreements were resolved by consensus. The quality of Japanese RCTs randomly sampled was assessed using the method guidelines for systematic reviews from the Cochrane Back Review Group. The factors affecting RCT quality were analyzed using a logistic regression model. RESULTS: A total of 1013 RCTs conducted in Japan were published in 2010. The majority was small-scale (55% of RCTs with sample size less than 50). Eighty percent of RCTs had no information on the funding source and only 8% had been registered before their implementation. RCTs not indexed in international databases were a moderate number (118 RCTs: 37.7% of non-indexed RCTs were of high quality). Surgical intervention studies for external causes of morbidity and mortality with a large sample size, trial registration and a large number of arms were most likely to be of higher quality. CONCLUSION: Despite a considerable number of RCTs conducted in Japan, their quality is not satisfactory in some domains. On the other hand, there are high-quality, non-indexed RCTs. The full disclosure of trial information and quality control of clinical trials are urgently needed in Japan.

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Reduction of high levels of internal radio-contamination by dietary intervention in residents of areas affected by the Fukushima Daiichi nuclear plant disaster: a case series.

Masaharu Tsubokura, Shigeaki Kato, Shuhei Nomura, Stuart Gilmour, Masahiko Nihei, Yu Sakuma, Tomoyoshi Oikawa, Yukio Kanazawa, Masahiro Kami, Ryugo Hayano

PloS one (PUBLIC LIBRARY SCIENCE) 9 ( 6 ) e100302 2014

Accepted, ISSN 1932-6203

Maintaining low levels of chronic internal contamination among residents in radiation-contaminated areas after a nuclear disaster is a great public health concern. However, the efficacy of reduction measures for individual internal contamination remains unknown. To reduce high levels of internal radiation exposure in a group of individuals exposed through environmental sources, we performed careful dietary intervention with identification of suspected contaminated foods, as part of mass voluntary radiation contamination screenings and counseling program in Minamisoma Municipal General Hospital and Hirata Central Hospital. From a total of 30,622 study participants, only 9 residents displayed internal cesium-137 (Cs-137) levels of more than 50 Bq/kg. The median level of internal Cs-137 contamination in these residents at the initial screening was 4,830 Bq/body (range: 2,130-15,918 Bq/body) and 69.6 Bq/kg (range: 50.7-216.3 Bq/kg). All these residents with high levels of internal contamination consumed homegrown produce without radiation inspection, and often collected mushrooms in the wild or cultivated them on bed-logs in their homes. They were advised to consume distributed food mainly and to refrain from consuming potentially contaminated foods without radiation inspection and local produces under shipment restrictions such as mushrooms, mountain vegetables, and meat of wild life. A few months after the intervention, re-examination of Cs levels revealed remarkable reduction of internal contamination in all residents. Although the levels of internal radiation exposure appear to be minimal amongst most residents in Fukushima, a subset of the population, who unknowingly consumed highly contaminated foodstuffs, experienced high levels of internal contamination. There seem to be similarities in dietary preferences amongst residents with high internal contamination levels, and intervention based on pre- and post-test counseling and dietary advice from medical care providers about risky food intake appears to be a feasible option for changing residents' dietary practices, subsequently resulting in a reduction in Cs internal contamination levels.

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Measurement of internal radiation exposure among decontamination workers in villages near the crippled Fukushima Daiichi Nuclear Power Plant.

Masaharu Tsubokura, Masahiko Nihei, Katsumi Sato, Shin Masaki, Yu Sakuma, Shigeaki Kato, Amina Sugimoto, Shuhei Nomura, Tomoko Matsumura, Makoto Miyazaki, Ryugo Hayano, Kenji Shibuya, Masahiro Kami, Taro Sasaki

Health physics 105 ( 4 ) 379 - 81 2013.10

Accepted, ISSN 0017-9078

Decontamination workers may face a high risk of exposure to internal irradiation through inhalation during decontamination activities; there is, however, little previous research on the levels of internal contamination during decontamination procedures. The authors reviewed the medical records, including whole body counter measurements, of decontamination workers in villages near the crippled Fukushima Daiichi Nuclear Power Plant to assess their levels of internal radiation exposure. In total, 83 decontamination workers were enrolled in this study. They were regularly engaged in decontamination activities in highly contaminated areas where surface 137Cs deposition density was over 100 kBq m-2. The present study showed low levels of internal exposure among the decontamination workers near the Fukushima Daiichi nuclear plant. The cesium burdens of all the decontamination workers were below detection limits. They had reported no acute health problems. The resuspension of radioactive materials may cause minimal internal contamination during decontamination activities.

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Interventions for reduction of stigma in people with HIV/AIDS

Windy M.V. Wariki, Shuhei Nomura, Erika Ota, Rintaro Mori, Kenji Shibuya

Cochrane Database of Systematic Reviews (John Wiley and Sons Ltd) 2013 ( 6 ) 2013.06

Accepted, ISSN 1469-493X

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Limited internal radiation exposure associated with resettlements to a radiation-contaminated homeland after the Fukushima Daiichi nuclear disaster.

Masaharu Tsubokura, Shigeaki Kato, Masahiko Nihei, Yu Sakuma, Tomoyuki Furutani, Keisuke Uehara, Amina Sugimoto, Shuhei Nomura, Ryugo Hayano, Masahiro Kami, Hajime Watanobe, Yukou Endo

PloS one 8 ( 12 ) e81909 2013

Accepted, ISSN 1932-6203

Resettlement to their radiation-contaminated hometown could be an option for people displaced at the time of a nuclear disaster; however, little information is available on the safety implications of these resettlement programs. Kawauchi village, located 12-30 km southwest of the Fukushima Daiichi nuclear power plant, was one of the 11 municipalities where mandatory evacuation was ordered by the central government. This village was also the first municipality to organize the return of the villagers. To assess the validity of the Kawauchi villagers' resettlement program, the levels of internal Cesium (Cs) exposures were comparatively measured in returnees, commuters, and non-returnees among the Kawauchi villagers using a whole body counter. Of 149 individuals, 5 villagers had traceable levels of Cs exposure; the median detected level was 333 Bq/body (range, 309-1050 Bq/kg), and 5.3 Bq/kg (range, 5.1-18.2 Bq/kg). Median annual effective doses of villagers with traceable Cs were 1.1 x 10(-2) mSv/y (range, 1.0 x 10(-2)-4.1 x 10(-2) mSv/y). Although returnees had higher chances of consuming locally produced vegetables, Cochran-Mantel-Haenszel test showed that their level of internal radiation exposure was not significantly higher than that in the other 2 groups (p=0.643). The present findings in Kawauchi village imply that it is possible to maintain internal radiation exposure at very low levels even in a highly radiation-contaminated region at the time of a nuclear disaster. Moreover, the risks for internal radiation exposure could be limited with a strict food control intervention after resettlement to the radiation-contaminated village. It is crucial to establish an adequate number of radio-contaminated testing sites within the village, to provide immediate test result feedback to the villagers, and to provide education regarding the importance of re-testing in reducing the risk of high internal radiation exposure.

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The relationship between media consumption and health-related anxieties after the Fukushima Daiichi nuclear disaster.

Amina Sugimoto, Shuhei Nomura, Masaharu Tsubokura, Tomoko Matsumura, Kaori Muto, Mikiko Sato, Stuart Gilmour

PloS one 8 ( 8 ) e65331 2013

Accepted, ISSN 1932-6203

BACKGROUND: The Fukushima Daiichi nuclear disaster caused a global panic by a release of harmful radionuclides. In a disaster setting, misusage of contemporary media sources available today can lead to disseminated incorrect information and panic. The study aims to build a scale which examines associations between media and individual anxieties, and to propose effective media usages for future disaster management. METHODS: The University of Tokyo collaborated with the Fukushima local government to conduct a radiation-health-seminar for a total of 1560 residents, at 12 different locations in Fukushima. A 13 item questionnaire collected once before and after a radiation-seminar was used on factor analysis to develop sub-scales for multiple regression models, to determine relationships between the sub-scales and media type consumed. A paired t-test was used to examine any changes in sub-scale of pre- and post-seminar scores. RESULTS: Three sub-scales were revealed and were associated with different media types: was with rumors, while concern for the future was positively associated with regional-newspapers and negatively with national-newspapers. Anxiety about social-disruption was associated with radio. The seminar had a significant effect on anxiety reduction for all the three sub-scales. CONCLUSION: Different media types were associated with various heightened concerns, and that a radiation seminar was helpful to reduce anxieties in the post-disaster setting. By tailoring post-disaster messages via specific media types, i.e., radio, it may be possible to effectively convey important information, as well as to calm fears about particular elements of post-disaster recovery and to combat rumors.

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Mortality risk amongst nursing home residents evacuated after the Fukushima nuclear accident: a retrospective cohort study.

Shuhei Nomura, Stuart Gilmour, Masaharu Tsubokura, Daisuke Yoneoka, Amina Sugimoto, Tomoyoshi Oikawa, Masahiro Kami, Kenji Shibuya

PloS one 8 ( 3 ) e60192 2013

Accepted

BACKGROUND: Safety of evacuation is of paramount importance in disaster planning for elderly people; however, little effort has been made to investigate evacuation-related mortality risks. After the Fukushima Daiichi Nuclear Plant accident we conducted a retrospective cohort survival survey of elderly evacuees. METHODS: A total of 715 residents admitted to five nursing homes in Minamisoma city, Fukushima Prefecture in the five years before 11th March 2011 joined this retrospective cohort study. Demographic and clinical characteristics were drawn from facility medical records. Evacuation histories were tracked until the end of 2011. The evacuation's impact on mortality was assessed using mortality incidence density and hazard ratios in Cox proportional hazards regression. RESULTS: Overall relative mortality risk before and after the earthquake was 2.68 (95% CI: 2.04-3.49). There was a substantial variation in mortality risks across the facilities ranging from 0.77 (95% CI: 0.34-1.76) to 2.88 (95% CI: 1.74-4.76). No meaningful influence of evacuation distance on mortality was observed although the first evacuation from the original facility caused significantly higher mortality than subsequent evacuations, with a hazard ratio of 1.94 (95% CI: 1.07-3.49). CONCLUSION: High mortality, due to initial evacuation, suggests that evacuation of the elderly was not the best life-saving strategy for the Fukushima nuclear disaster. Careful consideration of the relative risks of radiation exposure and the risks and benefits of evacuation is essential. Facility-specific disaster response strategies, including in-site relief and care, may have a strong influence on survival. Where evacuation is necessary, careful planning and coordination with other nursing homes, evacuation sites and government disaster agencies is essential to reduce the risk of mortality.

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The voice of the most vulnerable: lessons from the nuclear crisis in Fukushima, Japan

A. Sugimoto, S. Krull, S. Nomura, T. Morita, M. Tsubokura

BULLETIN OF THE WORLD HEALTH ORGANIZATION (WORLD HEALTH ORGANIZATION) 90 ( 8 ) 629 - 630 2012.08

Accepted, ISSN 0042-9686

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