[Feature: The COVID-19 Crisis and the University] Roundtable Discussion 2: Medical Sciences and Healthcare in the With-COVID Era

Today, I would like to hold a roundtable discussion on the theme of "Medical Sciences and Healthcare in the With-Corona Era."

In addition to the members who have been working day and night on COVID-19 countermeasures at Keio University Hospital and the School of Medicine, we are joined by Dr. Saito, who has been struggling as part of the Ministry of Health, Labour and Welfare's cluster response team. Based on Japan's efforts regarding coronavirus countermeasures, I hope we can have an active exchange of opinions on the situation on the ground so far and what lies ahead.

We never imagined this pandemic of the new coronavirus infection (COVID-19). On December 31 last year, the Wuhan Municipal Health Commission announced a cluster of atypical pneumonia of unknown cause in Wuhan, but I did not think it would enter Japan to such an extent.

Various things happened, such as the bus tour for tourists from Wuhan in January and the cruise ship issue from early February, and anxiety about the new coronavirus gradually increased from that time. However, the nationwide spread of infection that occurred from the end of March was beyond imagination. On April 7, a state of emergency was declared, and Japanese society as a whole, as well as Keio University Hospital, the School of Medicine, and Keio University, were heavily involved.

First, Dr. Saito, could you introduce the basic thinking behind Japan's COVID-19 countermeasures?

I am a graduate of the Juku's Department of Tropical Medicine and Parasitology. After working at the Ministry of Health, Labour and Welfare for three years starting in 2011, I came to my current position at the National Institute of Public Health. Currently, I am also active in the cluster response team.

Regarding the countermeasures for the new coronavirus this time, there are arguments about whether Japan has been successful or not, but I believe we have done well so far.

The reason is that we identified patients properly and early, and conducted thorough investigations into their infection routes. Furthermore, we recognized how this new coronavirus infection spreads and formulated strategies to take countermeasures. This is what is called cluster countermeasures, and it has been the central concept of Japan's early response.

What we learned from investigating the first 100 or so cases was that the mode of infection is not one where many infected people pass it on one after another like influenza, but rather a characteristic of this epidemic where a very small number of people, so-called superspreaders, spread the infection to many people.

Conversely, most people do not infect the next person. We found that a truly small number of people infect 5 or 10 others, leading to a large outbreak. Therefore, it becomes important how quickly we find these clusters, grasp their essence, and prevent clusters from occurring. Furthermore, we have focused on how quickly we can detect the phase where the epidemic increases exponentially and take action.

In mid-March, the number of infected people among travelers and returnees from Europe and the U.S. increased, and there were signs of a major spread within the country. Therefore, messages were quickly issued for Osaka and Tokyo to avoid moving across prefectural borders and to refrain from going out on weekends, and countermeasures gradually began in earnest in each prefecture.

Then, on April 7, the government declared a state of emergency based on the Act on Special Measures for Pandemic Influenza and New Infectious Diseases Preparedness and Response. By taking measures to significantly reduce person-to-person contact in society, we were able to considerably reduce the number of new infections that had been expanding and return to a state of lull. Now, I believe we are in a situation where we are proceeding with preparations for the second wave. (Refer to the Ministry of Health, Labour and Welfare website)

As of July 1, there are about 10 million infected people worldwide, with about 500,000 deaths, a mortality rate of about 5%. In contrast, Japan has just under 20,000 cases and about 1,000 deaths. One reason the number of new coronavirus infections and deaths in Japan has been kept so low is that cluster countermeasures were carried out effectively.

Now, since March, Keio University Hospital has also been greatly affected by the new coronavirus infection. I would like Director Kitagawa to briefly explain what has happened at Keio University Hospital so far.

I have described this in detail in the July issue of this magazine, but unfortunately, an in-hospital infection occurred at our hospital, originating from a patient transferred from another hospital. Additionally, a cluster infection occurred among residents who were infected in the community through a "dinner party." As the hospital director, I deeply apologize for the great inconvenience and concern these two major incidents caused everyone.

What I still feel poignantly when I look back is that we may have experienced patients with the typical difficult characteristics of this new coronavirus. There are asymptomatic individuals who test positive. These asymptomatic individuals are highly infectious just before and immediately after the onset of symptoms. And even if they are very few, special superspreaders exist. The first case we experienced as the source of the in-hospital infection had all of these characteristics.

When they were admitted for surgery for another disease, they had no pneumonia symptoms at all, but many infections occurred among roommates and healthcare workers.

Theoretically, if standard precautions are perfect, in-hospital infections should not occur, but I believe this is a virus with unknown aspects where in-hospital infections can occur even with such measures.

Looking at the fact that in-hospital infections are occurring even at university hospitals like ours or specialized medical institutions for infectious diseases, there can be situations where infection control is extremely difficult in the case of special patients. I feel poignantly that we must conduct medical care while always keeping in mind that in-hospital infections can occur if medical care is provided without recognizing it is COVID-19.

Also, the cluster infection among residents spread at a dinner party. Even if we strictly adhere to standard precautions in our daily medical activities, infection can occur when masks are removed and there is contact with others during lunch in the backyard or at dinner parties. Since community infection can occur among healthcare workers as long as they live as citizens, I felt poignantly that various precautions are necessary not only during medical activities but in life in general to prevent this.

On the other hand, for the in-hospital infections that did occur, we were able to control them by taking measures such as thorough contact tracing, rapid PCR testing, and rotating medical teams. The results of epidemiological analysis through viral genome sequence analysis were also very useful. I believe we also learned that control is possible by taking such fundamental responses quickly.

As the new coronavirus spread, there were reports about the characteristics of this virus from the WHO and various medical institutions, but there were many unknowns, and the field had to respond within that. I think the current situation is that we have faced the virus while dealing with many difficulties.

In particular, it was only in the U.S. CDC report on March 30 that asymptomatic infection became known. Since the case at Keio University Hospital occurred before that, there was not much awareness that there were people with such strong infectivity among asymptomatic individuals.

That's right. At that time, we had already established a PCR testing system in February, and all patients suspected of pneumonia were admitted to private rooms for PCR testing. While we thought we were taking solid border control measures for anyone even slightly suspicious, the in-hospital infection occurred through an unexpected route.

Japan as a whole, and the world as a whole, has faced this new coronavirus infection in such a situation. In that context, Japan's number of deaths relative to the population has been kept very low, and I think it is evaluated that infection countermeasures have been successful compared to other countries in the world.

Japan avoided the worst-case medical collapse, but from late March through April and May, there was a real sense of crisis, and I think Keio University Hospital also approached it with great trepidation.

From late March to April, patients came rushing in and the wards were in a dire situation. Now it has calmed down a bit, but there is some eerie movement. Based on this current situation, Dr. Fukunaga, who is closest to the front lines, what are your feelings?

In late March, amid the situation where in-hospital infections caused by transferred patients had occurred, I received a request from the hospital director to build a medical care system for COVID-19. Until then, Keio University Hospital had been steadily making preparations for COVID-19, such as PCR testing systems and infection prevention measures, but we had almost no clinical experience with this unknown infectious disease, and I felt that building a medical care system was an urgent task.

On the other hand, looking at the situation in other countries at the time, I imagined that if only doctors from limited specialized departments like our respiratory medicine department were to see COVID-19 patients, and if the number of patients increased rapidly, there would be a shortage of doctors who could provide treatment, leading to a medical collapse sooner or later. For this reason, I thought it was essential to create a system where many doctors have the opportunity to face this disease at an early stage and participate in medical care.

Therefore, we launched the "COVID-19 Life-Saving Medical Care Team" consisting of doctors from across Keio University Hospital. Our respiratory medicine department, which has extensive experience in infectious disease care, handles moderate cases where the condition is unstable and plays the role of identifying those who are becoming severely ill early. Then, doctors from anesthesiology and the emergency department mainly handle patients in the acute phase or those requiring ventilators.

We formed a team with cardiovascular surgery and cardiology in preparation for cases where extracorporeal membrane oxygenation (ECMO) becomes necessary. Furthermore, we created a system where doctors from internal medicine and surgery are dispatched to these severe to moderate teams on a rotating basis. For relatively stable mild patients, doctors from departments other than internal medicine and surgery within the hospital also provided medical care as a mild case team on a rotating basis.

On the other hand, seeing this mysterious disease places a significant mental burden on healthcare workers. Therefore, we had Professor Masaru Mimura of the psychiatry department lead the launch of a "Mental Care Team" to build a system that can also follow up on the mentality of healthcare workers.

Through this "Life-Saving Medical Care Team system," doctors who deepened their understanding of this unprecedented infectious disease from the initial stage stood together to face this disease, which may have been one of the keys to overcoming the predicament of the first wave.

Even if a second or third wave comes in the future, I believe the doctors at Keio University Hospital will be able to utilize their experience in this medical team to overcome it while collaborating with other healthcare workers as commanders at their respective sites.

Fortunately, Keio had been treating COVID-19 patients since mid-February when we accepted patients from the cruise ship, so the system for when patients arrived and the testing system were in place.

However, as mentioned earlier, there were situations where we were caught off guard, and we had a very strong sense of crisis. In that context, I think a very significant characteristic of Keio was that everyone from each clinical department cooperated to respond.

The School of Medicine and the research departments of the Clinical and Translational Research Center also worked together to respond. I imagine there were many hardships from the standpoint of faculty, student education, or supporting the hospital, but Dr. Amaya, please tell us about the situation at the School of Medicine when the first wave arrived.

In late March, the moment the in-hospital infection cases occurred, I saw from the perspective of the School of Medicine the scene where Dr. Kitagawa, Dr. Fukunaga, and other hospital-related personnel were putting their heart and soul into trying to control it together.

There, I asked Dr. Saya, as the director of the Clinical and Translational Research Center, to summarize what the School of Medicine could do. Naturally, the momentum grew among basic researchers to contribute to this emergency, and the first meeting was held on April 2.

The passionate feelings of the members who gathered there burst out all at once. People from various backgrounds shared information about what they could do to overcome COVID-19, and it didn't take long for it to spread to basic researchers on campus.

Dr. Saya will probably talk about specific measures, but the reason such a foundation existed is because of the, so to speak, genes of the Keio University School of Medicine. In other words, I believe the genes of what Shibasaburo Kitasato, the first dean of the School of Medicine, experienced and valued are being inherited.

In 1894, when the plague was epidemic in Asia, Shibasaburo Kitasato went to Hong Kong as the representative of the Japanese investigation team and achieved the great feat of isolating the causative agent of the plague, which had a mortality rate of over 90% at the time. The environment in Hong Kong was far worse than today's "Three Cs." At Kennedy Town Hospital, where research activities were conducted, more than five people were packed into a room of about 13 square meters, and the curtains were closed for fear of being seen by citizens, making it like a steam bath.

When there was a fatal case, they performed the incredible task of removing organs and staining them, and they achieved this feat in a situation where both infections and deaths occurred within the delegation.

I believe this momentum emerged because such genes exist in the 100-year history of Keio Medicine. And, naming it "Donnel" (meaning thunder in German) after Shibasaburo Kitasato's nickname "Thunderbolt Dad," the "Keio Donnel Project" was born, where basic and clinical research integrate to study the new coronavirus.

Dr. Saya, specifically what kind of framework is the Donnel Project and what is being done?

As Dean Amaya just explained, we have always conducted research to reflect basic medical research in clinical practice, being integrated as one, as in Dr. Shibasaburo Kitasato's words, "Basic and clinical are like one family."

Our Clinical and Translational Research Center is an organization that supports the transition of basic research born at Keio to clinical practice. This time, especially for this infectious disease, we consider it our mission to directly link research results to diagnosis and treatment as quickly as possible. Basic researchers are also integrated with clinical staff to face this COVID-19.

Actually, during the Great East Japan Earthquake, when medical resources were extremely limited, an organization called "Doctors Without Experience" was spontaneously launched by basic researchers wondering if they could contribute. This time too, when Dr. Koichi Matsuo took the lead in calling for volunteers at the School of Medicine, there were more than 100 registrations in just one week. The Donnel Project was born from the passionate desire of basic researchers to move toward diagnosis and treatment together with clinical staff.

People who had been working in different fields until now are demonstrating their expertise and cooperating to face this new coronavirus.

The development of systems to detect antibodies and antigens against the virus, and the creation of neutralizing antibodies against the virus, are progressing rapidly. Also, molecular genetics researchers quickly implemented viral genome sequence analysis to clarify whether a patient's virus came from Wuhan or was of European origin.

Furthermore, joint research with RIKEN and the National Institute of Infectious Diseases has started, and a system for diagnosis or new treatments for the second wave is growing within Keio.

The research system integrating basic and clinical is in place, and we are facing this infectious disease as truly one team.

The Donnel Project has various teams, such as a public health epidemiological analysis team, a testing team for antibody and PCR tests centered on the Central Clinical Laboratory, a team to read the virus sequence, and a team to develop new antibody tests. There are also teams trying to extract neutralizing antibodies for treatment, or extract serum from convalescent patients to link it to treatment.

At the same time, collaboration with RIKEN, the National Institute of Infectious Diseases, etc., has progressed, and many results have been produced in just three months since April. I expect those results will continue to be released to the world.

So, what should we do in the future? I would like to consider preparations for the second and third waves, including national policies.

Dr. Saito, based on the first wave from April to May, in what direction will the country's movements go from now on?

By taking measures such as reducing person-to-person contact by 80%, which made central Tokyo empty, we were somehow able to settle the first wave for the time being. By doing so, I believe we were able to buy time to particularly prepare the medical system.

However, taking such measures again would likely face strong social resistance and would be difficult from an economic perspective. Also, while borders are currently mostly closed, we cannot continue a state of no interaction with overseas for very long.

On the other hand, measures to achieve so-called herd immunity still seem to take time and might be difficult in one or two years. Considering that, future countermeasures are quite difficult.

One major policy is to raise the level of the medical and public health systems. By doing so, we will broaden the range of what is socially acceptable regarding this epidemic. Specifically, we will improve the treatment system for severely ill patients. Also, the development of therapeutic drugs is very important. If treatments or pharmaceuticals that make it harder to become severely ill are developed, social tolerance for this epidemic will naturally increase.

In terms of the public health system, we have been conducting cluster countermeasures, but I think we can increase social tolerance by monitoring the actual state of the epidemic as much as possible in real-time.

Also, in terms of infection countermeasures, by understanding in what situations cluster infections are likely to occur, I think we can take smarter infection countermeasures. By doing so, I hope we can increase social tolerance for events that gather large numbers of people and return to something closer to our previous lives. I think this is the general thinking of the country.

Among the world's COVID-19 cases so far, are the characteristics of the superspreaders you pointed out earlier understood?

Regarding superspreaders, I think there are two elements: people who shed a large amount of virus, and environments where it is easy to infect many people. Currently, while there are reports that elderly people shed more virus, there are also young people who are asymptomatic but shed a lot of virus. There are parts of its true nature that are still unknown.

In terms of an "environment where it is easy to infect," we have been talking about Three Cs countermeasures, and I think this is exactly the essence. There is a possibility of infecting others during conversations even when asymptomatic or without coughing, and this is the most difficult part. Because there are modes of infection that are difficult to avoid consciously, many people get infected. I think that is the kind of place the Three Cs represent.

In terms of the environment, the ease of infection has become understood. On the other hand, it is still unknown what kind of individuals have a high viral load at the individual level.

Is there a global consensus on whether the ease of infection or viral load depends on the type of virus, such as the Wuhan type or the European type? I believe there is data suggesting that viruses with the G614D mutation are the European type and are easier to infect.

I believe there is not yet clear evidence that can explicitly link viral mutations with ease of infection in the current epidemic situation.

Listening to Dr. Saito, I thought that what happened at Keio University Hospital was exactly these two typical examples. One was a case where a relatively elderly person with weakened immune function developed symptoms all at once and infected roommates around them.

Then, in the case of the residents, the source was community infection, but after that, the infection spread through group living in the residents' room, etc., and then spread all at once at a dinner party. I have the impression that we experienced the typical superspreader and cluster infection in an environment easy to infect that Dr. Saito mentioned.

On the other hand, there were many cases where people remained completely asymptomatic and did not pass it on, and how to distinguish that is a challenge. Clinically, I feel that is something I really want to know from now on.

It is clear that if there is a superspreader in an environment where it is easy to infect, infection will occur, so the most important thing is to avoid the so-called Three Cs and not create environments where it is easy to infect or be infected.

Another issue for the future is the testing system. What kind of testing should we do to live while reducing the risk of infection in the with-Corona era?

Currently, various tests are being conducted. First, there are methods to detect that someone is infected by detecting viral genes using the PCR method and methods to detect viral proteins using the antigen-antibody method. Furthermore, regarding methods to detect antibodies that show someone was infected, various ones with different sensitivities and specificities are on the market. How to use these while their simplicity, time required for detection, and sample processing methods differ is a very big discussion.

Of course, since the processing capacity of tests is increasing, I think we have become able to grasp the actual situation by conducting tests more widely, moving away from the previous direction of "finding by narrowing down targets as much as possible."

While that is a discussion from a public health perspective, how to use testing in places that must be protected as infrastructure, such as medical sites and for healthcare workers, is a separate issue.

Regarding testing methods based on antigen-antibody reactions, there are reports that sensitivity is not necessarily good, but I think risk can be reduced by identifying people with high viral shedding at least at the time of the test. I believe it is necessary to think about what purpose to use them for within field operations.

It means creating the most efficient testing system while dividing the locations and targets to some extent depending on the testing method. It is nonsense to do PCR on all cases every day; it costs too much and is not realistic. In places where risk must be avoided and results are needed quickly, for example, there might be a method to do it in a short time with a simple antigen test.

Since our hospital pioneered pre-admission PCR screening nationwide, many hospitals in Tokyo adopted this method. However, some hospitals think it is not necessary in the current situation, and it was not introduced much in hospitals outside the metropolitan area. However, I believe Tokyo, especially Shinjuku Ward, is a completely different environment from other places.

Keio University Hospital also cooperates in conducting PCR tests daily at the Shinjuku Ward PCR testing spot, and the positivity rate there is 30% to 40% as of today (July 1). Since we are practicing in such an environment, I believe we should continue to rapidly conduct pre-admission PCR, PCR when staff show even slight symptoms, or PCR when outpatient patients complain of feeling unwell.

Regarding antigen tests, they are currently certified to have almost the same sensitivity as PCR for several days from the stage symptoms appear, but verification is needed from now on. At the current stage, in our environment, we cannot treat someone as negative without confirmation of a negative result by the more sensitive PCR. Of course, even this is not 100%.

Since Keio University Hospital is a university hospital located in Shinjuku Ward and has experienced in-hospital infection, we will maintain a defense system based strictly on PCR testing for a while. However, if efficient and sensitive antigen tests emerge in the future, I think it will be necessary to also perform antigen tests for those with sudden changes in the emergency department, those who must undergo surgery immediately, or pregnant women whose delivery is imminent, to respond quickly.

The background for requiring patients to test negative via PCR before admission is that when we performed PCR on pre-admission patients at the beginning of April, the positivity rate was as high as 3.3%, and it reached 7.3% in the following week.

That was the third week of April. It coincides with the peak of infections in Tokyo. However, since then, there were zero positive cases in May and June, and if we total the screened patients, the current positivity rate is about 0.3%. This almost matches the antibody positivity rate in the Tokyo metropolitan area, so we can infer that the high screening PCR positivity rate in April reflected the community transmission situation at that time.

While the hospital is testing rigorously like that, how should we utilize testing for COVID-19 as educational and social activities become more active in the future at educational sites across Keio University as a whole or in general companies?

The School of Medicine alone has about 600 people, but for students across the entire Juku, the number is in the tens of thousands. Moreover, considering how to prevent cluster infections on campus while various daily lives are being led, the first step is to have each individual take infection prevention measures.

I think it is realistic to have people measure their body temperature every day, report any poor health conditions, and take measures. After adapting lifestyle standards for infection control, including dining out off-campus, they should contact the Health Management Center if they have symptoms such as a fever.

When faculty members face many students in class, there is the question of how to protect faculty and staff if there are students infected with COVID-19 at a certain risk level.

In that regard, there is an opinion that testing might reveal the risk to some extent, but the important thing is to thoroughly implement the basic principle: first, faculty, staff, and students must accurately monitor their temperature and physical condition, and if there is an abnormality, they must not come to campus.

If we completely ignore the issue of resources, there is the idea of performing PCR tests on a daily basis to always maintain a clean environment. The German soccer league is doing PCR twice a week.

However, in a place with so many people like a university, and considering resources, I think health monitoring will be one major pillar. I believe we must get through this long battle by observing the two major principles: "not getting infected" and "not infecting others."

Currently, at the School of Medicine, all students, faculty, and staff are required to take their temperature daily and enter it into a site called "keio.jp," which everyone associated with Keio has access to. This is then checked by a third party, and if someone has a fever, they are told not to come to the hospital or the School of Medicine.

Yes. It is a system where you enter your body temperature into "keio.jp" every day, and if it is 37.5 degrees Celsius or higher, a notification is automatically sent to the administrator and the Health Management Center. I believe that by utilizing this effectively, it is realistically possible to detect clusters or collective fevers early and take action.

Is the next step to expand this system across the entire Juku?

Yes, since this system itself can be expanded across the entire Juku, I believe it will become a management system that can properly handle responses for the whole Juku.

Dr. Saito, there is a lot of talk about "nightlife-related" cases now. Why does infection spread in restaurants with entertainment services (host clubs, cabaret clubs, etc.)?

There were nightlife clusters in Tokyo around March as well. Essentially, as an industry, it is difficult to thoroughly implement measures such as wearing masks while serving customers or talking from a distance. If people are talking while drinking, they might leave their masks off. Even if the shop takes measures, there is the issue of whether customers will follow them. As a service industry, it might be difficult to speak up. I think various difficult conditions like these are overlapping.

Also, people in those industries may not go to the hospital easily, or even if told they shouldn't work, they might find it hard to say they can't come in, or they might not be able to refuse due to income reasons. Furthermore, even if asked about their workplace or activity history in a survey, it can be difficult to find out that they went to such a shop for a drink or work there. Therefore, there are elements that make the actual situation very hard to see.

I think it is more accurate to say that rather than a specific act there being particularly dangerous, there is a complex situation where danger is hard to avoid and intervention is difficult.

Conversely, quite a bit of this information is circulating, and I think we need to be careful about the sense of security that "it might be safe if I don't go to the nightlife districts." Even if you lead a normal daytime life, if there are infected people in the community and you come into contact in a "Three Cs" (Closed spaces, Crowded places, Close-contact settings) environment, there is a risk of infection.

Yes. Also, there is the route of contact infection, and while everyone is gradually forgetting the necessity of washing hands, I think this is also very important.

How to return the hospital to its original state in this "With Corona" era is a very big challenge. Dr. Kitagawa, what are your thoughts?

We have had a difficult experience and learned many things. Within that, I believe the treatment strategy was optimized by a team that united the intensive care team, respiratory infection professionals like those in respiratory medicine, and experts in immune diseases like Dr. Takeuchi. If such a phase comes again, I believe we can provide the best treatment—not only saving lives in severe cases but also preventing moderate cases from becoming severe, or mild cases from progressing to moderate.

On the other hand, it is important how to quickly control it when an in-hospital infection occurs. While groping in the dark, I encountered many situations where I was forced to make major decisions, and I myself learned a lot. What I think is important now is how to get through such occurrences while minimizing the reduction of hospital functions.

We will zone the hospital and divide the medical teams into several groups, clearly deciding the places where those teams operate and the patients they are responsible for, to create a system that prevents major damage. Furthermore, I think it is very important to level out the medical care system and provide the same level of care without creating crowds.

Regarding defense, we have lowered the hurdle for PCR testing and are performing it quickly and broadly. We maintain a system where faculty and staff visit the Health Management Center even for very minor symptoms, always undergo a PCR test, and return to work only after confirming a negative result. Even so, community transmission may appear among outpatients and faculty/staff in the future.

It is important to thoroughly implement a lifestyle that does not create close contacts, so that even if community transmission occurs, it stops with that one person. And even if an in-hospital infection should occur, we will keep it small-scale and maintain medical functions. Within that, we want to provide the advanced medical care that we should originally perform as a university hospital to everyone, while also providing appropriate treatment for patients infected with COVID-19. I want to move forward by balancing these two.

One thing I would definitely like to add regarding the future hospital system is that Keio Hospital currently has complete infection control and is a safe hospital space.

This is the result of Hospital Director Kitagawa's leadership. Moreover, there has not been a single case of infection from a patient known to be infected to a healthcare worker. There were cases where healthcare workers were infected through community transmission, but not a single secondary infection occurred from them. In other words, if standard precautions are taken and lifestyle precautions are observed, infection can be controlled.

We have received a very powerful message. What I want the readers of Mita-hyoron (official monthly journal published by Keio University Press) to understand is that if people refrain from seeking medical care, there is a possibility that diseases other than COVID-19 may worsen. It is dangerous to think that you should wait until the COVID-19 crisis has passed to see a doctor. If there is a reason to go to the hospital, please do so just as before. I hope you will consider that Keio University Hospital and the School of Medicine are working together to provide your medical care.

Dr. Saito, according to recent reports, excess mortality has increased significantly more than usual in both the US and the UK. I think that is not just the mortality rate from COVID-19 itself, but also the overlapping effect of refraining from hospital visits due to COVID-19.

Excess mortality includes deaths indirectly affected in that way, in addition to deaths caused by COVID-19.

In Japan, excess mortality has been kept much lower than reported in the US or the UK, and I think it is just about the amount of people who died from COVID-19 added on. I believe the hospitals have handled the COVID-19 response that well.

From now on, we must ensure that excess mortality does not rise for other diseases because people refrained from hospital visits.

I think the battle to control this virus will last for years. At the School of Medicine, basic and clinical research is being conducted from various perspectives through the Donnel Project explained by Dr. Saya, so I hope you will support those activities. When results are achieved, I would like to share them with everyone in various forms.

I believe that the fact that Keio Hospital and the Shachu were able to work together as one, integrating everything from basic research to clinical practice for treatment and research, was a major achievement despite the difficult situation.

In the future, I hope to further develop these results while collaborating with doctors outside Keio Hospital, including alumni. I think it would be good to take this opportunity to build even stronger relationships with those outside the hospital while actively incorporating new tools, such as utilizing online medical consultations, which are currently in urgent need of widespread adoption.

It would be great if Keio's results continue to emerge, but even so, for example, vaccine development or drug development has many competitors and requires enormous research funds; it is not easy without an organization to support it. I feel that within Keio, we must train more infectious disease experts, virus experts, or vaccine development experts in the future.

Having received this damage, we have come to realize that we potentially underestimated infectious diseases. Perhaps there was a selfish assumption that we could win against infectious diseases. Because of that, I feel we have taken a major blow.

When I contacted the cancer center in Houston where I used to work, they said that because it was so widespread, they couldn't even perform cancer care sufficiently, and it would take several years to recover from this damage. Even the US was like that. Fortunately, we managed to get through the first wave, so to avoid following in those footsteps, the first thing is to cooperate with the current system to stop the second and third waves.

At the same time, considering the possibility of various infectious diseases becoming prevalent in the future, shouldn't we take measures during normal times? I believe it is necessary to enhance staff and systems, or to create SOPs (Standard Operating Procedures) using this experience as a lesson.

Considering that droplet infection when eating is significant, there are times when the virus is considerably contained in saliva when infectivity is strong. PCR from saliva is not yet generalized, but I am also thinking that I definitely want to properly prepare during this period so that testing can be done with saliva.

Regarding testing and treatment, I believe it is also our duty as researchers to quickly obtain information from around the world and to aggregate and provide the most advanced and useful information.

There are many people within Keio who are interested in infectious diseases, and in basic fields, there are many professors doing world-leading basic research, so I think it would be best if we could consolidate these strengths and contribute in some way.

Seeing various projects start up immediately this time, I thought, "That's Keio for you."

On the other hand, infectious disease research itself is an industry that does not receive much attention even within Japan. When you look at how many researchers actually handle pathogens, how many further handle animal experiments, and how many go out into the field to do epidemiological research or clinical development of vaccines, I think there are areas where we are shorthanded.

When a pandemic like this occurs, interest rises temporarily, but it is quickly forgotten once the danger has passed. I hope that society will once again recognize the necessity of long-term enhancement of crisis management for infectious diseases and the research systems for them.

Finally, Dr. Saito, do you have any message for the members of the Shachu?

One thing I definitely want to say about in-hospital infections is that risk reduction—doing tests and ensuring the virus absolutely does not enter the hospital—is very important. On the other hand, I think it is conversely dangerous to move toward a zero-risk mindset, thinking that because we are doing this much testing, there shouldn't be any infected people here, or that there must not be any infected people.

I think it is important to have a mindset where we assume that infected people will appear in the hospital no matter how hard we try, and then consider measures in the direction of how to prevent it from spreading there. I believe this is very important not only for Keio Hospital but also for related hospitals.

Also, from now on, I think society as a whole must consider a society where it is hard to catch COVID-19, or where it is hard for it to spread even if caught. Do we really have to gather to work? Does everyone always have to take vacations at the same time? Do we really all have to live in the city? I think this will be an opportunity to think about ways of living, including from such a broad perspective.

Thank you. That is a very important point. At Keio Hospital, the floors would always be full of patients at 8:30, and medical care would reach its peak in the morning. The challenge is to level out this bias in time and days of the week across the morning, afternoon, and evening.

I think it is also important for doctors and staff to level out their working styles as much as possible. Society as a whole may be required not to concentrate in one place, but for individuals to decide their own work styles. It will truly be about independence and self-respect—thinking for oneself, working in one's own way, and also enjoying oneself.

Thank you very much for the active discussion today despite your busy schedules.