The Marked Contrast in Pandemic Outcomes Between Japan and the United States

Eric Topol, MD


October 11, 2022

This article was originally published October 8 on Medscape Editor-In-Chief Eric Topol's "Ground Truths" column on Substack. 

A piece in The Economist this week about masks, and how at least half of the people in Japan are planning to continue to use masks indefinitely (where there was never a mandate), prompts a deeper look into what has been the secret of Japan's extraordinary success in the pandemic. Over time it has the least cumulative deaths per capita of any major country in the world. That's without a Zero-Covid policy or any national lockdowns, which is why I have not included China as a comparator.

Before we get into that data, let's take a look at the age pyramids for Japan and the United States. The #1 risk factor for death from Covid is advanced age, and you can see that in Japan that ~25% of the population is age 65 and older, whereas in the United States that proportion is substantially reduced at 15%. Sure there are differences in co-morbidities like obesity and diabetes, but there is also the tradeoff of a much higher population density in Japan.


Besides masks, which were distributed early on by the government to the population in Japan, there was the "Avoid the 3Cs" cluster-busting strategy, widely disseminated in Spring 2020, leveraging Pareto's 80-20 principle, long before there were any vaccines available. For a good portion of the pandemic, the Ministry of Foreign Affairs of Japan maintained a strict policy for border control, while hard to quantify, may certainly have contributed to its success.


Besides these factors, once vaccines became available, Japan got their population with the primary series to 83% rapidly, even after getting a late start by many months compared with the United States, which has peaked at 68%. That's a big gap.


But that gap got much worse when it came to boosters. 95% of Japanese eligible compared with 40.8% of Americans have had a booster shot. Of note, that 95% in Japan pertains to the whole population. In the United States the per cent of people age 65+ who have had 2 boosters is currently only 42%. I've previously reviewed the important lifesaving impact of 2 boosters among people age 65+ from 5 independent studies during Omicron waves throughout the world.


Now let's turn to cumulative fatalities in the two countries. There's a huge, nearly 9-fold difference, per capita. Using today's Covid-19 Dashboard, there are cumulatively 45,533 deaths in Japan and 1,062,560 American deaths. That translates to 1 in 2,758 people in Japan compared with 1 in 315 Americans dying of Covid.


And if we look at excess mortality instead of confirmed Covid deaths, that enormous gap doesn't change.


Obviously it would be good to have data for other Covid outcomes, such as hospitalizations, ICUs, and Long Covid, but they are not accessible.

Comparing Japan, the country that has fared the best, with the United States, one of the worst pandemic outcome results, leaves us with a sense that Prof Ian MacKay's "Swiss cheese model" is the best explanation. It's not just one thing. Masks, consistent evidence-based communication (3C's) with attention to ventilation and air quality, and the outstanding uptake of vaccines and boosters all contributed to Japan's success.


There is another factor to add to that model—Paxlovid. Its benefit of reducing hospitalizations and deaths for people over age 65 is unquestionable.


That's why I had previously modified the Swiss cheese model to add Paxlovid.


But in the United States, where 15% of the population is 65 and older, they account for over 75% of the daily death toll, still in the range of 400 per day. Here, with a very high proportion of people age 65+ left vulnerable without boosters, or primary vaccines, Paxlovid is only being given to less than 25% of the eligible (age 50+), and less people age 80+ are getting Paxlovid than those age 45. The reasons that doctors are not prescribing it —worried about interactions for a 5-day course and rebound—are not substantiated.

Bottom line: In the United States we are not protecting our population anywhere near as well as Japan, as grossly evident by the fatalities among people at the highest risk. There needs to be far better uptake of boosters and use of Paxlovid in the age 65+ group, but the need for amped up protection is not at all restricted to this age subgroup. Across all age groups age 18+ there is an 81% reduction of hospitalizations with 2 boosters with the most updated CDC data available, through the Omicron BA.5 wave


No less the previous data through May 2022 showing protection from death across all ages with 2 boosters


And please don't forget that around the world, over 20 million lives were saved, just in 2021, the first year of vaccines.


We can learn so much from a model country like Japan. Yes, we need nasal and variant-proof vaccines to effectively deal with the new variants that are already getting legs in places like XBB in Singapore and ones not on the radar yet. But right now we've got to do far better for people getting boosters and, when a person age 65+ gets Covid, Paxlovid. Take a look at Chris Hayes video segment from yesterday when he pleaded for Americans to get a booster shot. Every day that vaccine waning of the US population exceeds the small per cent of people who get a booster, our vulnerability increases. If we don't get that on track, it's likely going to be a rough winter ahead.


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