Earlier this year, a quiet outbreak of rubella began to sweep Japan.

Over 1,300 people — mainly men in their 30s and 40s — have been diagnosed with the virus as of early May.

But why should such a specific demographic be falling victim to rubella?

From 1977 to 1995, the government mandated that only female junior high school students should receive rubella vaccines. From 1995 onward, boys as well as girls aged between 12 months to 90 months became subject to the vaccination, but some people, especially boys who were junior high school students at the time, fell through the cracks of the policy change. Vaccination coverage among that group is estimated to hover around the 50 percent mark, according to a report published by the health ministry in 2002.

This is just one of a number of governmental vaccination policies that led Japan to earn itself a reputation as a “vaccine backwater.”

Japan gained that name from the mid-1990s to the early 2000s because it barely introduced new vaccines, widening the so-called vaccination gap between itself and other countries, including the U.S., which continued to introduce new vaccines to the market.

The vaccination gap decade was followed by a rush to close it, and the country’s vaccination policy has seen major changes over the years. Yet some believe there are still systemic gaps in governmental policy that have left the nation vulnerable to small, sporadic outbreaks of preventable diseases.

“In terms of vaccination policy, Japan is not a backwater anymore, but it isn’t a leading nation either,” said Tetsuo Nakayama, a project professor at Kitasato Institute for Life Sciences.

Unlike the vaccination gap decade, the government’s list of recommended vaccinations has been updated and is currently in keeping with that of the World Health Organization.

But a closer look at the list reveals the reason some would say Japan isn’t quite a role model when it comes to this area.

The list is separated into two smaller lists — one of “routine” vaccinations that are subsidized by the government if they are taken within a designated time frame, and “voluntary” vaccinations that parents must foot the bill for and are merely recommended.

“Having a list of ‘voluntary’ vaccinations sends the message that these vaccinations aren’t really necessary,” explained Hiroyuki Moriuchi, a professor at Nagasaki University who is an expert on vaccines.

That separation between routine and voluntary vaccines affects vaccination rates, said Nakayama.

Such rates in Japan for routine vaccines are among the highest in the world, in some cases reaching north of 95 percent. But in stark contrast to that, rates for voluntary vaccines are much lower.

For example, vaccination rates in 2011 for haemophilus influenzae type b and pneumococcus, which were voluntary at the time, were 53 percent and 43 percent for those 18 months old, respectively, while the figure in the U.S. was 90 percent and 92 percent, according to a report published by researchers at the University of Hawaii in 2014.

Yet vaccination rates have soared since both vaccines were put on the routine list of vaccines, with coverage reaching over 97 percent for toddlers under 12 months old, according to a report published by the National Institute of Infectious Diseases in 2017.

Low vaccination rates for voluntary vaccines are exacerbated by the fact that the cost burden is borne by the parents, said Moriuchi.

Wealthy municipalities, such as Shibuya Ward in Tokyo, have the means and money to subsidize voluntary vaccinations. But otherwise, the financial onus of voluntary vaccines shifts to individuals, especially for those who reside in municipalities that aren’t as well-off.

However, some believe Japan should be scaling back on encouraging everyone to get vaccinated.

“Japan is not a vaccination backwater,” said Hiroko Mori, former head of the infectious diseases department at the National Institute of Public Health and author of the Guidebook on Vaccines for Children and Parents.

Vaccination policy in Japan should be changed so that “those who want to get immunized can get immunized, and those who don’t want to aren’t forced into it,” Mori said, adding that the current discussion around vaccinations lacks nuance and there is too much pressure for everyone to get vaccinated.

“Some of these diseases may have been devastatingly fatal in the past, but we live in a day and age where they aren’t nearly as fatal … especially with the high standards of health here, it’s not necessary for everyone to be forced into getting immunized against all such diseases,” she said.

Instead, vaccinations should be done sparingly and effectively, such as immunizing pregnant women against rubella to prevent the birth of infants with congenital rubella syndrome, she said.

Mori believes that instead of having routine and voluntary vaccines, the government should make all vaccines voluntary and free of charge to everyone, so that individuals can have the choice to get the vaccinations they want, when they want.

The WHO, however, states that it is important, even with advanced nations’ higher levels of hygiene, sanitation and nutrition, to maintain optimum rates of immunization, or “herd immunity,” to prevent the diseases prevented by vaccination from returning.

The current system of separating routine from voluntary vaccines stems from the government’s bitter history of losing lawsuits from those who had suffered from the adverse effects of vaccines, as well as changes in public perceptions of vaccines.

In one emblematic case, Japan introduced the MMR (mumps, measles and rubella) combined vaccine in 1989, but after reports of adverse side effects, the public began to raise concerns about the vaccination and it was discontinued in 1993.

Although the side effects themselves were in some cases relatively severe, they were not widespread and some unrelated cases were counted as instances of the side effects, explained Moriuchi.

“It all became the vaccine’s fault though,” he said, adding that “the government’s vaccination policy and the public’s perception of vaccinations consolidated due to the MMR issue.”

In addition to changes in public perceptions following reports of the side effects of the MMR vaccine, the government also lost several lawsuits during the 1980s and 1990s regarding adverse reactions to vaccines.

The government overhauled the Vaccination Act in 1994, making vaccinations an individual responsibility instead of a social obligation, and therefore shifting responsibility from the government onto municipalities and individuals.

The government also began to take a more cautious approach to introducing and promoting new vaccines — which created a decade where new vaccines were barely introduced into Japan.

Nakayama believes that individuals need to educate themselves on vaccination issues so that they won’t fall into “vaccination hesitancy” — where people who don’t have strong opinions on vaccinations fail to vaccinate themselves or their children.

On top of structural, government-level changes, “what’s most important is for individuals to cultivate a good sense of judgment based on sound, scientific knowledge, so that they will be able to differentiate accurate information from misinformation,” he said.

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