The health ministry on Monday released guidelines for people who fear they have been infected with COVID-19 as officials said 99 more aboard the Diamond Princess cruise ship, including 43 Japanese citizens, had tested positive.

The newly identified people raised the total toll from the vessel to 454. A total of 3,711 passengers and crew were originally aboard the liner, but the total has dropped to about 3,100 as many elderly were allowed to disembark and some were transported to a hospital on land.

Meanwhile, many public events have been scrapped or scaled down due to fears of an epidemic.

The government issued the guidelines — which cover issues like when to get checked at a hospital — after experts said the coronavirus outbreak in Japan had entered a new phase, spreading among residents not directly linked to China.

Medical workers are concerned that large numbers of people suffering from cold-like symptoms, whether or not they are infected with the coronavirus, will flood hospitals and strain resources.

The guidelines urge people to stay home if they have symptoms. If symptoms grow serious, they are advised to call a special consultation center set up by the government.

“How patients go see a doctor is a crucial factor,” Takaji Wakita, the head of the National Institute of Infectious Diseases, said Sunday. “What we’ve come to know so far is there are many who only went through mild symptoms. … Those with mild symptoms are advised not to visit an outpatient doctor but call the consultation center.”

The guidelines advise that people seek a consultation if they have a fever of 37.5 degrees or above for four days or more, experience difficulty breathing or feel severe drowsiness. Medical staff at the center will then advise which hospitals a caller should visit for treatment.

If a person is elderly or has certain pre-existing conditions like diabetes, heart problems or respiratory diseases, or is undergoing dialysis or is taking an immunosuppressive or anticancer drug, they should call the center if symptoms continue for two days or more.

Health minister Katsunobu Kato urged those who have cold-like symptoms like a fever to stay away from school and work, and to check their temperature every day.

“This guideline presents under what kind of situation an individual should consult with (a consultation center) or go see a doctor at an appropriate time,” Kato said, adding the guideline is only “a criterion for reference.”

“In this way, necessary people, including people with high risks, are able to receive treatment at an appropriate time to prevent their conditions from getting worse,” he said.

Kato also said the virus testing capacity in Japan has been increased, noting that more than 3,000 samples can be tested daily.

The daily pace of new patients being reported did not slow down Monday.

In addition to the new case on the cruise ship, officials in Kanagawa Prefecture said a nurse in her 40s tested positive for the coronavirus. She was working at Sagamihara Chuo Hospital, where a woman in her 80s who tested positive had been hospitalized. The woman died last Thursday. Her son-in-law, a taxi driver in his 70s in Tokyo, was also infected with the coronavirus.

The nurse developed a fever Friday and was diagnosed with coronavirus Sunday. The hospital has stopped accepting outpatients and visiting inpatients.

The health ministry also said one of its officials in his 50s involved in dealing with the Diamond Princess tested positive. NHK reported that the official was in charge of collecting information onboard the ship and serving as a liaison during the quarantine between last Tuesday and Saturday.

The official said he believes he didn’t have close contact with passengers and crew members on the ship, according to the health ministry. However, while he was wearing a mask while working aboard the ship, he took it off when he ate a meal with other officials.

An official in Wakayama Prefecture said four more people were confirmed positive on Monday. Three are family members of those already infected at a hospital, but one person had not visited the hospital. Last week, a surgeon in his 50s who worked at the hospital tested positive for the virus.

The outbreak has begun to have ripple effects across the nation.

Worried about potential mass infection, the Imperial Household Agency on Monday canceled the general public’s visit to the palace in celebration of Emperor Naruhito’s birthday on Sunday. It would have been the first public visit on his birthday since his enthronement last year.

Organizers of the Tokyo Marathon, slated for March 1, dropped the general entry section, limiting participation to elite runners.

The government has already advised the elderly and those with pre-existing conditions to avoid crowded areas, but it has not officially requested that mass gatherings such as concerts be called off.

Prime Minister Shinzo Abe said the government will continue to work closely with municipalities, saying that 536 consultation centers dedicated to the outbreak will be operating 24/7 and that hospitals that can deal with coronavirus patients will be increased from about 700 to 800.

Meanwhile, a government-produced television commercial about the coronavirus started airing Monday.

“We’re going to go do all out to work on preventing the coronavirus from spreading to protect Japanese lives and health,” Abe said.

A fifth charter flight to bring home 65 Japanese citizens and Chinese with close ties to them returned to Tokyo from Wuhan, the outbreak’s epicenter, on Monday morning. Two people aboard the flight reportedly did not feel well upon arrival.

Information from Kyodo added

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