Japan is becoming a center of concern as the coronavirus spreads globally, with the country’s official infection tally suspected to be the tip of the iceberg of a much wider outbreak.

As of Monday afternoon, Japan had 263 confirmed cases of the pneumonia-causing virus, excluding those from the Diamond Princess cruise ship quarantined for weeks in Yokohama bay. In neighboring South Korea, however, infections have swelled rapidly, reaching more than 4,000 after the government tested tens of thousands of people to get a clearer picture of the deadly outbreak.

That divergence has experts — and members of the public — concerned about Japan’s approach to diagnosis.

“For every one who tests positive there are probably hundreds with mild symptoms,” said Masahiro Kami, chair of the Medical Governance Research Institute in Tokyo, and a practicing doctor. “Those with mild symptoms are not being tested.”

While the government says it has the capacity to do 3,800 tests a day, only 5,700 were actually carried out from Feb. 18 to 23, health minister Katsunobu Kato told the Diet on Wednesday. That included the tests on all aboard the Diamond Princess, where Japan’s attempt to quarantine the ship resulted in an explosion of more than 700 infections.

No bans

Japan’s low level of confirmed infections has enabled Prime Minister Shinzo Abe to maintain a relatively relaxed stance on the outbreak compared with South Korea and China, where more than 80,000 cases and over 2,900 deaths have been recorded.

Unlike other countries in the region, Japan has only imposed partial bans on people from highly infected nations — including China — and Abe has encouraged, but not enforced, the cancellation of major public events. Despite the government’s request for people to work remotely from home or stagger their commutes, however, many in Tokyo continue to board packed trains. As public criticism mounted, Abe last week asked all schools to temporarily close, starting Monday.

“In order to grasp the current situation, we should test,” said lawmaker Kazuhiro Haraguchi of the opposition Democratic Party for the People. “Tests are not 100 percent reliable, but we need to know the facts.”

Kato said public health centers had refused to test some people for the virus, probably because they were concerned they didn’t have sufficient capacity.

Japan has already come under fire for not testing the Diamond Princess passengers more extensively, with at least five Japanese testing positive for the virus after being sent home after testing negative. They had used public transport and spent time in public after disembarking.

There’s also rising anxiety over the number of patients whose infection routes can’t be traced. For example, authorities haven’t yet been able to identify connections between those who got infected in Hokkaido, which had the biggest cluster of infections in Japan with 72 cases as of Sunday.

Unlike some other Asian countries, Japan didn’t see a widespread local outbreak during the SARS and MERS epidemics. That lack of experience may have left it ill-equipped for dealing with the novel coronavirus, which is thought to be more infectious than severe acute respiratory syndrome and Middle East respiratory syndrome, though less deadly.

Unlike South Korea and many other developed countries, Japan doesn’t have a center for disease control, meaning virus prevention and outbreak control is in the hands of bureaucrats from the health ministry, aided by a group of experts.

While there is a national benchmark for how testing for the virus should be undertaken, some cities and regions are applying different standards.

Approach criticized

Some public health centers — including in Tokyo, Nagoya and Wakayama Prefecture — say they haven’t had consistent supplies of test kits to meet requirements. Wakayama, which has 13 infections, is using its own parameters to decide when testing is needed.

Hospitals and clinics could also be concerned that if a case is confirmed on site, they’ll be forced to shut down for disinfection, according to opposition lawmaker Haraguchi, who wants the government to compensate operators in these cases.

Even a member of the government’s expert panel on the virus has criticized their efforts on diagnosis. Hitoshi Oshitani, a professor at Tohoku University Graduate School of Medicine, said last month that Japan’s initial efforts at testing were like using a pen light to hunt for a ping pong ball at Tokyo Dome.

The handling of the Diamond Princess quarantine has already undermined trust in the government’s ability to handle the crisis. About a fifth of the ship’s 3,700 passengers and crew have tested positive for the virus.

‘Get tested’

Kato told the Diet last week the government is working on a system to support the private sector to conducts tests so that more people can be tested for the virus.

With trust in authorities eroded, a broader testing regime is now needed to calm public unease, said Kenji Shibuya, director of the Institute for Population Health at King’s College London, and a former chief of health policy at the World Health Organization.

“Scientifically we should target and prioritize the patients,” he said by email. “But it is now beyond that — we are dealing with public fear, and to tackle it, we need to give people an opportunity to get tested.”

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