TOKYO — As the number of COVID-19 cases surges in Japan, the country’s roughly 470 public health centers are under strain once again as they struggle with growing demand for testing, tracing and monitoring of the coronavirus.

“The volume of new patients now is far higher than that of the first wave,” said Masahiro Yamada, head of the Chuwa Public Health Center, located in a commuter town southeast of Osaka. There are enough beds for confirmed COVID-19 patients. But for suspected cases, “allocating medical services and drive-thru PCR testing is very hard,” Yamada said.

Japan’s daily caseload remains high, with 1,085 new infections reported Thursday. While the center of the outbreak in Japan has long been Tokyo, the virus has spread to other cities and prefectures. Nara’s 37 reported cases on Tuesday was a record for the prefecture.

The Chuwa center has been on the front line of Japan’s fight against the novel coronavirus since the first Japanese patient in the country was identified in January in Nara. Public health centers take calls from residents and clinics, arrange for testing, investigate infection pathways in confirmed cases and monitor the health of people who come into contact with those who are infected.

With fewer than 20 people handling the coronavirus response at the Chuwa center, staff hardly get a break these days. They sometimes work past midnight and on the weekends. With no clear end in sight for the pandemic, “it will be difficult to go on without [a means of] sustainable operation,” including manpower, said Yamada.

Little known among the public before the pandemic, Japan’s public health centers were set up in 1937 to deal with public health problems such as infectious diseases, particularly tuberculosis. These institutions help to explain how Japan has managed, at least initially, to contain the pandemic even with little past experience of recent epidemics in Asia, such as SARS or MERS.

The first Japanese person in Japan who tested positive for the coronavirus was a bus driver who transported tourists from Wuhan, the central Chinese city that was the epicenter of the pandemic.

The driver had typical cold symptoms, but for an unusually long period of 10 days. He was not considered a suspected case under the health ministry’s guidelines at the time because he had not been in Wuhan or come into contact with a person known to have the disease. But the clinic he visited reported his case to the Chuwa center, as clinics usually do for illness that can affect the public health, such as dengue fever, tuberculosis or food poisoning. After testing negative for several diseases including influenza, mycoplasma pneumonia and respiratory syncytial virus, the bus driver tested positive for the novel coronavirus.

“I did not imagine that the first case would be from Nara,” which is not a big city, said Yamada. The Chuwa center created a list of the bus driver’s close contacts based on the procedures used for tuberculosis infections.

When infections first peaked around April, while PCR testing capacity and hospital beds were still in short supply, public health centers came in for criticism. They were responsible for deciding who was tested, given the capacity constraints. “I think we tested those who needed to be tested the most from the very beginning,” said Yamada. “We made sure that [the system] did not collapse even with the lack of PCR testing, and protected those whose symptoms were becoming severe,” he said.

Staff members take calls from residents and clinics in May at a public health center in Tokyo.  (Photo by Hirofumi Yamamoto)

Toshio Takatorige, a professor of public health at Kansai University in western Japan, argues the country’s public health centers have helped to prevent infections from spreading in hospitals. But he also suggests Japan was fortunate to have public health professionals on the ground when COVID-19 struck.

The number of public health centers has fallen sharply in recent decades, from 850 in 1990 to 469 in 2020, according to the Japanese Association of Public Health Center Directors. As Japan followed the example of countries such as U.S., focusing more resources on advanced treatments and vaccines, public health centers were seen as less important. Meanwhile, discussions on handing over responsibility for outbreaks of infectious disease to hospitals, and setting up systems to support them, were still ongoing when the coronavirus came to Japan’s shores.

Public health centers have had staying power because of lingering cases of tuberculosis and renewed concerns, such as SARS and new strains of influenza, according to Takatorige. “Having a large medical research institution is not effective in combating new infectious diseases,” he said.

But with the number of COVID-19 patients climbing as people return to work, people are coming into greater contact with one another, multiplying possible infection routes. And as more tests become available, the burden on public health centers may reach the breaking point.

There were about 35,500 active public health nurses in Japan in 2019, but raising that number quickly is difficult. Public health nurses also have a wide range of duties, including dealing with suspected cases of child abuse, preventing “lifestyle diseases” such as diabetes and looking after people’s mental health. “Japanese medical institutions will now face a real test,” said Takatorige.

“I think it would be good if more hospitals can test suspected [coronavirus] cases on site,” rather than going through the time-consuming process of consulting with the public health centers, said the Chuwa center’s Yamada. “As we approach autumn and winter there will be many patients with symptoms that could either be flu or COVID-19,” he said.