Japan beyond 3.11 Stories of Recovery

The Mystery of the Pneumonia Epidemic

This page is adapted from the original transcript of NHK’s TOMORROW, broadcast on July 28, 2014

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Disaster scenes

Three years ago (2011), a massive earthquake struck north-eastern Japan. Over 18,000 deaths and missing people were recorded in the quake, tsunami and fires.


Survivors who escaped the tsunami and were living in evacuation shelters were confronted with another imminent threat...


An outbreak of pneumonia.


“We all prayed no one else would get pneumonia and everyone would safely make it through this disaster.”
(Noriko Saito: Head Nurse)

A doctor

In some cases, pneumonia caused the death of patients. Local doctors worked around the clock to respond to the medical disaster.

Hospital bed

Why was there a pneumonia epidemic in areas hit by the tsunami? How did people cope with it?

Morley and Saito

American journalist Morley Robertson takes an in-depth look at the pneumonia epidemic.

The Mystery of the Pneumonia Epidemic

Kesennuma, Miyagi Prefecture, a city with a population of 70,000.

It was devastated by the tsunami.


Not many people know that in the aftermath of the disaster, 52 pneumonia-related deaths were recorded here.

Morley Robertson

After the disaster, Morley Robertson reported from the coastal areas of Miyagi Prefecture.


“Back then I was completely unaware that diseases such as pneumonia were rapidly spreading among the survivors of the disaster. It was just difficult to focus on the various details because there was so much debris, the Self-Defence Forces were at work and people were just focused on getting by each day.”
(Morley Robertson: Reporter)

Kesennuma City Hospital

Most of the pneumonia patients were brought here to Kesennuma City Hospital, the only general hospital in the city.

Inside the hospital

As the largest hospital in the city, it receives over 1,000 outpatients every day.

It is also the city’s designated disaster medical center, and it acted fast to respond to the disaster.

Morley and Okinaga

Morley visits Shoji Okinaga, one of the doctors who treated pneumonia patients here at that time.

“Was it a rapid increase?”

Shoji Okinaga: Pulmonologist

Shoji Okinaga: Pulmonologist

“Yes, within the first few days after the disaster the numbers steadily rose. And within one week, pneumonia-related patients were being hospitalized almost every day.”
(Shoji Okinaga: Pulmonologist)

“Did you think it would soon end?”

“Well, there were times when 5 or 6 people would be hospitalized in one day. The beds were filling up very quickly.”
(Shoji Okinaga)

NHK footage of the hospital

This NHK footage shows the City Hospital the day after the disaster. No one had ever dealt with a tsunami of such severity. Emergency patients were being admitted one after the other, and the number of people developing pneumonia was growing.

X-ray of pneumonia patient

Pneumonia is a serious illness that affects one or both lungs.

Infected lungs

The lungs are usually sterile. However, when bacteria and microbes infect the lungs and cause inflammation, it can develop into pneumonia.

Pneumonia can become life-threatening

Symptoms such as frequent coughing, production of mucus, and a high fever are seen in the early stages of pneumonia. If conditions worsen it can cause respiratory failure. Severe cases can result in death.

In Kesennuma City Hospital, there were cases of pneumonia-related deaths.


At the time of the disaster, there were only two pulmonologists at the hospital. Help from other departments was necessary to treat the pneumonia patients.

Shinji Okinaga

“There were so many cases that we had to ask other surgeons to help us. We worked together to manage the overflow of pneumonia patients.”
(Shoji Okinaga: Pulmonologist)


As the team continued treating the patients, they noticed a common factor. Most of the patients with pneumonia were brought from evacuation shelters.

Morley visits an former evacuation shelter

Morley heads to a site that was an evacuation shelter during the disaster.

Former evacuation centre

It’s a nursing home ten minutes away from the City Hospital by car.

Morley arrives

125 people, including the staff, lived here as evacuees during the disaster.

Noriko Saito

“Let me show you the bedrooms. Usually four residents sleep in one room, but during the disaster we had to put six people in each room. So we had three beds here and another three there. That was the situation for about one month after the disaster.”
(Noriko Saito: Head Nurse)


These photos taken shortly after the disaster show the crowded rooms. Regular residents and evacuees who came to take shelter lived together in the nursing home.


For a long time, there were shortages of electricity, water, and gas. The number of pneumonia patients increased in living conditions like these.

According to head nurse Noriko Saito, within 20 days of the disaster five people were taken from the nursing home to the hospital suffering from pneumonia. All five of them passed away.

Noriko Saito

“Of course, I really wanted everyone to recover and be able to come back here. We prayed that no one else would get pneumonia and that everyone would safely make it through this disaster.”
(Noriko Saito: Head Nurse)

Nurses and carers

Even though caregivers used extra precautions, they could not find a way to prevent the spread of pneumonia.

“We were overwhelmed and couldn’t figure out what the cause was.”
(Noriko Saito)


“Among the hard-hit weakened people, there was a high incidence of pneumonia. Doctors and health workers were faced with a crisis of unknown magnitude and so far I could trace back their sense of concern and maybe some panic right after the crisis, the disaster.”

Kesennuma, Miyagi Prefecture

Kesennuma, Miyagi Prefecture

In April 2011, one month after the disaster, Hisayoshi Daito, a doctor specializing in respiratory diseases, arrived in Kesennuma.

Hisayoshi Daito

Daito, who researches respiratory medicine at Tohoku University, was appointed to Kesennuma City Hospital to support the treatment of the rapidly increasing number of pneumonia patients.


As he worked on treating the patients, he began investigating the situation. Had there really been a rapid increase in pneumonia patients? Was it occurring only at this hospital? He realized research was necessary to throw light on the phenomenon.


“I’m curious to know, what motivated you to study this particular case?”

“In a disaster, the healthcare providers themselves are also victims. Medical resources are very limited. When resources are limited, we have to figure out what kind of medical services are actually needed in order to provide effective disaster medical care. That was the reasoning behind my study.”
(Hisayoshi Daito: Pulmonologist)


At the time, most of the pneumonia-related patients being hospitalized were adults. Daito conducted a survey focused on patients with severe pneumonia who were 18 years or older.


He started by figuring out the total number of patients hospitalized for pneumonia in Kesennuma in the past year.


He conducted surveys at other hospitals as well as at Kesennuma City Hospital. Two other hospitals in the city have the facilities to admit seriously-ill patients.

Motoyoshi hospital

Motoyoshi Hospital is located about one kilometer away from the coastline.

Motoyoshi hospital's first floor was flooded

Research here proved difficult as the first floor had been entirely flooded by the tsunami. Patient records and X-rays vital for the research had been damaged.


“How did you feel when Dr. Daito asked if he could do research here during the chaos of the disaster?”

Miwako Sasaki: Chief Nurse

“I thought, if there’s anything that could help his research here at our hospital, then please go ahead! We all really wanted to give him more help but we were just all so busy that we couldn’t.”
(Miwako Sasaki: Chief Nurse)

Daito and Sasaki

The hospital let Daito use the nurse’s station on the second floor as his workplace. The patient records were all covered in mud. Daito began the difficult task of sifting through them looking for significant data.

Otomo hospital

Otomo Hospital, continued to admit patients after the disaster.

Daito at Otomo hospital

Overwhelmed with emergency care, at first it rejected Daito’s request. However, after a while, Daito was able to convince the hospital and they allowed him to do research.

Daito's data

Daito compiled and analysed patient records from all three hospitals. He observed that within three months of the disaster 225 people were hospitalized for pneumonia. 52 of them had died.

Paperwork and x-rays

The research brought to light that the increase in severe pneumonia patients was observed all around Kesennuma, not just in one hospital.

And 90% of the patients hospitalized for pneumonia were 65 or older.


A pneumonia epidemic among the elderly in areas hit by the disaster...

Kesennuma was not the only city that faced this issue.


Ishinomaki has a population of 150,000. A pneumonia epidemic was also observed in this city.

Red Cross Hospital

At the Red Cross Ishinomaki Hospital, 122 patients were hospitalized for pneumonia within one month of the disaster. That was seven times the usual rate.

Masaru Yagai: Pulmonologist

Masaru Yagai: Pulmonologist

This footage was taken during the disaster. How were pulmonologists viewing the rapid increase of pneumonia in Ishinomaki?

Masaru Yagai: Pulmonologist

“Small specks and clusters that developed in the lungs seemed to be leading to the onset of pneumonia. The conclusion we came to was that cause of this type of pneumonia was most likely the inhalation of dried-up tsunami sludge that was being carried around in the air as dust particles.”
(Masaru Yanai: Pulmonologist)

Dust clouds

After the disaster, huge amounts of dust were produced by the dried-up sludge from the tsunami and all the debris. It was speculated that air-borne dust particles were responsible for the rapid increase in pneumonia.

Dust in Kesennuma

There were dust particles everywhere in Kesennuma, too.


The oil tanks in the port city caught fire the day the earthquake struck. Exposure to oil dust from the damaged tanks could have caused pneumonia.

However Daito’s research results were unexpected. There were no cases of pneumonia caused by airborne dust.

Daito and Morley

“There was no increase of an unusual type of pneumonia or forms caused by particular pathogens. Nor was there any increase in pneumonia caused by inhaling particles such as oil dust.”
(Hisayoshi Daito)


The only unusual type of pneumonia observed in Kesennuma was pneumonia caused by the inhalation of tsunami water. But this was recorded in 8 out of the 225 patients, only about 4% of the subjects.

Daito at work

So what was causing the rapid increase in pneumonia?

The answer lay in an unexpected area.


Dentists from around Japan headed to Kesennuma to support local dentists with the recovery effort.


These dentists had been involved in other major disasters, such as the Hanshin-Awaji and Chuetsu earthquakes. They knew from past experience that pneumonia increases in post-disaster conditions.

Local dentists were aware of a possible outbreak of pneumonia in their city.

Oral examination

They paid special attention to bacteria breeding inside the mouth.

Bacteria culture of Strep. pneumoniae

They were not looking for any special strain of bacteria, as a host of different bacteria always reside inside the mouth.

Strep. pneunomiae

One familiar strain is Streptococcus Pneumoniae, a pneumonia-related bacteria that breeds inside the mouth. This type of bacteria usually exists only in small amounts.


But living conditions in evacuation shelters can cause it to increase suddenly.

Lack of water

One notable factor is the scarcity of water after a disaster.

Oral hygiene goes downhill

In many shelters, drinking water was limited, and brushing the teeth to maintain good oral hygiene became the least of the evacuees’ priorities.


The bacteria inside the mouth increased as a result of poor oral hygiene.

Spending too much time lying down

The daily life of evacuees was another factor. In an evacuation center, many people spend more time lying down or sleeping. Increased amounts of time spent in these positions is a risk factor for pneumonia.


Usually the bacteria inside the mouth pass down into the stomach, and then leave the body.


However if the bacteria are misdirected to the lungs, inflammation occurs that causes pneumonia. This is called ‘aspiration pneumonia’.


Aspiration pneumonia can also occur when substances in the stomach are regurgitated and push oral bacteria up into the lungs.


In particular, lying flat on the back can induce regurgitation, making it more likely for aspiration pneumonia to occur.


Large amounts of oral bacteria combined with extended amounts of time spent lying down are high risk factors for pneumonia.

How can pneumonia be prevented? Experience from past disasters had taught the dentists the right course of action.


This is the Keichoen nursing home in Kesennuma.

Stringent oral hygiene regime in place

Not a single resident of this home was hospitalized for pneumonia during the disaster. It was a result of the dentists’ active promotion of oral hygiene.

A resident in bed

After the disaster, over a hundred elderly people lived as evacuees at this facility. Water, food and other basic necessities were lacking or had been cut off.

Morley and the home director

“It was very cold after the disaster, so the risk of getting pneumonia must have been high. Why wasn’t anybody from here hospitalized for pneumonia?

“Good oral hygiene was a priority here even before the disaster. And we were able to maintain everyone’s overall physical wellbeing.”
(Hideo Kumagai: Nursing Home Director)


At this facility, oral care had been taken up as a priority more than five years before the disaster.

Oral care maintains cleanliness and improves the environment inside the mouth. Maintaining oral hygiene is effective in preventing pneumonia.

Hiroshi Kanazawa

Hiroshi Kanazawa, a local dentist, is in charge of oral hygiene at this facility. In the days following the disaster he teamed up with dentists from other prefectures to provide oral care.

Hiroshi Kanazawa

“Following the disaster, many people didn’t remove their dentures. If you saw them, you probably wouldn’t want to touch them! When they were taken out, you could see lots of inflammation and sores in the mouth. Basically, there were lots of people with what we call candidiasis.”
(Hiroshi Kanazawa: Dentist)

Dentists promoting oral care

Dentists were actively promoting oral care. But Dr. Daito, the pulmonologist who was researching the pneumonia epidemic in the same city, was unaware of their activities until after the epidemic settled down.

Morley and Daito

“Had you personally come across or heard about the promotion of oral care that began around the same time you started your research?”

“Actually, I wasn’t aware of it. I was surprised the dentists acknowledged the increase of pneumonia because other doctors knew of the increase but they were not completely convinced that it was an actual epidemic. So it was quite unexpected that the dentists were actively providing oral care to prevent a possible outbreak when they noticed pneumonia was spreading.”
(Hisayoshi Daito)


How was oral care actually performed following the disaster?

Morley has a check-up

Morley lies down for an oral hygiene check-up.


Wet napkins specifically for oral care are useful when water is scarce.


The napkin is wrapped around the finger.

Morley experiences the napkin

Not only does oral care clean the inside of the mouth, it prevents bacteria from growing by moisturizing the entire inside of the mouth.

Free face massage

Massaging the face to increase salivation is also effective when there are no napkins or water available.

Face massage

“On your face, there are three major glands that produce saliva. One is here under your ear, one here under your jaw and another here under your tongue. These are the three major ones.”
(Hiroshi Kanazawa)


By gently massaging the three major glands with the fingertips, saliva is produced in the mouth. Saliva keeps the mouth wet and strengthens immunity.

Morley mouth waters

“Yes, I can feel a little bit coming out.”

Sendai, Miyagi Prefecture

Sendai, Miyagi Prefecture

Can the oral care management observed in Kesennuma be made effective for disaster medical care in the future?

Morley with Prof Mitsuo Kaku

Morley visits Mitsuo Kaku, a professor who studies infectious diseases.

Professor Mitsuo Kaku

“Dentists were very active and made tremendous efforts in getting people to understand the importance of oral hygiene and care. Did their actions help to limit the spread of pneumonia?”

“Yes. definitely. Now we have data showing the direct relation between oral care, such as rinsing your mouth and brushing your teeth, and the prevention of pneumonia.”
(Mitsuo Kaku: Professor, Tohoku University)

“Even if you’ve contracted pneumonia, can you prevent it from getting worse with proper oral care?”

“Yes, I think it’s possible to stop it from worsening, and you can also reduce the risk of swallowing disorders developing. The dentists pointing out the loss of oral hygiene and helping people to maintain oral cleanliness was a major factor in controlling the aspiration pneumonia caused by inhaling bacteria.”
(Professor Kaku)


Currently in Kesennuma, the lessons learned from the disaster are being used to create disaster management plans for the future.

Medical staff gather

Staff from various fields of health care are getting together.

Doctors of different fields exchange knowledge on oral care

Doctors specializing in respiratory medicine, orthopaedic surgery and neurosurgery are working together with dentists, caregivers and nutritionists to hold study groups based on oral care.

Hiroshi Kanazawa

Dentist Hiroshi Kanazawa feels that cooperation between different fields of health care should have been in place before the disaster.

Hiroshi Kanazawa

“If we had all noted the relationship between oral hygiene and aspiration pneumonia at an earlier stage, I am sure that the number of deaths could have been much smaller. As health care providers, I really think we need to learn our lesson and acknowledge our weaknesses. It’s now necessary to cross the boundaries between different practices of medicine so that we can develop a higher level of healthcare for the whole region.”
(Hiroshi Kanazawa: Dentist)

Morley summarises

“Shortly after the Great East Japan Earthquake and tsunami, there was a prevalence of pneumonia among evacuees. At first it was speculated that air-borne particles, such as oil dust were responsible for the pneumonia. However, later careful analysis indicated that it was in fact a more common strain of pneumonia found amongst senior citizens. Health care professionals were rapid to step in. They responded with an aggressive campaign of oral hygiene. Three years later, here in Kesennuma, there’s heightened awareness of preventative healthcare with particular attention to oral hygiene. The Kesennuma model perhaps offers hints for how to respond medically in the future when disaster strikes once again.”

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