Coronavirus and heatstroke at the Tokyo Olympic Games
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FEATURE: CORONAVIRUS AND HEATSTROKE
Coronavirus and heatstroke
at the Tokyo Olympic Games
STUART GILMOUR, PHUONG MAI LE, KAZUKI SHIMIZU
O
n the 12th of June, 2021 humidity and the special demands of sporting events are scheduled in this
Christian Eriksen, midfielder coronavirus prevention, may combine period. It is the worst time of the year
for the Danish national to create unique health risks for athletes to hold elite competitive sports.
soccer team, collapsed on and spectators alike at this Olympics.
the pitch during the Finland-Denmark In general, the health risks of high
match of Euro 2021. Afterwards, his We have been researching the effect of temperatures are widely communicated
team confirmed he experienced the COVID-19 pandemic in Tokyo, and with the public; however, humidity
a cardiac arrest and required a also working on preparing infectious must also be taken into account, as
defibrillator on the pitch. Although disease countermeasures for the Tokyo high humidity can reduce heat loss,
the exact underlying cause of this Olympics. In late 2020, as part of this and negatively impact on the body’s
shocking event is not clear, it serves as a research, we realised that the Tokyo cooling mechanism. This makes it easier
reminder that even the fittest athletes Olympics faces a double burden of for people to develop heat illness. From
in the world can experience sudden, risk due to outbreaks of the novel this standpoint, the Wet Bulb Globe
unexpected medical emergencies. coronavirus during the pandemic and Temperature (WBGT) is commonly used
The risk to athletes in the past year heat stroke in both spectators and in daily life as a combined measure of
has been exacerbated by the novel athletes. Together these risks offer a humidity and heat, and for considering
coronavirus disease 2019 (COVID-19) unique combination of challenges for re-scheduling or cancelling sporting
pandemic, during which sports bodies the 2020 summer Olympics, and it is events. The weekly average of daily
and governments have attempted to not clear if the Olympics organisers maximum WBGT has increased
keep professional sports competitions are ready to deal with them. dramatically in mid-August in recent
open, at some risk to players. For years, from above 31°C to a maximum
example, the start of the Japan Rugby Heat illness, its impact on Tokyo of 33.5°C. There is a direct relationship
Union competition for 2021, the Top health system and the Olympics. between high WBGT and emergency
League, was delayed due to multiple A simple fact about Japan that is not transportations for heatstroke, with
COVID-19 outbreaks, and several widely appreciated outside of the the number of transportations
competitive combat sports events archipelago is the extreme nature increasing rapidly for every degree
have been modified at the last minute of its summer. Although short, the of WBGT over 30°C. This relationship
or canceled due to COVID-19 infection summer period in Japan from mid- can be seen in figure 1, which shows
among participants. These events are July to mid-September is a period of the cumulative total of emergency
not necessarily safe for spectators, extreme heat and humidity, which hospital admissions through different
either: the 2020 Cheltenham festival most non-Japanese cannot easily routes (left axis) and WBGT (right axis)
was identified as a potential “super- imagine. Temperatures in Tokyo in late during key weeks of the summer
spreader” event, as maybe was a prior July and early August routinely reach months for the past five years. As a
international rugby match attended the mid-30s, with relative humidity result, emergency medical services face
by the UK prime minister. Now, the in the 80s. Tokyo also has a ferocious difficulties in timely delivery of patients
perfect sporting super-spreader heat island effect, which exacerbates to appropriate healthcare institutions
event looms: the 2020 Olympics, the high summer temperatures, between late July and late August.
rescheduled to start in July 2021 in and due to its proximity to the ocean
Tokyo, Japan. But this Olympics carries the heat does not subside at night. The heat index in Tokyo is expected
an additional risk beyond the obvious Because of this, public advisories about to be much higher than in previous
threat of coronavirus. Heat stroke, and heatstroke prevention are ubiquitous competition venues of the Summer
the combination of extreme heat, in the summer months, and very few Olympic and Paralympic Games. A study
24 VOLUME 38 • ISSUE 4 2021
FEATURE: CORONAVIRUS AND HEATSTROKE
by our colleague Koji Wada showed
that the mean WBGT in Tokyo during
the period of the games reaches 34°C
in the afternoon, with a range from 32
– 36°C, while the peak in Rio de Janeiro
and Beijing was just 31°C. Furthermore,
this peak is unrelenting: there is no
point from midnight to midnight when
WBGT falls below 30°C in Tokyo, and it
is above 32°C for all sunlight hours. This
will mean that Olympic athletes who
have not yet adapted to the conditions
will not perform properly. Furthermore,
many groups with physical disabilities
have a higher risk of heat-related illness,
but no special health policy has been
implemented for Paralympic sports.
Given that many Olympic athletes
are performing at the peak of human Figure 1: Average Tokyo WBGT and distribution (right axis) and combined emergency hospital
physical achievement, and many will admissions for heat stroke (left axis) during key summer months in Tokyo, 2016 – 2020.
not be used to the kind of temperatures
they will experience in Tokyo, there is an
increased risk to their health, and the
possibility in some of the outdoor events
of serious accidents. But our experience
of COVID-19 in summer 2020 suggests
that coronavirus counter-measures – in
particular mask use and the need to
ventilate indoor spaces – will worsen
these already heightened risks. Our
research, published in the International
Journal of Environmental Research and
Public Health in early 2021, showed that
emergency admissions for heat stroke
in summer 2020 may have worsened
the challenges for emergency services
dealing with coronavirus. These hospital
admissions typically overwhelm
emergency services, and some
ambulances are forced to travel for long
periods of time to find open emergency
beds. We showed that in summer 2020,
Figure 2: Daily COVID-19 cases (left axis) and emergency transportations that did not find a
when Tokyo experienced a small wave of hospital within a defined time period (right axis) in Tokyo, March – September 2020.
coronavirus infections, there was a peak
in these delayed hospital admissions
that was not consistent with the number
of coronavirus infections, and was likely to find a reception hospital within on 20th June, and it is likely that by
a consequence of the combination of a defined time period (right axis). the start of the Olympics Tokyo will be
many hospital beds being taken up with experiencing a new wave of COVID-19
coronavirus patients at the same time as Although daily cases in Japan at cases. Moreover, COVID-19 clusters
the sudden surge in heat stroke cases. present are not especially high, with caused by several variants of concern
This pattern is shown in Figure 2, which Tokyo seeing between 300 and have been reported, and many of their
plots the daily case numbers of COVID-19 700 new COVID-19 cases every day, related cases have become untraceable.
(left axis) and the number of daily we are currently under a state of With the onset of the summer heat
emergency transportations which failed emergency that is expected to end this could cause the same sudden
VOLUME 38 • ISSUE 4 2021 25
FEATURE: CORONAVIRUS AND HEATSTROKE
Coronavirus and heatstroke
at the Tokyo Olympic Games
surge of hospital admissions, blocked which will reduce the effectiveness of
beds, delayed emergency admissions air conditioning and increase interior
and health system pressure that was temperatures, preventing sportspeople
seen in summer 2020 – only this time from gaining the respite they might
it will be exacerbated by the presence need to lower body temperatures.
of a large number of foreign visitors Of course, close environments will be
It is likely that by the start
who are at high risk of heat stroke and necessary for several competitions like
do not understand Japan’s summer of the Olympics Tokyo will badminton and table tennis, which
weather or its health system. be experiencing a new potentially have higher risks of COVID-19
transmission and could trigger super-
COVID-19, its impact on the Tokyo wave of COVID-19 cases. spreading events. Many athletes in
health system and the Olympics. track and field, equestrian, boating,
Compared to other high-income shooting, archery and other semi-
countries, Japan has so far mitigated outdoor and outdoor events may have
the worst epidemiological impact of to spend long periods of time waiting
COVID-19. Despite the fact the ongoing in high-temperature locations wearing
transmission of COVID-19 in Japan masks, possibly in direct sunlight, when
has been classified as “clusters of daytime WBGT values will lie in the
cases”, around 50% of contacts cannot extreme range. This will increase the
be traced in Tokyo, suggesting the among athletes at their accommodation risk of both minor heatstroke events
presence of some untraced community remains a significant risk. This will and major incidents with potentially
transmission. Furthermore, Japan have particular risk for some athletes life-threatening consequences for some
has lagged in COVID-19 vaccination who may be clinically overweight (for athletes. At the same time, a renewed
rates compared to other high-income example, heavyweight fighters and wave of coronavirus infections in the
countries. While the vaccination weight lifters), who may be dieting to general community will put pressure
program first started in mid-February, cut weight (for combat sports or other on the health system, leading to the
only 15% of the population (mainly health events with weight classes) or who same delays in emergency response
workers and people aged 65 and over) are older (for example shooters and that were observed in Tokyo in 2020,
had been vaccinated by early June. equestrian athletes) and at greater risk but exacerbated by the sudden
from viral infection. In addition to the risk demand placed on the system by heat
The International Olympic Committee to the athletes’ health, such outbreaks stroke among Olympic participants,
(IOC), International Paralympic may also lead to the interruption and/or support staff and spectators.
Committee (IPC), Tokyo 2020 Organising cancellation of events, and the possibility
Committee (Tokyo 2020), the Tokyo that the Olympics could become a However, it is also important to discuss
Metropolitan Government (TMG) global super-spreader event as athletes whether prioritising vaccination for
and the Government of Japan have and support staff from over a hundred the Olympic and Paralympic Games
developed a range of measures to nations return to their home countries. participants is truly fair and ethical, as rich
enable the Games safely in the context countries dominate vaccine supplies and
of COVID-19. They also said that 80% of For many athletes, strict COVID-19 many essential workers, even healthcare
the Village would be vaccinated, and countermeasures will require that they workers, in low-and middle-income
some countries prioritise vaccination of wear masks in public and at sporting countries are still facing challenges to
athletes ahead of the Olympic Games venues, while waiting between events be fully vaccinated. The 2021 Olympics
Tokyo 2020. Nonetheless, there are and in waiting areas for events. A presents the spectacle of rich countries
multiple risks surrounding the Olympic key component of Japan’s relatively hoarding vaccines to protect elite
and Paralympic games, connected successful countermeasures against athletes from coronavirus exposure in an
to both Tokyo’s unprecedented heat COVID-19 has been action against event the majority of Japanese citizens
and the unusual coronavirus situation. the “three Cs”: closed, crowded and think should be cancelled, only to create
Although many athletes are very fit close-contact settings. To be consistent a super-spreader event that inflicts new
and young and unlikely to experience with these counter-measures, event waves of the pandemic on countries
significant ill-effects of coronavirus venues will be generally ventilated with that are unable to access those same
infection, an outbreak of COVID-19 free movement of air from outside, vaccines. This is the perfect example
26 VOLUME 38 • ISSUE 4 2021
FEATURE: CORONAVIRUS AND HEATSTROKE
of sport acting as a mirror for global About the Authors
society’s ills, and there is little evidence
that the Olympics organisers have Stuart Gilmour is professor of biostatistics and
any interest in addressing this issue. bioinformatics at the Graduate School of Public
Health, St. Luke’s International University, Japan.
Olympics from the perspectives of Stuart was born in New Zealand and raised in
public health systems and services. Australia by British parents, and has lived in Japan
The peak of emergency transportations since 2006. He originally studied physics but shifted careers to public
due to heat illness overlapped the health where he began his career researching the health of
resurgence of COVID-19 in 2020, and marginalized populations, especially sex workers and people
an increase of heat illness patients who inject drugs. Stuart obtained his undergraduate degree in
with rising WBGT has been observed. mathematical physics at the University of Adelaide, completed
Without urgent reconsiderations and masters in Public Health at the University of Sydney, a Masters in
sufficient countermeasures, the double Statistics at the University of New South Wales and his PhD at the
burden of COVID-19 and heat-related University of Tokyo. His research interest is in quantitative health
illnesses in Tokyo will overwhelm system assessment, the use of statistics to improve our
the healthcare provision system and understanding of policies and interventions that can improve
maintaining essential health services will population health, especially where it is affected by inequality
be challenging during the 2020 summer and exclusion.
Olympic and Paralympic Games. Our
research provides clear evidence that Kazuki Shimizu A cosmopolitan-minded physician and scientist
emergency medical services faced of global public health. His expertise ranges across critical topics
difficulties in delivering patients to in global health, such as infectious disease epidemiology, health
appropriate healthcare institutions and emergency preparedness and response, global health security,
early intervention in July and August health system financing, and public private partnerships. At
2020 in Japan, and there is every risk London School of Economics, he was mainly involved in “The
that the same conditions which caused Lockdown” survey, a global initiative to capture the experience of
those health system burdens in 2020 social distancing policy and assess how the measures taken to
will be repeated or even worse in fight against the COVID-19 pandemic affected the educational
2021. This summer’s Olympics are still process, professional opportunities, and wellbeing. Previously, he
underprepared for safely organising was trained as a physician and completed his medical residency
the games in the context of both at the Medical Support Division, Toyota Motor Corporation. He also
COVID-19 and heat policy. Considering completed his externship at University of Florida Health Shands
the ongoing COVID-19 pandemic Hospital. He obtained his M.D. at Nagoya University, Japan, and
and Japan’s overwhelmed public earned M.Sc. from London School of Economics and Political
health systems, securing sufficient Science and London School of Hygiene and Tropical Medicine,
surge capacity for the games, such as United Kingdom. He is a certified physician in the Japanese Society
resources for regular COVID-19 screening of Travel and Health and holds a position as adjunct lecturer
and isolation facilities in multiple venues at Nagoya University Graduate School of Medicine, Japan.
where the games are scheduled, will
be an imminent challenge. People Phuong Mai Le is a Vietnamese researcher who has
watching the games at home should been living in Japan for 3 years. She completed a
remember the extreme heat stroke risk Masters of International Health in the Netherlands
that the athletes are facing, as well as the in 2016, and has rich experience in the HIV/AIDS
background risk of coronavirus spread response, with eight years working in the Vietnam
in Tokyo. These games are not popular Ministry of Health. Le presently works as a research assistant at the
in Japan, and the callous disregard Graduate School of Public Health, St. Luke’s International University
that the international organisers have in Japan. She has published articles related to the healthcare system,
shown for both the athletes and HIV/AIDS, and global health issues. Her research interests focus on
the citizens of Tokyo should not be promoting the health of vulnerable populations, such as ethnic
forgotten as the spectacle unfolds. minorities, particularly women and children.
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