TOKYO (BLOOMBERG) - With agreements to secure more coronavirus vaccines than it needs and legislation to distribute them for free, Japan may seem to have its inoculation plans in place. Yet a tense public history with vaccines and a cautious approval process have some concerned over how quickly the country can return to normal.

Japan has one of the lowest rates of vaccine confidence in the world, according to a Lancet study, which found that fewer than 30 per cent of people strongly agreed that vaccines were safe, important and effective, compared with at least 50 per cent of Americans. A recent poll by Japanese public broadcaster NHK found 36 per cent said they did not want to take a Covid-19 vaccine.

The government now faces a tricky balancing act: trying to move quickly to approve the jabs in order to restore the economy to full health, while avoiding creating the impression of a rush job - which might help turn an already-sceptical public off getting inoculated.

"Japan is very cautious about vaccines because historically, there have been issues about potential side effects," said Mr Haruka Sakamoto, a public health researcher at the University of Tokyo. "The government has been involved in several lawsuits related to the issue, which adds to their deep caution."

The sceptical attitude pre-dates the more recent Western "anti-vax" sentiment that has thrived on social media, with its roots instead in past vaccine-linked events and legal rulings that encouraged the government to take a passive stance on vaccination.

And ironically, Japan's relative success in handling the pandemic means an urgent roll-out of the shot is less of a priority. The country has avoided a second state of emergency, even as cases have increased to record levels.

As a result, Japan's roll-out is set to be slower than that of some other nations, which has led to frustration among those counting on vaccines to eradicate the virus. Only Pfizer has so far applied for local approval of its coronavirus shot, even as Britain and the United States have both administered more than half a million doses, mostly to the elderly and healthcare workers.

Local media have reported that vaccines will be rolled out in Japan from late February, when the government aims to inoculate about 10,000 front-line healthcare workers. The ministry is then preparing to vaccinate general medical staff, after which the vaccine will be gradually administered to the wider population.

Japan has not stated when it aims to complete its vaccination programme.

While figures such as US Vice-President Mike Pence and President-elect Joe Biden have gotten the dose, and leaders such as Indonesian President Joko Widodo are volunteering to be the first to receive it in their countries, Japanese Prime Minister Yoshihide Suga has said he will wait his turn.

Japanese Health Minister Norihisa Tamura said last Friday (Dec 18) that he has asked relevant bodies to prioritise the review of Pfizer's application, but did not give a timeline for approval. A health ministry spokesman also declined to comment on the reported timeline.

MMR issues

Japan's modern vaccine unease has its roots in a measles, mumps and rubella (MMR) inoculation that some suspected of leading to higher rates of aseptic meningitis in the early 1990s. Though no definitive link was established, the shots were discontinued and to this day, Japan does not recommend a combined MMR shot.

Another catalyst was a 1992 court ruling that not only made the government responsible for any adverse reactions related to vaccines, but also stipulated that suspected side effects would be considered adverse events, said Professor Tetsuo Nakayama from the Kitasato Institute for Life Sciences, whose research focuses on vaccines. Two years later, the government revised a vaccination law, scrapping mandatory vaccinations.

These events helped send a message that inoculations should be taken at one's own risk, and diluted the awareness of vaccination as a greater public benefit, said Professor Mikihito Tanaka from Waseda University, who specialises in science communication.

"Japan has a strong health insurance scheme and an accessible medical system," he said. "Compared with places like the US, that makes the incentive to gamble one's health with a new vaccine very low."

The handling of the human papillomavirus (HPV) vaccine also looms large in public memory. After media coverage on claims the vaccine's side effects included severe headaches and seizures, the Health Ministry in 2013 withdrew its recommendation for the shot, which has proven safe and effective in preventing cervical cancer.

While it remained available on request, the vaccination rate plummeted from 70 per cent to less than 1 per cent currently. That may have led to an additional 5,700 deaths, according to one study.

'Wide shows'

Japan's drug approvals require clinical trials involving Japanese people, but an emergency authorisation based on data from other countries is allowed. Vaccines for the 2009 H1N1 flu pandemic were given emergency approval after about three months' review.

Still, the government will have to carefully manage how the public perceives a speedy approval process. The economic impact of the pandemic and the forthcoming Tokyo Olympics could prompt a faster approval, but also arouse suspicion over whether the shots have been thoroughly vetted.

How the public will perceive some typical side effects is also concerning, Prof Nakayama said. Initial data from the vaccines show local pain in 80 per cent of cases and fatigue and headaches in up to 50 per cent, but "there has never been a vaccine in Japan that has caused reactions to these levels", he said.

Prof Tanaka said he was particularly worried about the influence of variety news programmes, known as "wide shows," which serve as both news and entertainment and are hugely influential in shaping public opinion, which ultimately will decide the scale of the rollout.

"The final decision to receive the vaccine or not will be made by the people," Health Minister Tamura said last Friday.