Dr. Sanjay Gupta: The Olympics’ pandemic playbook is put to the test

By Dr. Sanjay Gupta, CNN Chief Medical Correspondent

When I first told my medical colleagues that I would be traveling 14 hours to Tokyo, they looked at me with a bit of surprise, then hesitantly told me simply to “be safe.” It is the same reaction I have often received when jetting off to cover a natural disaster, like the earthquake in Haiti, or a conflict, like the wars in Iraq and Afghanistan. This time, however, the mission was to report on how people from all over the globe would converge for the Olympic games in a city under a state of emergency due to the pandemic.

My flight to Japan was nearly empty, just as they often are with my trips into hot zones. Given there were few or no spectators allowed for these games, there were no fans on the plane wearing country colors, speaking excitedly in different languages or exchanging their picks on favored athletes. It was quiet, serene and lonely.

My days prior to departure were filled with detailed planning and lots of testing: a Covid test within 96 hours of departure, and again within 72 hours of departure. Another one immediately upon arrival, and again daily for the duration of my stay. Each time, the possibility of a breakthrough infection lurking in the back of my mind, forcing me into isolation and my team into quarantine for an extended and unplanned stay.

A logistical nightmare

Even under the best of circumstances, planning to host the Olympic games is one of the most challenging logistical events on the planet. In the middle of an unfolding pandemic, it seemed nearly impossible. On top of that, local support for the games is anemic: Nearly 8 in 10 Japanese citizens said they preferred to cancel the games altogether in their home country, according to a recent poll. Many here feel the decision to hold them is irresponsible, because of the health risks involved with having, in essence, tens of thousands of potentially infected out-of-towners arriving on your doorstep in the middle of a pandemic.

But after postponing the games for a year, the Japanese government and the International Olympics Committee decided the show — the games — must go on.

And so they are — but they’re very different: strange and eerily quiet.

When I attended one of the first competitions, the women’s soccer match between the United States and Sweden on Wednesday, there were only about 50 spectators allowed in the stadium built for 48,000. There was no traffic on the streets, no vendors, and no lines. There were handwashing stations, temperature checks and plexiglass partitions — all of which probably make only a small difference controlling this particular virus. There was no proof of vaccination required either. The most effective measure was the absolute requirement for masks, which security diligently checked to make sure were properly fitted around our mouth and nose.

There was distant fan noise piped in and a smattering of applause after remarkable plays. The only time there was any significant noise was when a team scored. That is when the music blared — so loudly it was as if they forgot to turn down the volume, given it no longer had to compete with the tens of thousands of cheering fans. During this match, that thunderous music played three times, every time for Sweden. Final score 3-0.

Let the games begin

On the night of the opening ceremonies, it was a flurry to get into the stadium. Protests echoed from around the outside, but once I got in, the full beauty of architect Kengo Kuma’s creation sunk in.

Majestic and perfectly placed under a delightful night sky, it was filled with years of past planning and future potential.

It was a caged animal raring to run. On its biggest night, the night of the Opening Ceremony, however, it is tame, quiet and slumbering. You could almost imagine all the amazing events it will contain, full of cheering voices and smiling faces. Just not tonight.

Still, that didn’t take away from watching the athletes parade out country by country, waving to a nonexistent crowd, but still with smiles emitting from underneath their masks. Fireworks illuminated rows and rows of empty seats. It was a study in contrast. A public health emergency that was at the same time a mental health balm.

Over the next 16 days, more than 11,000 athletes from just over 200 countries, states and territories are expected to compete. That is, if they don’t test positive beforehand. As of Friday, there were at least 110 confirmed cases linked to the games. The infected include officials, contractors and of course athletes, like US alternate gymnast Kara Eaker and tennis player Coco Gauff, and three members of South Africa’s soccer team.

Most of the cases were caught before the infected people reached the Olympic Village — which officials hope to keep bubbled off as much as possible from the rest of society. As you might imagine, however, a bubble of that size, filled with exuberant, young athletes excited to see each other and eager to compete, is challenging to maintain. And, so it is hardly a surprise that a handful of cases have also been detected in the village, including the three members of the soccer team. This led to about 20 other Olympic Villagers being identified as “close contacts” and subjected to additional testing and quarantine measures.

While Tokyo is in a state of emergency through August 22 (well past the Closing Ceremony) because of the recent surge in cases and overall low vaccination rates among the Japanese, everyone is in a state of mild anxiety. Old friends greet each other from a distance, unsure of handshakes and hugs, their greetings muffled by masks.

The number of new infections in Tokyo has been steadily climbing since mid-June. New positive cases hit a 7-day daily average of 1,386 on Thursday, after hovering around an average of about 400 cases per day in mid-June.

Some of that anxiety worsened when Tokyo 2020 CEO Toshiro Muto said Tuesday he would not rule out an 11th-hour cancellation of the Games amid rising Covid-19 cases. It was a surprising statement given how close the games were to starting.

When I visited with Dr. Itaru Nishizuka at one of Tokyo’s largest community health centers, he thought the games would almost certainly go on, with one important caveat. The only thing that might change his prediction: a surge in hospitalizations that would overwhelm the city’s roughly 400-ICU bed capacity. He said currently about 200 of those beds are occupied. Hospitalization have been steadily increasing, from 1,625 at the start of July to 2,558 on Wednesday.

The game plan

I think it’s fair to say the pandemic has been giving the Japanese government and the International Olympic Committee a fair amount of heartburn since it first reared its head. Early hope that the pandemic would blow over and the games could be held as normal burned as bright as the Olympic torch but were quickly extinguished as wave after wave of Covid-19 surges washed over the planet.

So Olympic and government officials devised a pandemic playbook to make the games as safe as possible — even if they were always under threat of being cancelled outright.

While we have seen other sport leagues in the United States and abroad make it through seasons or tournaments safely and with little interruption — such as the National Football League, the National Basketball League, Wimbledon, the Australian Open — the Olympics bring a unique challenge, with athletes coming from far and wide, and traveling great distances at different time points to do so.

And then there was the novel coronavirus itself. “We had no idea what was coming to us in terms of Covid,” Dr. Brian McCloskey, chair of the independent expert panel advising the IOC on Covid-19 countermeasures, told me recently. He said when the decision was made to postpone the Olympics to 2021, everyone was only just learning about how the virus behaved and what worked and didn’t work to mitigate the risk of spread.

But McCloskey said postponing the Olympics again was not an option because of international sports schedules, so it was either cancellation or up to him and his team to figure how to hold the games “safely and securely” in 2021.

Part of that strategy involved sequestering the athletes as much as possible from the local population. That’s why nearly all spectators, both local and from abroad, have been banned in Tokyo, and athletes’ movements are mostly confined to the Olympic Village and the venues.

“The athletes aren’t travelling around Tokyo. They’re not using public transports. They’re using designated transports to go from the village to their training or competition venues, and back again,” McCloskey said during a news conference Monday.

Beyond that strategy, McCloskey says the rest comes down to the pillars of public health. “Physical distancing, wearing a mask, and hand hygiene — they were always at the fundamental core of what we knew would reduce the risk of Covid during the games. And then we started to layer on top of that the testing strategy that we now have,” he said.

The testing is extensive, along with careful tracking and tracing. Like me, athletes were tested twice, within 96 and 72 hours of departure, and upon arrival, then are given antigen tests daily. If anyone tests positive, a PCR test is used to confirm the result and they are immediately isolated. Any “close contact” is subject to quarantine.

Does the playbook miss the point?

But even that has not quelled the concern from both locals and health experts. “One of the things that has been a concern is that they really planned this Olympics around the concept of hygiene theater,” said Michael Osterholm, an epidemiologist and the director of the Center for Infectious Disease Research and Policy at the University of Minnesota.

“Originally, the plans were set up counting on this largely being a respiratory droplet — i.e. falling within three to six feet of the individual who might be infected — when in fact, as we now know, the primary means for transmission is actually through airborne transmission, aerosols, things that float in the air, like cigarette smoke,” Osterholm told me.

Linsey Marr, an engineering professor at Virginia Tech and an expert in how viruses behave in the air, said that cigarette smoke is a great way to visualize the most up-to-date understanding of how the virus lingers and how easily it can be spread. “Because it comes from our mouths and carries particles that are similar in size and behavior to the virus,” she said.

If you imagine an infected person exhaling the virus as smoke and watching that vapor drift easily in the air, it will forever change how you think about protecting yourself and others.

The much more contagious Delta variant, which has grown at least seven-fold in Japan since the start of June, compounds the problem.

“So before, it was like an infected person was smoking one small cigarette at a time, but now it’s like they’re smoking a few cigarettes at once because we think they shed more virus. More smoke means that more will still be in the room even after the person has left. After the person leaves, the smoke becomes diluted as outdoor air replaces some of the indoor air, but if there was more to begin with, then there will be more 15 minutes after the person leaves,” Marr said.

Osterholm said that shift in thinking makes barriers like plexiglass separators in places like the athletes’ workout areas ineffective, but face masks even more important. And like others, he’s also worried about the Delta variant.

“We had real concerns about the potential for transmission at the Olympics well before Delta as a variant took hold around the world. When that did happen, it only heightened our concern,” he said.

Right now, the IOC playbook states that a face mask must be worn at all times, except when training, competing, eating, drinking, sleeping or during interviews. But even that is incomplete, according to Osterholm, because there is no specification for what type of mask should be worn, other than “non-fabric where possible.”

“We already know the limited protection cloth masks provide versus N95s. [Officials] have provided no clear directions. They should be recommending N95 respirators,” Osterholm says.

Vaccines are another crucial tool against Covid, but they are not required because the independent expert panel thought doing so could have created profound issues of inequity.

“We were fairly confident that we would have a vaccine by now. But we also knew if we had one, it wouldn’t be equally available around the world [and] wouldn’t necessarily be in good supply,” McCloskey explained.

Also, it would be hard to justify an athlete receiving a vaccine when vulnerable people or health care workers in their home countries did not yet have access. Remember, in Africa, just over 1% of the population has been fully vaccinated. And in Haiti, the vaccination program began just last week. Those facts are a brutal reminder that while the United States is dealing with high levels of vaccine hesitancy, most of the developing world is begging for access to the shots. My colleague Christine Brennan told me nearly 100 athletes from the United States chose not to get vaccinated before arriving.

Despite the lack of a vaccine mandate, the IOC estimates more than 80% of residents of the Olympic Village will be vaccinated — above the estimated threshold needed for herd immunity. McCloskey said they’re a “bonus extra layer on top of the others, to give us even more reassurance.”

The world watches and waits with bated breath

All of these measures have not cleared the metaphorical cloud that continues to hang over the city as the world waits to see how this global event will fare in the face of a pandemic. The major question looming is: Will these now-small number of positive cases show that the protocols outlined in the playbook are working, or will the numbers spike up, underscoring the feeling that holding the Olympics was ill-advised in the first place? Only time will tell.

McCloskey is feeling optimistic. “What we’re seeing is what we expected to see. Essentially, if I thought all the tests that we did were going to be negative, then I wouldn’t bother doing the tests in the first place. We do the pretest because they are a way of filtering out people who might be developing an infection,” he said during a Monday news conference.

But others are not so sure. “Visitors, athletes, journalists, delegates — of course they are supposed to be within the bubble, but it’s not working well. It’s obvious that the bubble system is kind of broken, so there seems to be some sort of interaction between guests and visitors and also local people,” public health expert Dr. Kenji Shibuya said in an interview with Reuters earlier this week.

Dr. Ishizuka, who is also waiting with bated breath, is steadfast in his recommendation that the Olympics continue.

“Japan needed this,” he told me. “In 1964, the last Tokyo Olympics, because Japan lost the war, the games worked as an opportunity for us to come back. In this Olympics, we have Fukushima,” he said emotionally, referring to the 2011 earthquake and ensuing tsunami which led to a nuclear disaster. In total, more than 22,000 people went missing or died.

That the potential for healing mental and emotional health comes at the risk of physical health is a sentiment Osterholm understands as well.

“We want the Olympics to happen, the world wants them to happen,” Osterholm said. “This is something we need desperately for the world psyche, but at the same time, they have to be safe. If in fact we see spreading events occur associated with the Olympics, that will be a mark that will last forever.”

For now, at least the athletes get to come and live out their dream, even if family and other members of their delegation have to sit out the games at home. Many have worked for a good part of their lives to reach this pinnacle. And, of course, we the spectators look forward to watching the best competitors in our favorite sport vie for gold.

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CNN’s Andrea Kane, Keri Enriquez, Michael Nedelman and Amanda Sealy contributed to this report.