Impact of the Coming-of-Age Day and ceremony on the risk of SARS-CoV-2 transmission in Japan: A natural-experimental study based on national surveillance data

BACKGROUND: Quantifying the impact on COVID-19 transmission from a single event has been difficult due to the virus transmission dynamics, such as lag from exposure to reported infection, non-linearity arising from the person-to-person transmission, and the modifying effects of non-pharmaceutical interventions over time. To address these issues, we aimed to estimate the COVID-19 transmission risk of social events focusing on the Japanese Coming-of-Age Day and Coming-of-Age ceremony in which "new adults" practice risky behavior on that particular day. METHODS: Using national surveillance data in Japan in 2021 and 2022, we conducted difference-in-differences regression against COVID-19 incidences by setting "new adults" cases as the treatment group and the cases 1 year younger or older than these "new adults" as the control group. In addition, we employed a triple differences approach to estimate the risk of holding the Coming-Age ceremony by using a binary variable regarding the presence or absence of the ceremony in each municipality. RESULTS: We estimated the relative risks (RRs) of the Coming-of-Age Day as 1.27 (95% confidence interval [CI] 1.02-1.57) in 2021 and 3.22 (95% CI 2.68-3.86) in 2022. The RR of the Coming-of-Age ceremony was also large, estimated as 2.83 (1.81-4.43) in 2022. CONCLUSIONS: When planning large social events, it is important to be aware of the unique risks associated with these gatherings, along with effective public health messages to best communicate these risks.