INTRODUCTION Natural hazards pose significant threats to the continuity of healthcare delivery systems. Surgical care requires robust infrastructure, consistent utilities, and specialized staff, all of which are acutely vulnerable during catastrophic events. In response to previous major disasters, such as the 2011 Great East Japan Earthquake, Japan has promoted the seismic strengthening of healthcare facilities, development of disaster base hospitals, and implementation of business continuity plannings (BCPs).1,2 Despite these efforts, the devastating 2024 Noto Peninsula Earthquake (EQ-2024-000001-JPN) revealed critical gaps in hospital disaster readiness, especially regarding surgical functions. OVERVIEW OF THE 2024 NOTO PENINSULA EARTHQUAKE On January 1, 2024, at 16:10 JST, a magnitude 7.6 earthquake struck the Noto Peninsula and registered a maximum seismic intensity of 7 on the Japan Meteorological Agency scale. One year after the event, official reports released by Ishikawa Prefecture indicated over 500 fatalities, including 287 disaster-related deaths, and more than 1300 injuries. This earthquake caused extensive structural damage, forcing approximately 50,000 people to evacuate. One of the most persistent issues has been widespread and prolonged public water outages. Healthcare facilities in the affected areas sustained significant damage, including the loss of utilities and workforce shortages, leading to a critical collapse of the local medical care delivery system. From the acute phase onward, large-scale deployment of disaster medical assistance teams took place, and over 1700 patients (841 from hospitals, 610 from nursing homes, and 301 from evacuation centers) required wide-area medical evacuation. SURGICAL FUNCTION SURVEY: KEY FINDINGS To systematically assess the impact of the 2024 Noto Peninsula Earthquake on surgical service provision, we conducted a survey in August 2024 and April 2025, targeting 5 regional general hospitals. The guiding question behind this survey was whether the existing disaster preparedness measures were effective in maintaining surgical capacity. The participating facilities included Suzu General Hospital (northernmost), Ushitsu General Hospital (located in Noto Town), Wajima Municipal Hospital (western coast), and 2 hospitals in Nanao City: Keiju Medical Center and Noto General Hospital. The surveillance results are shown in Table 1, and the situation at Kanazawa University is presented for reference. The locations of the hospitals are shown in Supplemental Figure 1, https://links.lww.com/AOSO/A539. TABLE 1. - Results of Surgical Function Survey Medical Facilities(Number of Beds) Kanazawa Univ. Hospital(830) Keiju Medical Center(386) Noto General Hospital(330) Wajima Municipal Hospital (171) Suzu General Hospital(156) Ushitsu General Hospital (100) Seismic intensity; JMA scale 5+ 6+ 6+ 6+ 6+ 6− Resumption date for surgery with general anesthesia January 1, 2024 January 1, 2024 January 11, 2024 April 8, 2024 March 12, 2024 March 12, 2024 Earthquake-resistant structure Yes Yes Yes Yes Yes Yes Seismic isolation system Yes Yes No No No No Damage to the operating room No No Yes Yes~March 31, 2024 No Yes~March 12, 2024 Damage to the cleaning, sterilization system No No No Yes~March 22, 2024 Yes~January 31, 2024 No Public water supply outage No Yes~February 7, 2024 Yes~February 2, 2024 Yes~January 9, 2024 Yes~March 8, 2024 Yes~January 22, 2024 Damage to the water supply system No No No Yes Yes Yes~March 7, 2024 Destruction of the water tank No No Yes No Yes Yes Groundwater purification system Yes Yes No No No No Power outage No No No Yes6 h Yes~January 2, 2024 No Staff shortage No No No Yes Yes No The status of damage to the hospital and recovery of surgical functions after the Noto Peninsula Earthquake on January 1, 2024, is summarized. Seismic isolation and the availability of water played important roles.JMA indicates Japan Meteorological Agency. Immediately after the earthquake, 4 hospitals were unable to perform surgery under general anesthesia. Keiju Medical Center and Kanazawa University remained operational and were able to perform emergency surgeries on the day of the disaster. Noto General Hospital experienced a water supply disruption and resumed surgery on January 11. Suzu General Hospital and Ushitsu General Hospital restored surgical function by March, whereas Wajima Municipal Hospital resumed in April. Water supply failure was the most frequently cited cause of surgical service disruption, followed by operating room damage, sterilization system malfunction, and staff shortage (Supplemental Figure 2, https://links.lww.com/AOSO/A540). Notably, although most hospitals had water storage tanks, many suffered tank damage because of the seismic shock (Supplemental Figure 3, https://links.lww.com/AOSO/A541). By contrast, Keiju Medical Center, which continued surgical operations, benefited from a seismically isolated building structure that protected key infrastructure, including operating and sterilization facilities. Furthermore, the availability of a groundwater purification system enabled the hospital to maintain an adequate water supply for emergency surgeries even during a public water outage. Eight months after the disaster, surgical recovery remained incomplete in some hospitals. Keiju Medical Center, Noto General Hospital, and Ushitsu General Hospital recovered more than 80% of their prior surgical volumes. However, Suzu General Hospital and Wajima Municipal Hospital reported recovery rates of 24% and 58%, respectively. Emergency surgical capacity was notably limited in certain regions, with Suzu and Wajima hospitals performing only 13% to 34% of their respective predisaster emergency surgical volumes. In contrast, Keiju and Noto maintained 89% to 122% of their baseline levels. These figures underscore the pivotal role of Keiju and Noto hospitals in sustaining emergency surgical services in the northern Noto Peninsula during the postdisaster period. Although reports have described the immediate impacts of major earthquakes on surgical functions,3 this study offers additional value by evaluating the effectiveness of disaster preparedness measures and documenting the long-term recovery trajectory of surgical services following large-scale seismic events. SOCIAL CHANGES IN THE NOTO AREA AND FUTURE DIRECTIONS FOR HOSPITAL BUSINESS CONTINUITY PLANNING/BUSINESS CONTINUITY MANAGEMENT The 2024 Noto Peninsula Earthquake revealed significant vulnerabilities in regional infrastructure. Extensive water outages have occurred owing to aging and seismically unreinforced public water systems. Widespread damage to major roads and ports, caused by landslides, tsunamis, and coastal uplift, has exacerbated the geographically disadvantaged setting of the peninsula, resulting in delayed recovery support and prolonged disruption of critical services.4,5 These factors have led to severe regional recovery delays. Moreover, rapid population outflow has accelerated depopulation and aging, causing profound shifts in the social structure of the region.6 Consequently, discussions among local governments have begun to focus on consolidating public hospitals. Surgical services are now at a critical juncture, where region-wide strategic planning is urgently needed. Traditional hospital-specific BCPs have proven insufficient for large-scale disasters. Future preparedness must involve developing a regionally coordinated BCP/business continuity management (BCM) that defines the role of each hospital during a disaster.7–9 The Japan International Cooperation Agency, in collaboration with the Association of Southeast Asian Nations Coordination Centre for Humanitarian Assistance on Disaster Management, introduced Area-BCP/BCM as an expanded framework of BCP/BCM, with an emphasis on public–private partnerships.8,9 This initiative was originally developed to improve disaster resilience in industrial areas of the Association of Southeast Asian Nations countries. However, even in Japan's depopulated regions, it is considered extremely useful for assessing risks across regions, sharing resources, and prioritizing critical functions, including surgical capacity. These findings are not unique to the Noto Peninsula Earthquake. Similar challenges were documented in the aftermath of the 1994 Northridge Earthquake in California (moment magnitude 6.7), where 8 hospitals were forced to evacuate due to extensive nonstructural damage such as power outages, water leakage from ruptured plumbing, and equipment failure, despite the absence of immediate structural collapse.10 Notably, 2 hospitals initially passed safety inspections but were condemned days later after delayed identification of structural defects, highlighting the limitations of rapid postdisaster assessments. Collectively, these cases underscore the need for regional disaster preparedness plans that extend beyond individual hospitals. Integrated Area-BCP/BCM systems should incorporate routine infrastructure audits, postevent reassessment protocols, designated alternative care sites, and coordinated patient transfer mechanisms to ensure continuity of surgical care under adverse conditions. This concept is especially important because Japan is composed of many peninsulas, which would likely result in isolated areas in the event of a large-scale disaster. To prepare for the Nankai Trough earthquake, which is expected to occur within the next few decades, the development of a regionally coordinated BCP/BCM should be an urgent priority. Key components of such Area-BCP/BCM for surgical services should include: - Collaborative risk assessment and prioritization of essential surgical functions across hospitals. - Shared databases for emergency patient transport and bed capacity. - Interfacility agreements for resource sharing and mobile operational support. - Public–private partnerships in the supply chains of pharmaceutical and consumable medical devices. - Crossinstitutional disaster simulation exercises incorporating regional system collapse scenarios. CONCLUSIONS The 2024 Noto Peninsula Earthquake highlighted the importance of resilient infrastructure—such as seismic isolation and independent water sources—in preserving surgical capacity during disaster conditions, as demonstrated by Keiju Medical Center. At the same time, the limitations of stand-alone hospital BCPs became evident, with many facilities unable to maintain critical functions. To address future large-scale emergencies, preparedness must shift toward an integrated Area-BCP/BCM approach. This requires clear role delineation, proactive coordination among hospitals, and shared contingency planning to ensure that essential surgical services remain accessible when they are needed most. ACKNOWLEDGMENTS We would like to express our sincere gratitude to Dr. Hitoshi Moritomo of Noto General Hospital, Dr. Naomi Nojima, Mr. Masahiko Gamada and Mr. Hideaki Ueno of Ushitsu General Hospital, and Dr. Makoto Shinagawa and Mr. Masato Mizukami of Wajima Municipal Hospital for their valuable cooperation in the questionnaire survey. We would like to thank Editage (www.editage.jp) for English language editing.
Takada et al. (Thu,) studied this question.