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TThe last year of Covid-19 has taught us that it is the behavior of governments, more than the behavior of the virus or of individuals, that shapes the experience of the crisis in countries. Talking about pandemic waves has given the virus far too much power: until recently, the apparent waves of infection were driven by government action and inaction. It is only now with the emergence of more infectious variants that it might be appropriate to speak of a real second wave.
As governments craft their battle plans for year two, they can be expected to base their strategies on the wealth of data on what works best. And the evidence to date suggests that countries that pursue Covid-19 elimination are faring better than those that attempt to suppress the virus. Going for zero-Covid produces more positive results than trying to ‘live with the virus’.
Here are 16 reasons why we believe all countries should at least consider an elimination approach:
1. It saves lives. Not surprisingly, eliminating transmission of the virus minimizes Covid-19-related deaths. Countries pursuing elimination have death rates from Covid-19 that are typically less than 10 per million, which is 100 times lower than many countries “living” with the virus.
2. The elimination of community transmission also spares populations from the “long Covid”, which causes persistent health problems in survivors. These problems are reported by the majority of people hospitalized due to Covid-19 and can also affect those with even a mild infection.
3. Elimination is pro-equity. Pandemics almost invariably cause disproportionate damage to the most disadvantaged groups due to their ethnicity, income, and long-term illness. Eliminating Covid-19 can minimize these inequalities, particularly if an appropriate social ‘safety net’ is also provided.
4. Countries that have eliminated Covid-19 are experiencing less economic contraction than countries trying to live with the virus. Mainland China and Taiwan are probably the only countries to experience net neutral or positive economic growth in 2020.
5. Elimination is achievable and works in a variety of settings. Globally, many countries and jurisdictions are pursuing successful elimination approaches, including Mainland China, Taiwan, Vietnam, Cambodia, Laos, Mongolia, Singapore, Australia, and New Zealand. They are diverse in terms of geography, population size, resources, and styles of government.
6. The virus can be eliminated even after intense local transmission. Mainland China demonstrated this in Wuhan. The state of Victoria in Australia was also able to eliminate Covid-19 even after a period of intense local transmission with rates higher than those reported in the UK at the time.
7. It is easier if more countries take this approach. Border controls can be relaxed, creating “green zones” and allowing travel without quarantine with associated social and economic benefits. This opening is already happening between the Australian states and between the Pacific Islands and New Zealand.
8. The deployment of effective vaccines will make the elimination of Covid-19 easier to achieve. Effective vaccines, combined with other public health measures, have been essential to the successful elimination of diseases such as polio and measles[MB1] in many countries.
9. Having an explicit “zero-Covid” goal provides strong motivation and coordination. The crackdown does not offer a clear end point, leaving countries vulnerable to rapid resurgences, as seen recently in countries like Ireland[MB1] . The resulting uncertainty makes planning impossible, with huge consequences for schools, businesses, family life and much more.
10. It is sustainable. Eliminating countries have experienced setbacks in the form of border breaks and epidemics, but most have been able to contain them and regain their elimination status[MB1] .
11. If the virus mutates, elimination still works. The main methods used for the elimination of Covid-19 (border management, physical distance, wearing a mask, testing and contact tracing) are relatively unaffected by viral mutations (although testing may theoretically be less effective if the virus changes markedly, and epidemic control would become more important (difficult with more infectious variants).
12. It also works if the vaccines offer only limited long-term protection. For example, if vaccines are poorly effective in preventing transmission, elimination methods could supplement this limitation.
13. It can reduce the emergence of more dangerous viral variants. Elimination approaches result in a much lower circulation of virus. Consequently, there will be fewer opportunities for the emergence of new, more infectious variants, which could escape the protective effects of vaccines, or even be more lethal.
14. The use of interlocks should be less necessary. A relatively short and intense lockdown to eliminate transmission of Covid-19 in an area is expected to ease control measures in the absence of circulating viruses. Countries like New Zealand have had much less lockdown time than most countries pursuing the crackdown that have had to move in and out of lockdown for extended periods of time to keep their health services from being overwhelmed.
15. Vigorous control of Covid-19 infection has substantial side benefits. Elimination approaches have reduced the transmission of other respiratory viruses, including influenza, resulting in fewer hospitalizations and deaths from these respiratory pathogens.
16. It provides a good interim strategy as we identify an optimal long-term approach, which is currently uncertain. One scenario could be regional elimination or even global eradication, as we have seen with Sars. Another plausible option is endemic infection, with the health burden being managed with vaccines, as we see with influenza.
These benefits of pursuing a Covid-19 elimination strategy must be weighed against the costs and potential negative effects. However, these costs are also incurred by countries trying to remove the virus, except in their case, they come repeatedly, after each resurgence.
Overall, elimination appears to be the “less bad choice” for many jurisdictions. We hope that all governments, as well as the World Health Organization, will consider the elimination strategy when planning the second year of our global response to the pandemic.
Michael Baker is Professor of Public Health at the University of Otago
Martin McKee is Professor of European Public Health at the London School of Hygiene and Tropical Medicine
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