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Covid-19: Should the UK be aiming for elimination?

BMJ 2020; 370 doi: (Published 03 August 2020) Cite this as: BMJ 2020;370:m3071

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  1. Ingrid Torjesen
  1. London

Scotland’s leader has proposed that the four UK nations align around a covid-19 elimination strategy similar to New Zealand’s, but is it feasible? Ingrid Torjesen investigates

Scotland is urging England and Wales to join Scotland and Northern Ireland in a four nation covid-19 elimination strategy.

Scotland’s first minister, Nicola Sturgeon, told a press briefing on 28 July that she had suggested that all four UK nations align “around a strategy that is effectively about trying to eliminate the virus.”

“If we could all align around an approach that is very explicitly about driving this virus down to the lowest possible level and allow our policy decisions to flow from that, then I think that would be a good step forward, as opposed to having an approach that allows the virus to hover around at a certain level and then hope it doesn’t overwhelm you,” she said.

This elimination approach has been advocated by the non-official advisory committee Independent SAGE.1 “Northern Ireland and Scotland have explicitly adopted zero covid as a strategy, and the Republic of Ireland has basically been working to that way,” said Susan Michie, director of University College London’s Centre for Behaviour Change, who sits on both Independent SAGE and the official SAGE, as well as its behavioural science subcommittee, SPI-B.

“There is no reason why as a joint couple of islands we can’t get to covid zero if we all pull in the same direction,” she added, holding up New Zealand as “proof of principle.” She added, “An elimination strategy is much more feasible for us than a country on mainland Europe.”

Uncertainty and adherence

In the short term this would require tougher measures to stop community transmission, she said. High risk places, such as indoor pubs and indoor gyms, where people are likely to shout or breathe heavily and are touching each other and touching surfaces, would need to be shut down. But the economy could then reopen with fewer controls and more certainty.

The government’s current “whack a mole” approach meant constant “yo-yoing” which “brings uncertainty, lack of adherence, lack of control and it is really unsettling for people and terrible for business,” said Michie.

Once community transmission is down to zero a good test, trace, and isolate system would be needed “to jump on and suppress” localised outbreaks, with border checks and isolation to prevent inward transmission, she explained. This would need to be underpinned by reliable data and involvement of public health teams,2 as well as public health messaging to tackle ignorance around the key covid-19 symptoms and on where and how to get tested, a strategy to support people who have to isolate and could be hit financially, and—crucially—trust in the government and the system designed to get people to isolate and hand over their contacts.

She said, “The [Westminster] government has lost a huge amount of trust over its mixed messaging, being so unclear about what it is that people need to do, and the Dominic Cummings affair, obviously.”

Honest and open

Michie said that the Westminster government could learn a lot from the direct, honest, and open communication style of the leaders of Scotland and New Zealand. “That is what engenders trust, and the trust is needed for adherence,” she said, recommending that more direct communication should be handed over to scientists who commanded a high level of public trust.

Having one coherent UK strategy was not only likely to be more effective but would help create trust, “which is key in terms of peoples’ behaviour, which is key in terms of getting out of the pandemic,” said Michie. The public were confused when leaders said that their policies were based on science and then the different UK countries took different approaches, she explained.

The BMJ contacted the governments of England and Wales for comment on the proposals, but they did not respond before publication.

A spokesperson for Northern Ireland’s Department of Health said that “a very robust approach to tackling and maximally suppressing covid-19 amongst our population” was being taken and that cooperation with the Republic of Ireland through a formally agreed memorandum of understanding had been “central to controlling the virus on both sides of the border.”

The antithesis of a “covid zero” approach is in Sweden,3 which has had no mandatory lockdown and has no plans to require the public to wear face coverings.4 Figures from the Office for National Statistics this week showed that it was not Sweden but the UK that had been hit much harder by the covid-19 pandemic, as England had the highest levels of excess mortality in Europe during the first half of 2020.5

Speaking exclusively to The BMJ, Anders Tegnell, Sweden’s state epidemiologist, warned that an elimination strategy requiring stringent lockdown measures and border closures “could possibly cause a lot more damage to public health.”

He said, “When this whole thing started out many of us looked on this coronavirus like SARS [severe acute respiratory syndrome] and MERS [Middle East respiratory syndrome], and I think that guided much of the thinking in the beginning, and probably much thinking in China—really trying to really get rid of it.

“Now when we have the spread that we have today, when we even see cases in closed places like North Korea,6 I don’t think we can seriously believe that we can get rid of this virus unless we get a very, very good vaccine.”

Uneven geographical spread

The world has been watching Sweden, as there are hopes that its approach might produce herd immunity. So far, however, levels of exposure and immunity have been difficult to determine.

What is apparent from measures taken in different populations is the “very uneven spread” geographically, with exposure levels ranging from a few percent up to around 30%, said Tegnell. “Any measurements we try to take by taking a random sample of population is very much easily skewed in some way or another,” he explained. “At least personally I don’t have good hope of getting a very good number any time soon, unfortunately.”

Like the UK, the number of cases in Sweden has fallen very rapidly. “Right now, admissions to [intensive care] are down to many days without even one case, then one or two cases,” said Tegnell. “Mortality is also down to single digit per day.”

The expectation had been for a slight rise over the summer months, with more people travelling around and meeting new people and possibly creating new transmission chains. But Tegnell said, “It doesn’t seem to have happened to any great extent, so we figured at least immunity must play some part in it. How big a part, we don’t know.”

He believes that the decline in rates is probably due to a combination of immunity, the public heeding advice to socially distance, and people spending more time outside in summer. “The combination of these three factors sort of driving the same way seems to produce this result, and of course we are very happy about it,” he said. “I think this sort of shows that the relation between lockdowns and rapid decline in cases is very difficult to determine, because obviously you can have a rapid decline in cases without having a lockdown.”

Ultimately a plateau will be reached, he predicts, “because I don’t think it’s going to disappear. We have seen a number of countries in Europe that have been hovering around 10, 20, 100 cases a day. Maybe it is somewhere there that the virus will sort of settle down. That remains to be seen.”


  • Correction: We amended this article on 4 August 2020 to correct the spelling of Anders Tegnell’s name.

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