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Should countries aim for elimination in the covid-19 pandemic?

BMJ 2020; 370 doi: (Published 09 September 2020) Cite this as: BMJ 2020;370:m3410

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  1. Andrew Lee, reader in global public health1,
  2. Simon Thornley, epidemiologist2,
  3. Arthur J Morris, clinical microbiologist3,
  4. Gerhard Sundborn, senior lecturer4
  1. 1School of Health and Related Research, Sheffield University, UK
  2. 2Section of Epidemiology and Biostatistics, University of Auckland, New Zealand
  3. 3LabPLUS, Auckland District Health Board, New Zealand
  4. 4Section of Pacific Health, University of Auckland, New Zealand
  1. Correspondence to: A Lee andrew.lee{at}, S Thornley s.thornley{at}

Elimination is possible and is the only way to prevent the biggest loss of life and economic harm in the long run, says Andrew Lee. But Simon Thornley, Arthur J Morris, and Gerhard Sundborn argue that the cost to quality of life years is too big a risk when “possible” is not the same as “achievable”

Yes—Andrew Lee

Independent SAGE, a group of scientists providing independent scientific advice on covid-19, has called on the UK government to work towards a “zero covid UK”1—in other words, the elimination of covid-19.

Elimination is usually pursued for diseases that cause serious illness or death such as smallpox, polio, measles, and Ebola. The alternative approach is suppression, which attempts to reduce disease incidence to acceptable levels. This normally applies to low consequence infections, such as diarrhoeal diseases2—the risk of death is low, and the disease continues to circulate in the population at low levels.

It could be argued that pursuing elimination with intensive control measures, including societal lockdowns, is too costly. Indeed, in some major economies, gross domestic product (GDP) could fall by 20-25% because of control measures implemented so far in the pandemic.3 Against the backdrop of rising unemployment and economic recession, suppression may seem the most economical approach. However, this is a short term perspective. Societal costs in the longer term need to be considered.

Failure to eliminate

Take influenza, for example. The 1918 flu pandemic is estimated to have killed 40 million people worldwide and caused a 6% decline in GDP, similar in magnitude to the 2008-09 recession.4 Each year a billion people are infected with flu, and as many as 650 000 die from it.5 The costs of immunising, treating, and controlling flu are substantial.

The US alone spends over $8bn (£6.03bn; …

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