Elimination could be the optimal response strategy for covid-19 and other emerging pandemic diseases

Dear Editor

Of relevance to this topic is a new Report from a European think tank that aimed to identify an optimal COVID-19 response strategy (https://www.institutmolinari.org/2021/04/03/the-zero-covid-strategy-prot...). It considers more recent mortality data, GDP impacts, and mobility data, and suggests that COVID-19 elimination appears to be superior to mitigation/suppression strategies in health and economic terms.

This Report is a useful contribution to the knowledge-base, but it also has a number of limitations as we discussed in a scholarly blog (https://blogs.otago.ac.nz/pubhealthexpert/more-evidence-that-elimination...). Indeed, more data and a longer-term perspective are needed, before we can be really certain about the relative benefits and costs of different COVID-19 control strategies.

Dear Editor

"When you settle on a problem, devote the resources to it and have at least some ability to incorporate new information, every time, it gets better. I don’t have any experience, anywhere, where you just apply yourself, along with others, and then do not see progress"

Paul Farmer referring to his logical optimism. [1]

Suppression strategy taken by high income nations, such as those in North America and Europe, appears to have failed to suppress the spread of covid-19, and is still failing as of this writing. The strategy, also referred to as "a hammer and dance suppression strategy" [2], did not suppress the epidemic enough to give an opportunity to "dance". Rather, the "dance" period induced an even larger resurgence of the epidemic in a given region, wasting all efforts to suppress the infection, ending up with fatigue and complacency among citizens, and making infection prevention even more difficult. Japan was once called a "success case" among high income nations, with stringent contact tracing of clusters, but it also failed to suppress the epidemic after months of a suppression strategy, which led to the reluctance of people to follow the recommendation. The resurgence was even worsened by counterproductive economic measures taken by Japan's government to encourage traveling and eating out, which resulted in spreading the infection further.[3] Even with the help of newly introduced vaccines, we are not certain how effective they are in contributing to the fight. Therefore, we agree with Baker et al. that elimination instead of suppression might be a better option for the covid-19 pandemic.

However, the harsh reality is that there have been no follower countries that took the same step after the success of New Zealand, Australia, China, or Taiwan. Furthermore, it is not realistic to expect that the world will turn to the elimination strategy all at once. Every nation-state as a stakeholder of the covid-19 pandemic has its own interests. Even within a country, obtaining a consensus in selecting a single strategy can be a daunting task. Some may even be skeptical about the achievability of the elimination strategy despite the evidence of successful cases. The elimination strategy is scientifically sound but is likely to be dismissed by many in the real world.

Therefore, we would like to propose an additional strategy to the measures cited by Baker et al., to make it more achievable; namely, a segmentation strategy.

Eliminating SARS-CoV-2 is harder when we want to achieve it in large, densely populated areas. Therefore, we would propose to first implement it in a smaller area, such as states, municipals, or prefecture level, and scale it up. We need more successful cases of elimination to convince people that it is achievable. By gradually increasing (and expanding) the covid-free areas, people are more likely to follow the same step. The key to success is, while maintaining the covid free status among these areas, to expand those covid free areas. Effective border control or quarantine suggested by Baker et al. would be of great relevance.

We should learn from cases with success, not from ones with failure. Historically, many elimination strategies were initially laughed at with cynicism, because they did not have precedents, and we, specialists, are often inclined to overemphasize obstacles in implementing them. However, we should take these obstacles as "handles to overcome", not as "reasons to give up". We need to be logically optimistic to progress, in the calamity of the current pandemic.

References
1. Even the Pandemic Hasn’t Made Public-Health Icon Paul Farmer Lose Hope [Internet]. Time. [cited 2021 Jan 19]. Available from: https://time.com/5917382/paul-farmer-public-health-pandemic/
2. Jung F, Krieger V, Hufert FT, Küpper J-H. How we should respond to the Coronavirus SARS-CoV-2 outbreak: A German perspective. Clin Hemorheol Microcirc. 74(4):363–72.
3. Shimizu K, Wharton G, Sakamoto H, Mossialos E. Resurgence of covid-19 in Japan. BMJ. 2020 Aug 18;370:m3221.

Dear Editor

The question of which strategy for response to the Covid-19 pandemic has been most effective is probably now best left to historians of disease, population and public policy.

However, advocacy of the New Zealand elimination strategy rests on an important, and entirely unexamined, presupposition: that Covid-19 will be sufficiently dangerous in a post-vaccination world to justify the social, psychological and economic overhead costs of the controls described by the authors. If the clinical trial data are to be believed, the average infection fatality risk of populations, and the associated risk of serious illness, will rapidly reduce to somewhere close to that of the average healthy 18-50 year old. This would be comparable to, or lower than, the risks of other respiratory viruses, which humans have been happy to live with for millennia.

More work needs to be done to specify and quantify the ‘Long Covid’ risk, but some reports clearly confuse unrealistic expectations of the speed of recovery from a serious illness or from ICU treatment with a genuine post-viral syndrome. To the extent that serious illness and ICU admissions will be dramatically reduced by vaccination, post-infection damage should decline equally.

The New Zealand scenario could well be described as an iatocracy, where the conventional politics of compromise between conflicting ideals is replaced by the rule of biomedicine in the sole interests of the prevention of one particular infection that, with vaccination, is unlikely to be of any great consequence. Moreover, it is a regime that creates new opportunities for private interests to profit at the public expense. We should already be concerned about the deep investment of commercial interests in the promotion of a policy of constant testing, of constant checking of immunity or vaccination status, and of constant quarantines. The interdependence of private and public interests seen in aviation security post 9/11 is not an example to follow.

If the promise of the vaccines is realised, Covid-19 simply becomes another endemic respiratory infection that most of us will get several times in our lives, some of us may need additional medical support to fight off and a few of us will die from. Our societal response must be proportionate to that risk and not to the grim and atypical images from our hospitals over the last twelve months.

Dear Editor

Are We Killing The COVID Canary?

Cough is one of the most important warning symptoms of COVID-19. It's like a canary in a coal mine... A warning of possible infection. It warns workers to stay at home… to self isolate. It warns the cougher to get tested… It warns contacts to ’stay away,' be careful, to self isolate and get tested, 'just in case.' In a sense cough and other common symptoms are a Covid-19 canary.

Clinical trials have shown that Covid-19 vaccines suppress symptoms including cough. If the vaccines stop symptoms, but don't stop transmission then we’ve lost our warning. No staying at home 'just in case.' No testing to find out our COVID-19 status. No self isolation to protect others. No followup contact tracing. Vaccinated but infected people just going about their daily activities infecting others. Infecting the vulnerable we think we are protecting by being vaccinated. Infecting our colleagues at work. Infecting our family and friends in the community. All of the above.

In New Zealand, border staff are being prioritised for vaccination on the assumption that vaccination stops transmission thereby protecting the community from border breaches. If the vaccines are suppressing symptoms but not stopping transmission then are we actually increasing the risk of community transmission rather than reducing it?

What does the FDA say in its Q&A’s regarding fast tracking these vaccines?

Q: If a person has received the the Pfizer-BioNTech COVID-19 Vaccine, will the vaccine protect against transmission of SARS-CoV-2 from individuals who are infected despite vaccination?

A: Most vaccines that protect from viral illnesses also reduce transmission of the virus that causes the disease by those who are vaccinated. While it is hoped this will be the case, the scientific community does not yet know if the Pfizer-BioNTech COVID-19 Vaccine will reduce such transmission. (1)

In other words, these vaccines have been allowed to be marketed (not approved) in the HOPE that they will reduce transmission.

In a subsequent press release the FDA have said, "At this time, data are not available to determine how long the vaccine will provide protection, nor is there evidence that the vaccine prevents transmission of SARS-CoV-2 from person to person.” (2)

The UK’s deputy chief medical officer, Professor Jonathan Van-Tam, went a step further and used the word ‘magic’ and ‘hope’ in the same breath in explaining that people must continue to be extremely cautious about transmission even after they’ve been vaccinated. (3)

The scientific community actually knows quite a lot about the relative ineffectiveness of intra muscular vaccines in preventing transmission of respiratory infections. We know that IM vaccines stimulate an IgG immune response, but they don’t stimulate a mucosal IgA immune response. We know that mucosal IgA immune response is a major component of prevention of infection and transmission of respiratory infections.(4)

Without prevention of transmission there can be no vaccine herd immunity, the very thing we have been promised to break the back of the pandemic.

The first person to be given an FDA authorised COVID-19 vaccine generated the headline, "I Trust Science.” (5)

Another early recipient of a vaccine, a nurse, was interviewed on TV and said, “I have had the vaccine because now that I’m protected, it will be safe for me to go and visit my elderly parents whom I haven’t been able to visit for nearly a year.”

Given that it is a year since these vaccines were conceived it beggars belief that our regulators haven’t mandated the simple addition of tests for carriage and transmission of SARS-CoV-2 virus post vaccination. It is as if they don’t want science to get in their way of their hope and magic.

When scientists talk in terms of “hope" and “magic,” on what basis do we trust science?

Are we killing the COVID-19 canary?

Ron Law
Risk & Policy Adviser

(1) Pfizer-BioNTech COVID-19 Vaccine Frequently Asked Questions
https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regula...

(2) FDA Takes Additional Action in Fight Against COVID-19 By Issuing Emergency Use Authorization for Second COVID-19 Vaccine
Action Follows Thorough Evaluation of Available Safety, Effectiveness, and Manufacturing Quality Information by FDA Career Scientists, Input from Independent Experts
https://www.fda.gov/news-events/press-announcements/fda-takes-additional...

(3) How effective will the coronavirus vaccine be at reducing the spread of Covid-19?
https://www.independent.co.uk/life-style/health-and-families/vaccine-cor...

(4) Krammer, F. SARS-CoV-2 vaccines in development. Nature 586, 516–527 (2020). https://doi.org/10.1038/s41586-020-2798-3, https://www.nature.com/articles/s41586-020-2798-3.pdf

(5) https://www.nytimes.com/2020/12/14/nyregion/us-covid-vaccine-first-sandr...