Elimination could be the optimal response strategy for covid-19 and other emerging pandemic diseases
BMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m4907 (Published 22 December 2020) Cite this as: BMJ 2020;371:m4907Read our latest coverage of the coronavirus outbreak

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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.
Competing interests: No competing interests
Dear Editor
The countries who seemed to eliminate the virus quickest, were those which shut their borders the quickest and most completely. Countries like the UK, who demonstrated a half hearted approach to border control, have suffered the worst.
Competing interests: No competing interests
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.
Competing interests: No competing interests
Dear Editor
I read the letter Ron Law with interest. [1] I note the words of Chief Medical Officer Chris Whitty in the government advert on Sky News, saying "vaccines give clear hope for the future" [2]. This also makes no claim of effectiveness for the intervention. There is no doubt about the government’s commitment to a vaccine solution [3,4] but does it presently have scientific substance?
[1] Ron Law, 'Are We Killing the COVID Canary?' , 18 January 2021, https://www.bmj.com/content/371/bmj.m4907/rr-4
[2] COVID-19: Professor Chris Whitty's warning in new government advert. Sky News 2021 January 8. https://news.sky.com/video/covid-19-professor-chris-whittys-warning-in-n...
[3] Prime Minister Boris Johnson closes the Global Vaccine Summit #GVS2020 YouTube 4 Jun 2020
[4] https://www.gov.uk/government/speeches/prime-ministers-speech-to-un-gene...
Competing interests: AgeofAutism.com, an on-line daily journal, concerns itself with the potential environmental sources for the proliferation of autism, neurological impairment, immune dysfunction and chronic disease. I receive no payment as UK Editor. I also moderate comments for the on-line journal ‘The Defender’ for which I am paid. I am also a member of the UK Medical Freedom Alliance
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.
Competing interests: No competing interests
Dear Editor,
I confess to a high degree of confusion when I first read this article, since the authors do not clearly define what they mean by an elimination strategy. Despite not providing a definition the authors are at pains to make a distinction between elimination and suppression, yet any of the measures used against the pandemic are likely, if used properly, to reduce transmission and therefore contribute to the eradication of the virus from the population. In their earlier paper (reference 6) they state that a successful elimination strategy requires:
"1) high-performing epidemiological and laboratory surveillance systems;
2) an effective and equitable public health system that can ensure uniformly high delivery of interventions to all populations, including marginalised groups (in this instance intervention is focused on diagnosis, isolation of cases and quarantine of contacts rather than vaccine); and
3) the ability to sustain the national programme and update strategies to address emerging issues. "
In the earlier paper they go on to say: "[t]he essential elements of an elimination strategy for COVID-19 are likely to include:
1. Border controls with high-quality quarantine of incoming travellers;
2. Rapid case detection by widespread testing, followed by rapid case isolation, with swift contact tracing and quarantine for contacts;
3. Intensive hygiene promotion (cough etiquette and hand washing) and provision of hand hygiene facilities in public settings;
4. Intensive physical distancing ... that includes school and workplace closure, movement and travel restrictions, and stringent
measures to reduce contact in public spaces, with potential to relax these measures if elimination is working;
5. A well-coordinated communication strategy to inform the public about control measures and about what to do if they become unwell, and to reinforce important health promotion messages."
With great respect, none of this is new. If the authors believe that all of these measures need to be put in place but that certain measures (such as tighter border controls and a more vigorous approach to testing, contact tracing and quarantining/isolation) need to be instituted in the UK, why not say so? Where are the data (if they exist) that allows health policy makers to prioritise one element of the strategy over another?
Competing interests: No competing interests
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...
Competing interests: No competing interests
Dear Editor
Elimination of Sars-cov-2 in UK (GB) will be an uphill struggle. Had the government shut all ports and airports in March and closed all sporting events we might have had a different outcome. Alas, the government singularly failed to have a plan in place to anticipate a global respiratory pandemic. Having run down its manufacturing sector during the 1980s-90s and converting to a deliveroo service economy left UK unable to source vital PPE, and other essential supplies.
The plan to insist on mandatory PCR tests for all those travelling from outside UK is flawed. The PCR test only detects viral RNA, it cannot tell if someone is infectious. A negative PCR does not necessarily mean that person is not infectious, they could be incubating the virus. A positive PCR test result does not necessarily mean the person is infectious, the PCR can also detect RNA fragments from a previous infection. It cannot distinguish RNA from live virus and RNA from an earlier infection, where the person has recovered, but can still give a positive result weeks afterwards but is no longer infectious.
To differentiate PCR results simultaneous viral cultures should be taken. If the viral culture shows live virus for a person with either positive or negative PCR, they are infectious. If no virus is found by viral culture they are not infectious. Is viral culture carried out at airports before departure?
The vaccines at present have no definitive proof they can prevent viral transmission and the duration of immunity is unconfirmed. They may possibly attenuate covid-19 symptoms so reducing hospital admissions, however their long term unintended adverse effects are as yet unknown and work in progress. The recent deaths in Norway of 23 elderly care home residents after they received the Pfizer vaccine is causing concern and is being investigated.
I am in the under 65 age group, so far I have managed to avoid Covid-19, however I am reluctant to accept either vaccine until I am convinced they are safe and efficacious. Recent articles in BMJ suggest the trials were never designed to show the vaccines save lives, improve health outcomes, reduce admissions. It seems the entire population has been sleepwalked into a massive cohort challenge study with an uncertain outcome. By next year, there will be other vaccines for example protein sub unit and inactivated, non-GMO type, which in my opinion seem a lot safer and less risky than the recombinant/viral vector type. Only time will tell.
There are now 33 documented cases of Covid-19 reinfection listed on the cov-19 reinfection tracker site. The mean interval between infections being 87 days, just under 3 months, which means that extending the time between vaccine jabs to 12 weeks, risks exposing people to infection before they receive their second jab.
Competing interests: No competing interests
Dear Editor
Great poignance to the juxtaposition of the letters of Janet Menage [1] and Ellen Grant [2] today. Surely if we as a species cannot reinstate the pre-eminence of natural immunity we have had it.
[1] Janet Menage, ‘ Re: Redefining the Herd’, 30 December 2020, https://www.bmj.com/content/371/bmj.m4907/rr-1
[2] Ellen CG Grant, ‘ Vitamin D and C deficiencies Re: NICE guideline on long covid’, 30 December 2020, https://www.bmj.com/content/371/bmj.m4938/rr-0
Competing interests: AgeofAutism.com, an on-line daily journal, concerns itself with the potential environmental sources for the proliferation of autism, neurological impairment, immune dysfunction and chronic disease. I receive no payment as UK Editor. I also moderate comments for the on-line journal ‘The Defender’ for which I am paid. I am also a member of the UK Medical Freedom Alliance
Re: Elimination could be the optimal response strategy for covid-19 and other emerging pandemic diseases
Dear Editor
Related to the theme of this article is the issue of global eradication of covid-19. Given the availability of both public health and social measures (PHSMs) and safe and highly-effective vaccines against covid-19, we recently aimed to assess the feasibility of covid-19 eradication globally, relative to the benchmarks of smallpox and polio (see this pre-print: https://osf.io/preprints/socarxiv/f67gn/). On our scoring for eradication feasibility using a three-point scale and across 17 variables, the mean (total) scores were smallpox at 2.7 (43/48), then covid-19 at 1.8 (30/51), and then polio at 1.5 (26/51). More specifically for covid-19 eradication, animal reservoirs may potentially prevent it; but the main challenges are probably around the high upfront costs and achieving international cooperation. Nevertheless, an advantage for covid-19 eradication over these other diseases is that effective PHSMs can complement vaccination and there is very high global interest in covid-19 control (due to the massive scale of the health, social and economic burden). Given this potential, there is a need for a more formal expert review of feasibility and desirability of attempting covid-19 eradication by the World Health Organization or coalitions of national health agencies.
Competing interests: No competing interests