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

BMJ 2020; 371 doi: (Published 22 December 2020) Cite this as: BMJ 2020;371:m4907

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Rapid Response:

What is an elimination strategy?

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

18 January 2021
Roger A Fisken
Retired consultant physician