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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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Elimination of covid-19. A practical roadmap by segmentation

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.

1. Even the Pandemic Hasn’t Made Public-Health Icon Paul Farmer Lose Hope [Internet]. Time. [cited 2021 Jan 19]. Available from:
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

20 January 2021
Kentaro Iwata
Professor of Infectious Diseases
Yuki Aoyagi (Internist, Dunedin Hospital, New Zealand)
Division of Infectious Diseases Therapeutics, Kobe University Graduate School of Medicine
Kusunokicho 7-5-2, Chuoku, Kobe, Hyogo 650-0017 Japan