Aggressive containment, suppression, and mitigation of covid-19: lessons learnt from eight countries
BMJ 2021; 375 doi: https://doi.org/10.1136/bmj-2021-067508 (Published 29 November 2021) Cite this as: BMJ 2021;375:e067508Read the full collection
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Dear Editor
The SARS CoV2 virus continues to wreak havoc globally with a huge toll on lives, livelihoods and well-being. Many of this pandemic’s future impacts, including the burden of “long COVID” and the deleterious impacts on children’s learning and routine immunisation, loom large.1,2 What is clear is that future pandemic responses must glean and apply every lesson possible from the current calamity to ensure that all countries are in a much stronger position to apply optimal strategies.
Thus the insightful multi-country analysis by Wu and colleagues of diverse pandemic response policies, which concludes that aggressive pandemic containment (virus elimination) is the premier strategy for saving lives and bolstering the economy, while awaiting effective vaccines and treatments, deserves careful attention.3
What is salient from Australian experience is that there appears to be a time-limited golden period, ideally less than 12 months, during which the community will tolerate the stringent measures and impositions on personal liberties necessary for an effective elimination campaign. This provides a defined time-frame for developing, testing, promoting and rolling-out vaccines. Although previously inconceivable, the development of novel vaccine platforms, particularly mRNA vaccines, has transformed this fantasy into a reality.
However, gross inequality precludes all countries from experiencing elimination strategy benefits, and this threatens all people through selection of escape variants and festering vaccine hesitancy. Three prerequisites are key to attempting elimination in all countries during a future pandemic.
Firstly, surveillance must be strong everywhere. The Omicron variant likely emerged many weeks before the publicised discovery in Gauteng, South Africa but was only detected when it arrived in a setting with greater clinical surveillance capacity, and access to PCR testing and genotyping capability.
Secondly, mRNA vaccine production capacity must be rapidly expanded beyond wealthy countries to developing Regions. The monopoly on production and wealthy bidders means that where vaccine development against novel pathogens is required or adaptation is necessary to respond to vaccine escape mutants, the great north-south divide delays access to effective vaccines well beyond any tolerable period of aggressive pandemic containment.
Finally, having wonderful vaccine platforms but an inability to deliver vaccines to everyone everywhere demands innovative administration strategies so that neglected communities are not held hostage by weak health systems, cold chain fragility and the need for skilled immunisers. Accelerated validation and scale-up of micro-array patches, offers a potential mechanism for ensuring universal timely access to pandemic, and other, vaccines.4
More equitable access to these pivotal weapons in the battle against future pandemics is certainly aspirational, but we neglect this investment at all countries’ peril.
1. Ward H, Flower B, Garcia PJ, et al. Global surveillance, research, and collaboration needed to improve understanding and management of long COVID. Lancet 2021; 398: 2057-2059.
2. Durrheim DN, Andrus JK, Tabassum S, et al. A dangerous measles future looms beyond the COVID-19 pandemic. Nature Medicine 2021; 27: 360–361.
3. Wu S, Neill R, Foo CD, et al. Aggressive containment, suppression, and mitigation of covid-19 lessons learnt from eight countries. BMJ 2021; 375:e067508 doi: 10.1136/bmj-2021-067508.
4. Kristensen D, Giersing B, Hickling J, et al. A global collaboration to advance vaccine product innovations – The Vaccine Innovation Prioritisation Strategy. Vaccine 2021; https://doi.org/10.1016/j.vaccine.2021.05.102
Competing interests: No competing interests
Identifying an optimal pandemic response: Assessment needs longer-term analyses and consistent terminology
Dear Editor
The paper by Wu et al provides helpful insights into the impact of covid-19 pandemic response choices [1]. We previously reached a similar conclusion that elimination appears to be the optimal response to an emerging infectious disease like covid-19, at least during the initial response when effective vaccines and antimicrobial agents are not usually available [2]. Several countries in the Asia-Pacific region chose elimination ahead of mitigation and suppression from early in the covid-19 pandemic, including New Zealand [3].
While elimination may also be the preferred longer-term strategy, the complex evolving nature of both the pandemic virus and interventions such as vaccination mean there is a need for analyses that use multi-year health and economic data. Indeed the recent regression analyses by König and Winkler [4] provides a more useful approach to analysing pandemic control strategies and should be repeated with longer-term data.
We also consider that Wu et al have unnecessarily complicated the pandemic strategy assessment field by using the term “aggressive containment” rather than the term “elimination” [2]. There are multiple reasons for sticking with the term elimination in this context, including its brevity, simplicity, and wide use during the current covid-19 pandemic (references available on request). It has a long established meaning in infectious disease epidemiology [5], and evolutionary biology [6]. Individual countries and the World Health Organization have national and regional elimination strategies for various diseases such as polio and measles. Without appropriate and consistent terminology, it will be harder to progress a meaningfully evaluation and comparison of response strategies that can inform our future management of emerging pandemic diseases [2].
Baker MG, Wilson N
University of Otago, Wellington, New Zealand
References
1. Wu S, Neill R, De Foo C, et al. Aggressive containment, suppression, and mitigation of covid-19: lessons learnt from eight countries. BMJ 2021;375:e067508. doi: 10.1136/bmj-2021-067508
2. Baker MG, Wilson N, Blakely T. Elimination could be the optimal response strategy for covid-19 and other emerging pandemic diseases. BMJ 2020;371:m4907. doi: 10.1136/bmj.m4907 [published Online First: 2020/12/20]
3. Baker MG, Kvalsvig A, Verrall AJ, et al. New Zealand's elimination strategy for the COVID-19 pandemic and what is required to make it work. N Z Med J 2020;133(1512):10-14. [published Online First: 2020/04/04]
4. Konig M, Winkler A. The impact of government responses to the COVID-19 pandemic on GDP growth: Does strategy matter? PLoS One 2021;16(11):e0259362. doi: 10.1371/journal.pone.0259362 [published Online First: 2021/11/06]
5. Anon. Global Disease Elimination and Eradication as Public Health Strategies. Proceedings of a conference. Atlanta, Georgia, USA, 23-25 February 1998. Bull World Health Organ 1998;76 Suppl 2:5-162.
6. Telenti A, Arvin A, Corey L, et al. After the pandemic: perspectives on the future trajectory of COVID-19. Nature 2021;596(7873):495-504. doi: 10.1038/s41586-021-03792-w
Competing interests: No competing interests