The past year of Covid-19 has taught us that it is the behaviour of governments, more than the behaviour of the virus or individuals, that shapes countries’ experience of the crisis. Talking about pandemic waves has given the virus far too much agency: until quite recently the apparent waves of infection were driven by government action and inaction. It is only now with the emergence of more infectious variants that it might be appropriate to talk about a true second wave.
As governments draw up their battle plans for year two, we might expect them to base their strategies on the wealth of data about what works best. And the evidence to date suggests that countries pursuing elimination of Covid-19 are performing much better than those trying to suppress the virus. Aiming for zero-Covid is producing more positive results than trying to “live with the virusâ€.
Here are 16 reasons why we think all countries should at least consider an elimination approach:
1. It saves lives. Not surprisingly, eliminating transmission of the virus minimises Covid-19 deaths. Countries pursuing elimination have Covid-19 mortality rates that are typically below 10 per million, which is 100 times less than many countries “living†with the virus.
2. The elimination of community transmission also spares populations from “long-Covidâ€, which causes persistent health problems in survivors. These problems are reported by the majority of people hospitalised because of Covid-19 and can also affect those with even mild infection.
3. Elimination is pro-equity. Pandemics almost invariably cause disproportionate harm to the most disadvantage groups based on ethnicity, income and long-term illness. Eliminating Covid-19 can minimise these inequalities particularly if a suitable social “safety-net†is also provided.
4. Countries that have eliminated Covid-19 are experiencing less economic contraction than countries trying to live with the virus. Mainland China and Taiwan are possibly the only places with neutral or net positive economic growth in 2020.
5. Elimination is achievable and works in a variety of settings. Globally, multiple countries and jurisdictions are successfully pursuing elimination approaches, notably mainland China, Taiwan, Vietnam, Cambodia, Laos, Mongolia, Singapore, Australia and New Zealand. They are diverse in geography, population size, resources, and styles of government.
6. The virus can be eliminated even after intense local transmission has occurred. Mainland China demonstrated this in Wuhan. The state of Victoria in Australia was also able to eliminate Covid-19 even after a period of intense local transmission with higher rates than were being reported in the UK at the time.
7. It’s easier if more countries adopt this approach. Border controls can be relaxed, creating “green zones†and allowing quarantine-free travel with associated social and economic benefits. This opening-up is already happening among Australian states and between Pacific islands and New Zealand.
8. The rollout of effective vaccines will make Covid-19 elimination easier to achieve. Effective vaccines working in combination with other public health measures have been crucial to the successful elimination of diseases such as polio and measles[MB1] in many countries.
9. Having an explicit “zero-Covid†goal provides a strong motivating and coordinating focus. Suppression does not offer a clear end point, leaving countries vulnerable to rapid resurgences, as seen recently in countries like Ireland[MB1] . The resulting uncertainty makes it impossible to plan, with enormous consequences for schools, businesses, family life, and much else.
10. It is sustainable. Countries pursuing elimination have had setbacks in the form of border failures and outbreaks, but have mostly been able to contain them and regain their elimination status[MB1] .
11. If the virus mutates, elimination still works. The major methods used for Covid-19 elimination (border management, physical distancing, mask wearing, testing and contact tracing) are relatively unaffected by virus mutations (though testing could theoretically be less effective if the virus changed markedly, and outbreak control would become more difficult with more infectious variants).
12. It also still works if vaccines provide only limited long-term protection. For example, if vaccines are poorly effective at preventing onward transmission then elimination methods could supplement that limitation.
13. It may reduce emergence of more dangerous virus variants. Elimination approaches result in far fewer circulating viruses. Consequently, there will be fewer opportunities for emergence of new variants that are more infectious, and that might escape the protective effects of vaccines, or even be more lethal.
14. The use of lockdowns should be less necessary. A relatively short, intense lockdown to eliminate Covid-19 transmission in an area should allow control measures to be relaxed in the absence of circulating virus. Countries such as New Zealand have had far less time under lockdown than most countries pursuing suppression which have needed to go in and out of lockdown for long periods to avoid their health services becoming overwhelmed.
15. Vigorous control of Covid-19 infection has substantial co-benefits. Elimination approaches have reduced transmission of other respiratory viruses, notably influenza, resulting in fewer hospitalisations and deaths from these respiratory pathogens.
16. It provides a good interim strategy while we identify an optimal long-term approach, which is currently uncertain. One scenario could be regional elimination or even global eradication as we saw with Sars. Another plausible option is endemic infection with the health burden being managed with vaccines, as we see with influenza.
These benefits of pursuing a Covid-19 elimination strategy need to be balanced against the costs and potential negative effects. However, these costs are also experienced by countries trying to suppress the virus, except in their case they come repeatedly, after each resurgence.
On balance, elimination looks like the “least bad choice†for many jurisdictions. We hope that all governments, and the World Health Organization, will consider the elimination strategy as they plan year two of our global response to the pandemic.
Michael Baker is a professor of public health at the University of Otago
Martin McKee is a professor of European public health at the London School of Hygiene and Tropical Medicine
