There is a growing call in the United Kingdom (UK) for the total elimination of the rampaging COVID-19 pandemic.
Experts, however, say any approach to controlling an infectious disease has one of three broad aims- suppressing, eliminating or eradicating it.
The UK’s strategy so far seems to be focusing on suppressing the virus, trying to limit its spread. But, some of its concerned nationals have been thinking whether it is the best course of action.
Independent SAGE, which produces advice on managing COVID-19 alongside the British government’s official scientific advisory group, is calling for a national effort to work towards a “zero COVID UK“: that is, completely getting rid of the disease from the country.
However, in Germany, one in five patients hospitalised over the coronavirus succumbed to the disease, with the fatality rate rising to 53 percent for those who received ventilation, a study showed on Wednesday.
Data of 10,000 patients admitted to 930 German hospitals between February 26 and April 19 were analysed by the German Interdisciplinary Association of Critical Care and Emergency Medicine, the Technical University of Berlin and AOK health insurance group’s research arm WIdO.
Hospitalised male patients had a higher mortality rate than women, with 25 percent compared to 19 percent.
Older patients were also significantly more vulnerable, as 27 percent of patients in their 70s died while 38 percent of those above 80 years old failed to pull through.
“These high mortality rates clearly show that a relatively high number of patients with a very serious course of disease were treated in hospitals”, says Director of WIdO, Juergen Klauber.
While warning that such serious course of diseases mainly affects older people and people whose health is already compromised, but also occur in younger patients, he urged the population to take necessary precautions to prevent new infections.
Of the 10,021 patients, 1,727 were given mechanical ventilation. While almost twice as many who received ventilation were men, the mortality rates were similar gender-wise, the study said.
Patients were staying in hospitals for an average of 14 days, with those not on ventilation hospitalised for an average of 12 days while the duration for those who needed help breathing rose to 25 days.
Professor of healthcare management at TU Berlin, Reinhard Busse, notes that on average, 240 days of ventilation will be required for every 100 hospitalised patients.
“These are important numbers to prepare for a second wave of the pandemic. However, we do not anticipate any problems with normal hospital beds, even with high infection rates”, he adds.
Thanks to its decentralised healthcare system, Germany has been able to significantly ramp up its capacity to treat COVID-19 patients, avoiding scenes like in Italy where some hospitals were overwhelmed by the sudden huge caseload.
However, health experts have urged against complacency, with the head of the RKI disease control agency, Lothar Wieler, repeatedly urging the population to keep to hygiene rules like social distancing or mask-wearing.
With the summer holiday season in full swing, politicians are also watching anxiously at infection numbers which have ticked up in recent weeks.
As of Wednesday, Germany recorded 206,926 cases of infections including 9,128 deaths.
So is totally wiping out the disease actually possible, and if so, what will this entail? Could a less ambitious aim be the right way forward instead?
To answer these questions, there is a need to consider not only what is possible and required, but also how much value can be placed on the final outcome.
The three options
Beyond doing nothing, suppression is the least ambitious way to handle the disease. This is where you attempt to reduce infection, ill-health and death to acceptable levels. It’s an approach normally applied to low-consequence infections, such as diarrhoeal diseases, where the risk of death is low.
With suppression, infection levels remain within the health system’s capacity. The disease continues to circulate in the population, albeit at lower levels than if you didn’t act. Consequently, measures continue to be needed to keep infections down and to control localised outbreaks.
Elimination, on the other hand, aims to reduce infection in a country or region to zero. This has been achieved in the UK with polio, and momentarily with measles in 2017. Diphtheria and rubella are close to being eliminated too.
After a disease has been eliminated, continued measures are needed to stop it re-establishing itself, as new infections can be imported from abroad, either by returning travellers or migrants. Elimination is often pursued for diseases that cause serious illness or death.
The final approach is eradication. This seeks to permanently eliminate a disease worldwide, meaning control measures are no longer needed. Thus far, this has only been achieved with smallpox.
One important thing to note is that elimination measures aren’t necessarily different from suppression ones—lockdowns, social distancing, face masks and so on might be used to control COVID-19 under either strategy.
The difference is how rigorously they’re applied and enforced. For suppression, the measures intensify as things get bad and ease when they improve. Whereas, elimination efforts try to get ahead of the outbreak by being intense from the beginning.
The UK government decided to ease its lockdown in response to cases falling, but with the virus still circulating at relatively high levels. The reason why this seems to be a suppression approach is that if the UK were trying to eliminate the virus, it will be continuing to strictly apply infection control measures to drive transmission down to zero.
COVID-19 is a killer that can affect everyone but is principally dangerous to the elderly, those with pre-existing health conditions and ethnic minority groups. We know it’s contagious and has mutated to become even more infectious. Treatment for it can be costly, especially if intensive care is needed, and survivors may suffer long-term health impacts.
COVID-19, therefore, is not a low-consequence infection. A suppression approach that leaves the virus circulating at low levels could still mean potentially thousands of deaths in the UK each year, especially in vulnerable populations.
But the public and policymakers may weigh the healthcare costs and burden of death and disease on one hand against the economic and social costs of continuing with strict control measures on the other.
Faced with rising unemployment, businesses going bust and economic recession, some may question whether trying to eliminate the disease is too costly. In many major advanced economies, GDP may fall by 20%-25% in response to control measures used so far. So from a cost-benefit angle, suppression may seem the most economical approach.
However, these considerations are seen from a short-term perspective. Societal costs in the longer term cast disease control in a different light.
Take the example of influenza. Each year a billion people get infected, and up to 650,000 die from it. The costs of immunizing, treating and controlling influenza are considerable. The US alone spends an estimated US$10 billion (£7.7 billion) a year fighting the flu, with its economy losing tens of billions more due to people being off work. This has wider economic impacts, affecting productivity and national economic growth. And that’s just one year’s worth of cost. Extrapolate that across the world over 50 to 100 years and the costs become astronomical.
There are also lessons from the 1918 influenza pandemic when elimination was not possible. Spanish flu is estimated to have killed 2.1% of the world’s population (~40 million) and caused a 6% decline in GDP, similar in magnitude to the 2008-09 recession. Suppression can be a lose-lose solution for both health and economic outcomes.
That leaves elimination as the more desirable option. Zero COVID status has been achieved in New Zealand, Brunei and several island states in the Caribbean. This shows that it’s possible. In recent months we’ve seen what actions are needed.
Crucially, elimination doesn’t necessarily demand new measures, but rather wider, more consistent and more prolonged adherence to measures we’ve already used. Elimination requires physical distancing, widespread adoption of hygiene practices (including handwashing) and ubiquitous use of face coverings.
Early detection and isolation of cases will be key, using robust test and trace systems. If the transmission of the virus begins to increase, there needs to be a low threshold for implementing new local and national lockdowns. If and when a vaccine becomes available, then mass immunization programs could help boost immunity in the population.
All of these measures taken together can work, but it will come at a cost to society. However, unless elimination is sought, COVID-19 looks very likely to become an endemic disease. We can then expect it to recur every year in outbreaks and seasonal epidemics.
It also won’t be enough to eliminate COVID-19 in our own countries. In a globalized world, infections can travel between continents within a matter of days.
A coordinated global effort at eradication—eliminating COVID-19 permanently everywhere—is needed. This is considerably more challenging, but if we don’t aim for this, the threat of the disease will remain.