Since the declaration of the novel coronavirus as a pandemic by the World Health Organization, a variety of strategies have been implemented to combat its spread. Among these strategies, two predominant approaches have emerged: elimination and mitigation. Elimination, also known as the 'Zero-COVID' strategy, is primarily adopted by island states such as New Zealand, Australia, Singapore, Japan, South Korea, Vietnam, mainland China, Hong Kong, and Taiwan.

Zero-COVID approach seeks to achieve a goal of zero deaths by vigorously containing the virus through short-term lockdowns, followed by stringent find, test, trace, and isolate measures. It places a strong emphasis on the protection of lives at all costs. On the other hand, countries such as India, the United States, the United Kingdom, and Sweden have implemented anti-pandemic measures that follow a mitigation strategy. This approach employs relatively lenient or relaxed measures to restrict virus transmission. (1)(2)

Benefits of Zero-COVID strategy

• One of the main arguments for justifying the Zero-COVID strategy is based on societies' overarching duty to protect human life, whereby every COVID-19 death is considered unacceptable. This argument suggests that since the Zero-COVID approach has a better track record in terms of saving lives than the mitigation strategy, it should be favoured over the latter.

• In terms of short-term benefits, the Zero-COVID-19 strategy has been shown to prevent avoidable infections, hospitalizations, and deaths caused by the virus. In comparison to societies that adopt a "living with COVID-19" mitigation policy, individuals in societies that implement the Zero-COVID-19 approach typically have much lower rates of COVID-19 infection. For instance, an analysis of COVID-19 data from 72 countries conducted in 2020 revealed that the elimination strategy provides significantly greater protection to society members in terms of COVID-19 deaths, when compared to other anti-pandemic measures.(3)(4)

• Multiple studies have shown that the Zero-COVID approach is more effective in saving lives than the mitigation strategy. For example, Oliu-Barton conducted a study comparing countries that adopted the Zero-COVID-19 approach with those that adopted the mitigation approach, and found that countries that implemented Zero-COVID had COVID-19 death rates that were 25 times lower than those that adopted the mitigation strategy.(5)

• Overall, the argument in favour of the Zero-COVID approach is that it provides significant short-term benefits in terms of preventing COVID-19 infections, hospitalizations, and deaths, particularly when compared to the mitigation strategy.

Argument against Zero-COVID strategy

It is important to note that health equity concerns are not exclusive to the Zero-COVID strategy, but can also arise under the mitigation approach. In particular, marginalized communities can be disproportionately burdened by the pandemic and the societal responses to it, especially when such communities are already facing structural racism or poverty.(6)

For instance, the implementation measures, such as physical distancing and quarantine, may not be feasible or effective for individuals living in crowded and under-resourced communities. Such communities may lack access to adequate healthcare services, personal protective equipment, and information on how to protect themselves against COVID-19. As a result, these communities may face a higher risk of infection and more severe outcomes, including hospitalization and death.(7)

Research has found that strict lockdowns can have a significant impact on health services for individuals with chronic diseases, such as heart disease, stroke, chronic kidney disease, and cancer. The diversion of medical resources to combat the pandemic can compromise routine check-ups and follow-up treatments for these patients, leading to negative consequences. During the recent Omicron wave in Shanghai, strict lockdowns resulted in interruptions in regular medical care and limited treatment resources, causing havoc among residents. For instance, individuals requiring dialysis were unable to receive treatment due to hospitals' policies of no admission without a negative polymerase chain reaction (PCR) test for COVID-19. These findings indicate that while lockdowns may be an effective measure for controlling the spread of COVID-19, they can have unintended consequences for individuals with chronic health conditions.(8)

Therefore, it is essential to consider health equity concerns in the development and implementation of any pandemic response strategy. This includes taking into account the unique circumstances and needs of marginalized communities and ensuring that measures are in place to address any adverse impacts on their health and well-being. Such efforts may include targeted outreach and education, provision of resources and support, and partnerships with community organizations to build trust and foster engagement.(9)(10)

Change in strategy

The change from a zero-COVID approach will come with many advantages, but also great challenges.

Advantages

Challenges

Conclusion

• The Zero COVID strategy can be effective in controlling infectious diseases, especially in the early stages of an outbreak when little is known about the disease and there are no effective measures to control it. However, with the advent of vaccines and wide vaccination coverage, as well as a decreasing case fatality rate, it may be more advantageous to opt for a mitigation strategy rather than a Zero COVID approach.

• Vaccines have been developed and deployed at an unprecedented pace, providing significant protection against the virus and drastically reducing the risk of severe disease and death. This has enabled governments to shift their focus from the elimination of the virus to the management of its impact on society. Instead of trying to completely eradicate the virus, mitigation strategies focus on reducing the transmission and severity of the disease while keeping the economy and society open.

• Furthermore, a Zero COVID strategy may not be feasible in the long term as it requires strict and often draconian measures, such as complete lockdowns, which can have severe economic and social consequences. Mitigation strategies, on the other hand, can be adapted to the changing situation and can be less disruptive to daily life while still being effective in controlling the spread of the virus.

References

1.         Coronavirus disease (COVID-19): Variants of SARS-COV-2 [Internet]. [cited 2023 Feb 24]. Available from: https://www.who.int/news-room/questions-and-answers/item/coronavirus-disease-(covid-19)-variants-of-sars-cov-2

2.         Su Z, Cheshmehzangi A, McDonnell D, Ahmad J, Šegalo S, Xiang YT, et al. The Advantages of the Zero-COVID-19 Strategy. International Journal of Environmental Research and Public Health. 2022 Jan;19(14):8767.

3.         Frontiers | Asymptomatic Transmissibility Calls for Implementing a Zero-COVID Strategy to End the Current Global Crisis [Internet]. [cited 2023 Feb 24]. Available from: https://www.frontiersin.org/articles/10.3389/fcimb.2022.836409/full

4.         Helliwell JF, Norton MB, Wang S, Aknin LB, Huang H. Well-being Analysis Favours a Virus-Elimination Strategy for COVID-19 [Internet]. National Bureau of Economic Research; 2021 [cited 2023 Feb 24]. (Working Paper Series). Available from: https://www.nber.org/papers/w29092

5.         Oliu-Barton M, Pradelski BSR, Aghion P, Artus P, Kickbusch I, Lazarus JV, et al. SARS-CoV-2 elimination, not mitigation, creates best outcomes for health, the economy, and civil liberties. Lancet. 2021 Jun 12;397(10291):2234–6.

6.         Open letter from African intellectuals to leaders over COVID-19 [Internet]. [cited 2023 Feb 24]. Available from: https://www.aljazeera.com/features/2020/4/17/open-letter-from-african-intellectuals-to-leaders-over-covid-19

7.         Saalim K, Sakyi KS, Fatema-Tuz-Zohra, Morrison E, Owusu P, Dalglish SL, et al. Reported health and social consequences of the COVID-19 pandemic on vulnerable populations and implemented solutions in six West African countries: A media content analysis. PLOS ONE. 2021 Jun 16;16(6):e0252890.

8.         Kluge HHP, Wickramasinghe K, Rippin HL, Mendes R, Peters DH, Kontsevaya A, et al. Prevention and control of non-communicable diseases in the COVID-19 response. Lancet. 2020;395(10238):1678–80.

9.         Bai W, Sha S, Cheung T, Su Z, Jackson T, Xiang YT. Optimizing the dynamic zero-COVID policy in China. Int J Biol Sci. 2022;18(14):5314–6.

10.       Jecker NS, Au DKS. Does Zero-COVID neglect health disparities? J Med Ethics. 2022 Mar;48(3):169–72.