LETTERS BMJ: first published as 10.1136/bmj.n349 on 8 February 2021. Downloaded from

1 Division of Infectious Diseases, Kobe ELIMINATION OF COVID-19 University Hospital, Kusunokicho 7-5-2, Chuoku, Kobe, Hyogo 650-0017, Japan Elimination of covid-19: a practical roadmap by segmentation

2 Dunedin Hospital, Dunedin, New Kentaro Iwata, 1 Yuki Aoyagi2 Zealand [email protected] “When you settle on a problem, devote the resources to it, and have at least some ability to incorporate new Cite this as: BMJ 2021;372:n349 information, every time, it gets better. I don’t have any experience, anywhere, where you just apply yourself, http://dx.doi.org/10.1136/bmj.n349 along with others, and then do not see progress.” Published: 08 February 2021 Paul Farmer referring to his logical optimism.1 We agree with Baker and colleagues that eliminating covid-19 should be the goal.2 The “hammer and dance suppression strategy”3 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, 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 harsh reality is that no countries followed the same steps after the successes of elimination in New Zealand, Australia, China, and Taiwan. The elimination strategy is scientifically sound but is likely to be dismissed by many in the real world. We propose an additional strategy to the measures cited by Baker and colleagues—a segmentation strategy. Eliminating SARS-CoV-2 is harder when we want to achieve it in large, densely populated areas, so it should be implemented in a smaller area first and then scaled up. By gradually increasing (and expanding) the covid-free areas, people are more likely to follow the same steps. We should learn from successes, not failures. Historically, many elimination strategies were laughed at with cynicism. But we should consider these obstacles as hurdles to overcome, not reasons to give up. We need

to be logically optimistic to progress, in the tragedy of the current pandemic. http://www.bmj.com/

Competing interests: None declared.

Full response at: https://www.bmj.com/content/371/bmj.m4907/rr-8.

1 Ducharme J. Even the pandemic hasn’t made public-health icon Paul Farmer lose hope. Time 2020 Dec 3. https://time.com/5917382/paul-farmer-public-health- pandemic/ 2 Baker MG, Wilson N, Blakely T. Elimination could be the optimal response strategy for covid-19 and other emerging pandemic diseases. BMJ on 29 September 2021 by guest. Protected copyright. 2020;371:m4907doi: 10.1136/bmj.m4907. 3 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 2020;74:363-72. doi: 10.3233/CH-209004 pmid: 32390611

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