Is SARS-CoV-2 elimination or mitigation best? Regional and disease characteristics determine the recommended strategy

Public health responses to the COVID-19 pandemic varied across the world. Some countries (e.g., mainland China, New Zealand, and Taiwan) implemented elimination strategies involving strict travel measures and periods of rigorous non-pharmaceutical interventions (NPIs) in the community, aiming to achieve periods with no disease spread; while others (e.g., many European countries and the United States of America) implemented mitigation strategies involving less strict NPIs for prolonged periods, aiming to limit community spread. Travel measures and community NPIs have high economic and social costs, and there is a need for guidelines that evaluate the appropriateness of an elimination or mitigation strategy in regional contexts. To guide decisions, we identify key criteria and provide indicators and visualizations to help answer each question. Considerations include determining whether disease elimination is: (1) necessary to ensure health care provision; (2) feasible from an epidemiological point of view; and (3) cost effective when considering, in particular, the economic costs of travel measures and treating infections. We discuss our recommendations by considering the regional and economic variability of Canadian provinces and territories, and the epidemiological characteristics of different SARS-CoV-2 variants. While elimination may be a preferable strategy for regions with limited health care capacity, low travel volumes, and few port of entries, mitigation may be more feasible in large urban areas with dense infrastructure, strong economies, and with high connectivity to other regions.