The Advantages of the Zero-COVID-19 Strategy

Abstract Introduction: To curb the COVID-19 pandemic, countries across the globe have adopted either a mitigation or anelimination policy, such as the zero-COVID-19 strategy. However, further research is needed to systematically investigate the advantages of the zero-COVID-19 strategy in the literature. To bridge the research gap, this study examines the zero-COVID-19 strategy in terms of its advantages as a global anti-pandemic framework. Methods: A literature review was conducted in PubMed, PsycINFO, and Scopus to locate academic articles that discussed the advantages of the zero-COVID-19 strategy. Braun and Clarke’s thematic analysis approach was adopted to guide the data analysis process. Results: The findings of our study show that the advantages of the zero-COVID-19 strategy range from short-term (e.g., limited virus infections, hospitalizations, and deaths), to medium-term (e.g., reduced presence of other infectious diseases), and long-term (e.g., low incidence of long COVID-19). While local residents mainly leverage these advantages, they also impact the global community (e.g., stable global supply of essentials, such as COVID-19 vaccines). Conclusions: COVID-19 is catastrophic, yet controllable. Our study examined the advantages of the zero-COVID-19 strategy from a nuanced perspective and discussed how these advantages benefit both the local and the global community in pandemic control and management. Future studies could investigate the shortcomings of the zero-COVID-19 strategy, especially its unintended consequences, such as adverse impacts on vulnerable populations’ mental health, so that society could more efficiently, economically, and empathetically capitalize on the potential of the zero-COVID-19 strategy for the betterment of personal and public health.


Introduction
COVID-19 was, and still is, catastrophic [1]. In attempting to control the pandemic, two strategies have been widely adopted; the elimination and mitigation approaches [2]. As outline the methods used to answer the research question, as well as the results and overall insights gained from the process.

Data Characteristics
A review of the literature review was conducted to answer the research question. The review focused on scholarly articles that discussed the advantages of the zero-COVID-19 strategy. The initial search included articles published between 11 March 2020,when the World Health Organization first characterized COVID-19 as a pandemic [17], and 1 October 2021. To ensure that the up-to-date studies published during the review process were also considered. A follow-up search was conducted on 27 June 2022. The PubMed, PsycINFO, and Scopus databases were adopted for their inclusive and representative collection of medical publications, especially those focused on COVID-19 [18][19][20]. Two search themes were adopted: the strategy (i.e., the zero-COVID-19 strategy or the elimination policy) and the disease context (i.e., . Example search terms utilized can be found in Table 1. In addition to societies that adopted the zero-COVID-19 strategy, such as Australia, Hong Kong, New Zealand, Macau, North Korea, Singapore, and Taiwan, China was extensively examined for its consistency in its adherence to the zero-COVID-19 strategy. In addition to the publication date, the following inclusion criteria were also utilized to screen articles: (1) the article must be published in English, (2) the research must be conducted in the context of COVID-19, and (3) the article must discuss the advantages of the zero-COVID-19 strategy as an integrated disease elimination approach, as opposed to singular countermeasures of the strategy (e.g., studies solely focused on lockdowns [21]) or the mere eventuality of reaching zero COVID-19 cases (e.g., [22]). Table 1. Example search terms adopted.

Data Analysis
Braun and Clarke's thematic analysis approach was adopted to guide the data analysis process [23], which includes six steps: (1) become familiar with the data, (2) generate initial codes, (3) identify preliminary themes, (4) review emergent themes, (5) define and name themes, and (6) produce the report. After reviewing the title, abstract, and the full text of the records, we removed articles that did not meet the selection criteria. The remaining articles were subsequently read and examined, focusing on content that discusses the advantages of the zero-COVID-19 strategy. After identifying all relevant sections closely related to the aim of the study, we then applied Braun and Clarke's analytical approach to identify common themes across the included articles.

Results
A total of fifty articles were included in the final review, as listed in Table 2. The advantages of the zero-COVID-19 strategy are broadly understood as short-term (e.g., reduced risks of COVID-19 infections, hospitalizations, and deaths), medium-term (e.g., low presence of other infectious diseases), and long-term benefits to society (e.g., the limited presence of COVID-19). A key advantage of the zero-COVID-19 strategy centers on its ability to prevent avoidable virus infections, hospitalizations, and deaths. In a 2022 article, Burki noted that, "China's policy has been enormously successful. Throughout theentire course of the pandemic, the country of 1.4 billion people has reported 1,655,477 cases of COVID-19 and 13,524 deaths . . . The nation's economy grew by a healthy 8.1% last year" [24]. In a modelling study, Cai and colleagues further found that, without zero-COVID-19 measures, such as lockdowns, the city of Shanghai would have to face "a projected intensive care unit peak demand of 15.6 times the existing capacity and causing approximately 1.55 million deaths" amid the Omicron outbreaks [25].
One of the most noticeable medium-term health benefits of the zero-COVID-19 strategy is the reduced presence of infectious diseases (e.g., [26]). In a study of Kawasaki disease, a communicable disease that can cause high fever and coronary vasculitis in children, researchers found that compared to 2018 and 2019, the incidence of the disease in Taiwan decreased by 30% and 31% in 2020, respectively [27]. In terms of long-term benefits, in addition to limiting the presence of long COVID-19 (e.g., [28]), economic considerations are also discussed throughout the literature. In an analysis of 44 countries' COVID-19 policies, König and Winkler concluded that "countries successfully applying the elimination strategy achieved better health outcomes than their peers without having to accept lower growth" [29].
More targeted comparisons are also studied to offer nuanced insights into the positive impacts of the zero-COVID-19 strategy. In an analysis conducted in New Zealand, for instance, Wilson and colleagues noted that the country's elimination strategy reached desired success "in both health and economic terms compared to other OECD countries" [30]. While the advantages of the zero-COVID-19 strategy are mainly experienced by local residents, such as vulnerable populations such as the elderly and the immunocompromised, they also impact the global community. Ding and Zhang discuss how China's zero-COVID-19 strategy has helped slow the global spread of the virus and vaccine production and, by extension, vaccine equity [31]. The heterogeneity of the COVID-19 pandemic and national responses: an explanatory mixed-methods study Chen et al. [41] 2022 China can prepare to end its zero-COVID policy Cheng et al. [42] 2022 Rapid spread of SARS-CoV-2 Omicron subvariant BA.2 in a single-source community outbreak

Discussion
In this study, we set out to examine the advantages of the zero-COVID-19 strategy. While the strategy has advantages and disadvantages, to ensure research focus, we closely focused on the potential of the zero-COVID-19 strategy to help society better cope with the pandemic. To our knowledge, this is one of the first studies discussing the benefits of the zero-COVID-19 strategy from a nuanced perspective. In the following sections, we will discuss the research findings in greater detail, with a close focus on the advantages of the zero-COVID-19 strategy from the lens of: (1) short-term, (2) medium-term, and (3) long-term benefits to the local and the global community.

Short-Term Benefits
One of the most pronounced short-term advantages of the zero-COVID-19 strategy is its ability to prevent avoidable virus infections, hospitalizations, and deaths (see Table 3). Overall, compared to individuals living in societies that adopt a "living with COVID-19" mitigation policy (e.g., the U.S.), individuals often have a considerably lower presence of COVID-19 when the zero-COVID-19 strategy is applied [69][70][71]. For instance, in an analysis of COVID-19 data from 72 countries that were accumulated in 2020, researchers found that, compared to other anti-pandemic measures, the elimination strategy offers substantially greater protection for members of the society, evidenced by indicators ranging from COVID-19 deaths, income, unemployment, trust, as well as mental and physical health at the population level [69]. In general, public health advantages associated with the zero-COVID-19 strategy mirror the essence and the namesake of the umbrella term: the elimination policy aims to eliminate the pandemic [9], including COVID-19 infections, hospitalizations, and deaths. The mitigation policy, on the other hand, sets out to mitigate the pandemic [9]; by not aiming to interrupt the virus transmission patterns (i.e., the elimination of COVID-19 cases), this approach essentially assigns normalcy to COVID-19 infections, as seen in the "Freedom Day" sponsored by the U.K. government [72].

Medium-Term Benefits
It is also important to note that hikes in COVID-19 cases, hospitalizations, and deaths often translate into heightened demand for medical services, which could result in substantial burdens on COVID-19 patients, non-COVID patients, and health care professionals [73][74][75]. Take health professionals such as doctors and nurses, for instance. Recurring evidence shows that health care professionals have to shoulder substantially more physical and psychological stress when COVID-19 infection, hospitalization, and death rates rise [76][77][78]. In a comparison study on breast cancer patients, COVID-19 frontline nurses, and non-frontline nurses, results show that both the patients and the COVID-19 frontline nurses have experienced greater levels of psychological issues (e.g., depression) compared with non-frontline nurses [79]. Evidence further indicates that, compared to non-medical workers, health professionals often experience greater adverse health outcomes, ranging from higher rates of anxiety and depression to insomnia [80][81][82][83]. In addition to the workload associated with COVID-19, mounting evidence shows that in countries that utilized the mitigation strategy (e.g., the U.S.), health care professionals often have to make agonizing, if not impossible, decisions-such as rationing the oxygen supply or intensive care unit beds-essentially being forced to determine who should live and who should die [84]. However, in light of the unintended consequences that the zero-COVID-19 strategy could cause, such as a high demand for health care professionals for testing and tracing, more rigorous empirical evidence is needed to reach a more grounded conclusion in terms of whether the strategy also has a positive impact on the physical and psychological health of health professionals and other vulnerable populations, including COVID and non-COVID patients. Other than potentially reduced knock-on effects on the overall health and social infrastructure, medium-term advantages of the zero-COVID-19 strategy, such as a reduced presence of other infectious diseases and relatively undisturbed economic productivity, have also been discussed in the literature [26,27]. In addition to the reduced presence of health conditions, such as fractures and Kawasaki disease [26,27], it is possible that the relatively low presence of monkeypox in zero-COVID-19 countries such as China may also be contributed to the zero-COVID-19 strategy's rigorous capability in curbing the transmission of viruses.

Long-Term Benefits
While a wide array of achievements could be contributed to the zero-COVID-19 policy, the continuity of economic activity is one of the most noticeable advantages of the zero-COVID-19 strategy from a long-term perspective. Across the pandemic, countries such as the U.S. and the U.K. have faced severe bouts of disruptions to their medical infrastructure, ranging from shortages of face masks, depleted oxygen supplies, and overpacked intensive care units, to decade-long backlogged non-COVID-19-related surgeries [85][86][87]. By contrast, these shortages are considerably less likely in zero-COVID-19 strategy countries. Take China for instance. Rather than debilitated by shortages of critical medical goods and supplies, China emerged as one of the countries that not only produced, but also donated a wide range of medical essentials, such as COVID-19 vaccines [88]. Another long-term benefit of the strategy that is relatively poorly studied is the low presence of long COVID-19 in zero-COVID-19 strategy countries such as China.
While our understanding of the pandemic is still unfolding, recurring evidence shows that long COVID-19 is extremely prevalent among infected populations [89][90][91]. Long COVID-19 refers to a wide range of sustained symptoms, ranging from fatigue, dyspnea, joint pain, chest pain, and anosmia, to cognitive impairment, that "occurs in individuals with a history of probable or confirmed SARS-CoV-2 infection, usually 3 months from the onset of COVID-19 with symptoms and that last for at least 2 months and cannot be explained by an alternative diagnosis" [92]. In a study of approximately 2 million people in the U.S., for instance, researchers found that among participants who had contracted COVID-19, approximately 1 in 5 of those aged 18-64 years and 1 in 4, aged 65 years and over, experience at least one long COVID-19 symptom [93]. This means that, while some mitigation countries, such as Sweden, might have a relatively less daunting toll of COVID-19, especially when compared to nations such as the U.S. (see Table 3), they may still have to face long-term issues, such as long COVID-19. Moreover, factoring in current debates on whether to classify long COVID-19 as a form of disability, it is safe to conclude that one of the long-term advantages that the zero-COVID-19 strategy provides to society is the considerably limited presence of long COVID-19.

Concluding Thoughts
The zero-COVID-19 strategy holds great potential and promise, as discussed in our study. Essentially, the strategy's ability to effectively curb virus spread, and in turn, prevent avoidable COVID-19 morbidity and mortality rates, not only explains why it has been adopted widely amid the current pandemic, but also shows its applicability for future infectious disease outbreaks. The relevance of elimination methods, such as the zero-COVID-19 strategy, could be particularly pronounced amid the early days of outbreaks, when knowledge about the disease is still accruing, testing and tracing capabilities are still building, and effective pharmaceutical interventions, such as vaccines, are either absent, or still under development. As seen amid the worldwide monkeypox outbreaks in 2022, for instance, due to poor understanding of what might have caused the erratic behaviors of the virus [94], even countries that are known for their "live with COVID-19" philosophy, such as the U.S. and the U.K., have advised strict non-pharmaceutical measures, such as self-quarantine, to help at-risk populations better navigate their infections [95]. This, in turn, further suggests that, rather than a privileged pandemic strategy that is only compatible with certain societies, the zero-COVID-19 strategy can be readily applied to most, if not all, societies. From a theory-building perspective, these insights could further enrich the classification and application of pandemic control methods, which are often categorized in terms of templated guidelines (e.g., mitigation vs. elimination policies), as opposed to flexible toolboxes.
It is also important to note that the adoption of the zero-COVID-19 strategy is not a guarantee for sustained pandemic control success. Many factors could shape the formation and impacts of pandemic control policies [58,[96][97][98]. For instance, in addition to the makeup and structure of anti-pandemic measures, differences in policy administration and prioritization of public health may also explain why there are variations in zero-COVID-19 countries' pandemic performances [76]. We also noticed that, in discussing the advantages of the zero-COVID-19 policy, articles often either explicitly or inexplicitly assumed government and health officials' respect for and prioritization of public health as a pretext for adopting or adhering to the zero-COVID-19 strategy. Whether this assumption mirrors reality requires trustworthy evidence to prove, which could serve as a direction for future research. Overall, it is our hope that insights provided in our study, as well as those from future research, could help society more confidently dissect questions such as whether nations in the Middle East (e.g., South Arabia), Far East (e.g., Japan), South Asia (e.g., Thailand), Sub-Saharan Africa (e.g., Sudan), and Europe in general (e.g., Sweden) could also benefit from the zero-COVID-19 strategy, or the elimination policy in general, during COVID-19 or future pandemics.

Limitations
While our study bridges important gaps in the literature, it is not without limitations. First, the findings of this study are solely focused on the advantages of the zero-COVID-19 strategy. It is important to note that the policy has many downsides as well, as discussed in the literature [77,78], such as its disruptions to people's routines and business practices as a result of rigorous adherence to physical distance mandates (e.g., high Stringency Index scores [99]). In addition to unintended consequences, such as loss of access to essential health and social services, mental health challenges caused by strict quarantines and lockdowns, especially poorly executed ones seen in Shanghai amid the city's Omicron outbreaks [100], should also be extensively investigated to prevent future (preventable) miseries across social sectors. However, as the downsides of the zero-COVID-19 strategy are not within the scope of our research question, they were not investigated in the current study. Last but not least, in light of the uncertainties associated with COVID-19 (e.g., breakthrough cases [101]), it is possible that novel advantages and/or disadvantages of the zero-COVID-19 strategy may emerge as the pandemic evolves. Researchers could update the impact of the policy for society at large in a timely fashion to address this issue.

Conclusions
COVID-19 is catastrophic, yet the adverse impacts of the pandemic are both containable and controllable. Our study examined the advantages of the zero-COVID-19 strategy from a nuanced perspective, and discussed how these advantages benefit both the local and the global community in pandemic control and management. To gain a more balanced understanding, future studies could investigate the shortcomings of the strategy, especially its unintended consequences, such as adverse impacts on public mental health, so that society could more efficiently, economically, and empathetically capitalize on the zero-COVID-19 strategy for the betterment of personal and public health in the long run.