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Commentary: China could face a catastrophic COVID-19 surge as it lifts restrictions

The transition out of zero-COVID has been painful for any country that’s done it and China faces some unique challenges, says this biology professor.

Commentary: China could face a catastrophic COVID-19 surge as it lifts restrictions
Passengers wearing protective overalls wait for their train at a train station in Shanghai, May 2022. (Leah Zhang via AP)

LONDON: China is the only major country which, until now, has continued to enforce a zero-COVID strategy. Other countries, including Australia, New Zealand and Singapore, also sought to eliminate COVID-19 entirely earlier in the pandemic. But all eventually abandoned this approach because of the mounting social and economic costs and the realisation that local elimination of COVID-19 was largely futile and only transient.

China’s strategy, which has relied on measures including mass testing, shutdowns of entire cities and provinces, and quarantining anyone who may have been exposed to the virus, has increasingly become untenable. The harsh and often arbitrary enforcement of zero-COVID has fuelled growing resentment among the population, culminating in large public protests.

The restrictions have also shown their limits in the face of Omicron. This variant has a shorter incubation period than previous COVID-19 lineages, and largely bypasses protection against infection conferred by the original vaccines.

It’s logical that Chinese authorities are now moving to ease restrictions. However, the transition out of zero-COVID has been painful for any country that’s done it. And China faces some unique challenges in making this shift.


China has successfully suppressed widespread COVID-19 transmission since early 2020. Although figures differ between sources, close to 10 million cases have been reported to the World Health Organization since January 2020.

This represents only a tiny fraction of the country’s population, numbering 1.4 billion. So the Chinese population has acquired minimal immunity to COVID-19 through exposure to the virus to date.

Hundreds of protestors gathered on the banks of Liangma river, many holding blank white papers, in protest against China's harsh COVID-19 restrictions. (Photo: AFP/Noel CELIS)

Vaccination rates in China are largely in line with those in Western countries. But an unusual feature of China’s vaccination rates is that they decrease with age. Older adults are by far the demographic at highest risk of severe COVID-19, yet only 40 per cent of people over 80 have received three doses.

Vaccine efficacy against transmission has been severely tested, especially since Omicron started spreading in late 2021. That said, protection against severe disease and death provided by the mRNA vaccines used in Western countries has remained high.

China has used different vaccines; primarily “inactivated” shots made by Sinovac and Sinopharm. Inactivated vaccines are based on pathogens (so SARS-CoV-2, the virus that causes COVID-19, in this case) but these are killed, or inactivated, before inoculation. Inactivated vaccines are generally safe, but they tend to elicit lower immune responses than newer vaccine technologies, such as mRNA (Pfizer-BioNTech and Moderna) or adenovirus vector-based vaccines (AstraZeneca and Johnson & Johnson).

The performance of the Chinese vaccines has been mixed. While two doses of the Sinovac shot reduced deaths by 86 per cent in Chile, results from Singapore suggested the inactivated vaccines provided poorer protection against severe disease relative to their mRNA counterparts.


It’s true the globally dominant Omicron variant is associated with significantly lower disease severity and death than the Delta variant it replaced. But Omicron remains a major threat for populations with little prior immunity – particularly among the elderly.

Hong Kong was facing similar problems to mainland China in early 2022 with comparably low virus exposure across the population. Hong Kong had even poorer vaccination rates among older adults than China does now, though a more robust healthcare system.

The Omicron wave that swept Hong Kong in March led to more deaths per inhabitant in a matter of days than many countries have seen through the entire pandemic.

COVID-19 infections are now rising quickly in China, numbering above 30,000 new daily cases in recent days. As various restrictions are eased, there’s little question numbers will continue to surge.

Given the low level of immunity in China, a major surge would likely see large numbers of hospitalisations and might lead to a dramatic death toll.

If we assume, say, 70 per cent of the Chinese population becomes infected over the coming months, then if 0.1 per cent of those infected die (a conservative estimate of Omicron’s mortality rate in a population with hardly any prior exposure to SARS-CoV-2), a back-of-the-envelope calculation suggests we’d see around 1 million deaths.

There’s relatively little China can do at this stage to avert significant death and disease – though any last-ditch vaccination campaign focusing on older adults will likely help.

People receive COVID-19 vaccines in China's southwestern city of Chongqing. (Photo: AFP/STR)

Chinese healthcare is fairly fragile and the dearth of critical care beds represents a particular vulnerability.

The country would be well-served to lift restrictions gradually, to try to “flatten the curve” and avoid the healthcare system becoming overwhelmed. Effective triaging of patients, in particular ensuring that only those most in need of care are admitted to hospital, could help reduce deaths if the epidemic got out of control.


A major wave in China won’t necessarily have a significant impact on the global COVID-19 situation. The SARS-CoV-2 lineages currently spreading in China, such as BF.7, can be found elsewhere around the world.

Circulation in a largely immunologically naive population should not exert much additional pressure on the virus to evolve new variants that can escape our immunity.

But China is facing a possible humanitarian catastrophe, and I would argue this is a much greater challenge.

There’s an irony in China having been the first country affected by COVID-19 and also the last to give up on its elimination. Chinese authorities pioneered and championed unprecedented measures to suppress viral spread, providing a blueprint for harsh pandemic suppression strategies globally. China then implemented those measures more ruthlessly and for longer than any other major country.

Yet in the end, zero-COVID proved largely futile. China, the last domino, will fall soon due to the unsustainable social and economic costs of zero-COVID policies.

The virus will spread in China as it did elsewhere, leaving in its wake its trademark of disease, death and bitter dissension in the population.

Francois Balloux is the Chair Professor of Computational Biology at University College London. This commentary first appeared on The Conversation.

Source: Others/ch


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