Schools in Shanghai closed on Monday, as did the US Embassy in Beijing while the streets of major Chinese cities are reportedly deserted as residents retreated from a wave of COVID-19 cases.

In the past week, the country has officially reported over 148,000 new cases – but this is likely to be much higher as it recently relaxed testing requirements. Only two deaths have been officially reported but there are widespread reports on social media about funeral homes being overwhelmed by COVID-related deaths.

While most of its citizens have been under strict lockdowns on and off for the past three years as part of its “zero COVID” strategy, the Chinese health authorities did not roll out sufficient vaccine boosters to its captive audience to ensure more protection against the fast-spreading Omicron variant.

While 87% of Chinese people are vaccinated with two shots of the local homologous vaccines, Sinopharm and Sinovac-Coronavac, only 55% are boosted, according to the World Health Organization (WHO).

Older Chinese who are more vulnerable to serious illness have been particularly resistant to boosters.

But China’s vaccines are only about 60% effective against severe infection in comparison to the over 90% protection offered by mRNA vaccines, and experts recommend a third booster shot to raise their level of protection. 

mRNA Vaccines only for non-Chinese

Last month, US Treasury Secretary Janet Yellen told the New York Times that China had not been interested in importing the US-produced mRNA vaccines, Pfizer and Moderna.

Similarly, Germany had also appealed to China recently to grant regulatory approval to the BioNTech-Pfizer COVID vaccine.

However, Chinese Ministry of Foreign Affairs spokesperson Mao Ning told a media briefing earlier this month that “China and Germany have reached an agreement on providing German vaccines for German nationals in China” – but not for the wider population. In exchange, Chinese nationals in Germany have been authorised to take the Chinese vaccines.

At her weekly briefing on Wednesday, Ning sought to allay fears of widespread COVID cases and deaths, assuring the media briefing that the zero-COVID approach had “provided maximum protection to people’s lives and health” and the country was currently adapting its COVID response measures “to better coordinate epidemic response and socioeconomic development”.

“China is ready to work with the international community to deepen solidarity and cooperation, jointly address the COVID challenge, make greater efforts to protect people’s life and health, promote sound recovery and growth of the world economy, and advance the building of a global community of health for all,” said Ning.

Weak vaccines, lack of boosters

“Although there is a high rate of vaccination, comparatively low effectiveness of the vaccines used in China against Omicron and the long duration since vaccination for many individuals mean that 80% of the population is susceptible to Omicron infection,” according to a briefing document from the Institute for Health Metrics and Evaluation (IHME) at the University of Washington.

Based on modelling that includes the implementation of social distancing, the IHME “expect 323,000 total deaths from COVID-19 by 1 April 2023” but warns that one million Chinese people could die from COVID-19 next year.

Although there is a perception that Omicron is mild and will not have a high death toll, “the experience in Hong Kong, however, where 10,000 died in the first months of the Omicron wave, would suggest otherwise”, according to the IHME. 

It describes Hong Kong as a good indicator of what is likely to happen in China, as it has  “similar levels of vaccination with a comparatively poor vaccine and low levels of vaccination in the over-80 population, who are at the highest risk of death”. 

“Over 2022, the infection-fatality rate in Hong Kong was over 0.1% overall.”

The IHME predicts huge numbers of elderly people with severe disease, and hospitals being overwhelmed.

“Strategies to greatly reduce the death toll have been available but not used: switching to the more effective mRNA vaccines and producing or acquiring Paxlovid to manage disease in the vulnerable populations.”

However, Chinese importer Meheco signed an agreement last week with Pfizer to import its antiviral, Paxlovid, according to Reuters. However, there has been no indication that the country will acquire mRNA vaccines although the US has announced that it will make these available to the country if asked.

Currently, Paxlovid is available in China – but often sold out, and with a hefty price, according to Professor John Ji from Tsinghua University in Beijing.

Antiviral #paxlovid is now available in #China, but often sold out. Retail cost is RMB 2900 ($415 USD). #COVID pic.twitter.com/2DLbVzFxI7

— John Ji (@ProfJohnJi) December 20, 2022

Meanwhile, three Hong Kong-based scientists published in a preprint last week calling on China to implement “fourth-dose heterologous boosting” to 4-8% of the population per week, and ordering enough antiviral treatment to cover 60% of the population, as well as public health measures including social distancing and mask-wearing. 

This would avoid “catastrophically overburdening health systems and/or incurring unacceptably excessive morbidity and mortality” as the country exited its “zero COVID” strategy.

“With fourth-dose vaccination coverage of 85% and antiviral coverage of 60%, the cumulative mortality burden would be reduced by 26-35% to 448-503 per million, compared with reopening without any of these interventions,” according to the researchers, who are based at the WHO Collaborating Centre for Infectious Disease, Epidemiology and Control at the Hong Kong University’s School of Public Health.

Back in May, WHO Secretary-General Dr Tedros Adhanom Ghebreyesus told a media briefing that China’s strategy was no longer sustainable in the face of the more infectious but less lethal Omicron.

“When we talk about the zero-COVID strategy, we don’t think that it’s sustainable, considering the behaviour of the virus now and what we anticipate in the future,” said Tedros, prompting a rebuke from Chinese officials