Can China’s dynamic zero-COVID policy survive in the face of citizen protests, infectious variants?

China is recording more than 70,000 COVID-19 cases daily, a pandemic high for the country  

By Taran Deol
Published: Friday 02 December 2022
Can China’s zero-COVID policy survive in the face of citizen protests, infectious variants? Photo: iStock

China has been loyal to its ‘dynamic zero-COVID’ policy since the beginning of the pandemic, but the ongoing FIFA football world cup came as a rude shock for the country’s residents. 

The massive crowd seen enjoying the game without masks or physical distancing at the stadiums in Qatar was in complete contrast to how the Chinese have been living under the draconian restrictions.

An unprecedented civilian pushback against the administration’s strict non-pharmaceutical measures is underway, even as the Chinese state television censored streaming the world cup to remove shots of packed crowds.

The resistance is unfolding in the backdrop of more than 70,000 COVID-19 cases being recorded daily — a pandemic high for the country. The total caseload in China is now 1.6 million, with around 5,000 deaths, according to Our World in Data, an independent online data repository. 

The wave is reportedly driven by an extremely infectious omicron sub-variant, likely BF.7. These statistics are monumentally lower than what any other nation has recorded, evidence of the ‘dynamic zero-COVID’ policy’s success. Under this, the ultimate aim is to minimise infections to restrict their spillover into the community and control outbreaks as quickly as possible, Ben Cowling, professor of epidemiology at the University of Hong Kong’s School of Public Health, told Down To Earth (DTE). 

Broadly speaking, each different part of the country will be in one of these two phases at each point in time: No daily local cases, where the priority is strict application of travel-related measures such as testing and quarantines to keep the virus out of the location, and the outbreak phase, where the priority is rapid control of the outbreak to get back to zero daily cases. 

Cowling added:

In the second half of 2020 and the whole of 2021, most locations in China had no cases most of the time. This was due to the very successful application of the zero-COVID measures. In the second half of 2022, more and more outbreaks have been occurring, and there seems to be less and less time spent at zero daily cases. 

Why China

Some experts are of the opinion that China is a ticking time bomb in terms of variant evolution, as the virus spreads unabated in an immunologically naive population. “The fitness landscape for the virus would be very different from what it is elsewhere at this point. That is, the features under selection will not be the same,” Ryan Gregory, professor of evolutionary biology from University of Guelp’s Biodiversity Institute of Ontario, noted in his analysis, assuming an overall low immunity and high population densities in some cities.

“Specifically, it will be about transmissibility, not immune escape,” he said. “Variants which emerge in such a population may not have the same fitness against hosts with prior infection from other variants of omicron. 

A large COVID-19 outbreak in China is unlikely to have consequences for the global population outside the country, according to Cornelius Roemer, a computational biologist from Switzerland. 

In 2020 and for some time in 2021, there were several other flag-bearers of the zero-COVID policy. The virus outsmarted all their defences one by one, with New Zealand, Singapore, Hong Kong and Australia giving up the strategy and adopting a more sustainable approach based on large-scale vaccinations. 

China, as the lone follower of the Zero COVID policy, is now at a dangerous crossroads. Civilian unrest and lockdown fatigue is already making it difficult to persist with this policy, while lifting restrictions now runs the risk of widespread infections. 

A modelling study by Airfinity, a life science analytics company, published November 28, 2022 estimated 1.3 to 2.1 million deaths if the zero-COVID policy ended. 

Hong Kong was at a similar inflection point when omicron sub-variant BA.1 breached its defences in February this year. At the time, immunity derived from natural infection was low, as was vaccine uptake, particularly in the elderly vulnerable population. 

What followed was a peak of more than 8,000 daily cases per million and 37.96 deaths per million people, showed Our World in Data. The region gave up its ‘zero-COVID’ policy but before that, focused on vaccinating its elderly, managing to protect 43 per cent of this vulnerable population at the peak of the BA.1 wave.

Source: Airfinity

Like Hong Kong, China is not prepared for a large surge in infections. Vaccination levels remain low, with less than 40 per cent of its 80+ population receiving three doses and around 70 per cent of its 60-79 age group receiving three doses, data from Nikkei Asia citing government sources showed. 

Unlike other countries, this population group was not prioritised when China first began its vaccination drive in 2021. Moreover, the vaccines being administered here — Sinovac and Sinopharm — have shown little efficacy without a booster shot, with the World Health Organization recommending at least three doses. 

While the  burden of managing the outbreak resides with the public health system and local administrations which are struggling to pay for the Zero COVID measures, the country’s healthcare system may not be ready for a severe outbreak. 

China has only 3.7 beds per 100,000 population, lower than Hong Kong (7.1), Japan (7.3) Singapore (11.4) and Taiwan (28.5), according to a January 2020 paper published in Critical Care Medicine journal.

To control the outbreaks that are currently occurring, Cowling said, China will need to double down on stringent measures. But the country may be relaxing the ‘zero-COVID’ policy — strict lockdowns, repeated testing and quarantine measures — due to the nationwide protests, according to media reports. 

Citing a weakening omicron variant and rising immunisation rates, Vice-Premier Sun Chunlan spoke of a “new situation” requiring “new tasks” at the National Health Commission on Wednesday, state-run Xinhua news agency reported. 

Lockdown restrictions have been lifted in several districts including Haizhu, Baiyun, Fanyu, Tianhe, Conghua, Huadu and Liwan.

A transition strategy to avoid an exit COVID-19 wave will require careful communication and planning, Cowling said. But does China want to take this step? Einar Tangen, senior fellow at the Tahei Institute, told Bloomberg: “I don't think there will be any kind of back down. (The Chinese government) will continue to express this ‘zero-COVID’ policy. They were loosening restrictions, taking a much more surgical approach, which is what resulted in a spike. 

While science should not be politicised, experts believe Xi Jinping sees the control of COVID-19 until now as a success. “He defended the strategy vigorously at the recent Communist party congress, and any sudden policy shift may be seen as an admission of failure,” Devi Sridhar, chair of global public health at the University of Edinburgh, wrote for The Guardian

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