The number of deaths could be reduc by increasing vaccination rates, spreading the use of masks, and imposing movement restrictions. According to the first projections made since the government removed many of its strict zero-COVID-19 rules, up to one million Chinese could die from COVID-19 in the coming months.

James Wood, an infectious disease modeler at Sydney’s University of New South Wales, Australia, says, “There’s no question that China is in trouble for a couple of months.”

Two studies have shown that a fourth vaccine can reduce the death rate. This is combine with strict adherence to temporary restrictions placed on social interaction when death rates rise. These measures could reduce the hospital burden.

“It’s never too late for you to flatten the curve,” says Xi Chen (an economist at Yale University in New Haven Connecticut who studies China’s public-health system).

The Chinese government has removed many restrictions that it had imposed over the last month to stop the spread of the virus. It has lifted travel restrictions within and between areas, and ended mass lockdowns in entire cities. People infected by SARS-CoV-2 can now isolate at home rather than in central facilities. Chongqing allows people infected with mild to no symptoms to go to work. The National Health Commission has announced last week that testing is voluntary and will no longer report the number of people infected with no symptoms.

Although the official number of cases has dropped since November due to changes in testing requirements there are signs that some infections have increased rapidly. According to an analysis on transmission in Beijing, posted on MedRxiv on 16/12/12 without peer review, it appears that infections in Beijing may have peaked.

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Fourth Doses

One of the modeling studies was post as a Preprint without peer review on December 14. It uses data from earlier outbreaks in Hong Kong, Shanghai, and other parts of China to show how different scenarios could look. The study shows that hospitals will become overwhelmed if the rate of infection rises as fast as anticipated due to the recent easing of restrictions. The study predicts that this will lead to approximately one million deaths in the coming months.

These estimates do not include deaths directly related to COVID-19 and they don’t account for deaths from delays in treating non-COVID-19 illnesses, according to Ewan Cameron, a modeler at Telethon Kids Institute, Perth, Australia.

According to the study, if 85% receive a fourth dose of vaccine other than inactivated-virus vaccines, it may slow down the increase in infections and decrease the number of deaths and severe infections. The combination of giving antiviral medications to people 60 years and older, and pushing for a fourth dose could lead to a reduction in deaths of up to 35%.

James Trauer, an infectious disease modeler at Monash University, Melbourne, Australia, says that China must achieve maximum vaccination coverage in the time period before a major epidemic occurs. He notes that the projections of the epidemic’s impact on the spread of the disease and their toll are still uncertain.

The government announced on 13 December that anyone over 60 years old and those in high-risk areas should receive a fourth dose, preferably one that uses a different technology than their primary dose. Only 70% of China’s more than 260 million people over 60 have had a third dose, while 40% are aged 80 or more.

Wood points out that China may not be able to take advantage of the virus-slowing effects from fourth doses, as there is already widespread transmission after many restrictions have been lifted. Wood is not convinced that an additional dose of the virus will make a significant difference in transmission. This is because Omicron viruses, which are circulating, have a strong ability for the body to resist the immune response.

Fewer Deaths

A second model predicts that China will have a half-million deaths from COVID-19 by April next year and 1.6 million deaths by 2023 if it continues its current course. The model forecasts and tracks the global burden of COVID-19 and is maintaine by the Institute for Health Metrics and Evaluation, University of Washington, Seattle. According to Ali Mokdad, an epidemiologist at MIT, the death rate in China could reach close to 9,000 per day by March.

If China introduces certain measures to reduce the death rate above a certain threshold, the model predicts that the total number could drop to approximately 290,000. These include restrictions, high levels of third- or fourth-dose vaccinations and high antiviral drug treatments for at-risk populations. A widespread use of masks could further reduce the number of deaths to approximately 230,000. China is a country where masking is very popular. Mokdad says that people have changed their behavior to limit their movements due to the loosening restrictions. “They won’t let it rip.”

Cameron says that the two studies are broadly in agreement on mortality estimates and how interventions affect them. Cameron says that this agreement reflects the understanding that herd immunity can only be achieved if there is a widespread and hard-to-control spread of transmission across the country.