How deadly could China’s covid surge get? Answers to that and more.

China’s zero-covid policy initially saved lives, kept hospitals from being overwhelmed and gave the country time to disseminate vaccines. But it essentially pushed much of the pandemic’s impact into the future.

Now, that future has arrived.

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When China ended the drastic lockdowns and restrictions that were in place for the past three years, it triggered a surge of cases and deaths in a population with little natural immunity and low levels of vaccine boosting. With data about the scale of this covid surge sparse and unreliable, scientists observing China’s crisis must piece together scraps of evidence to forecast the trajectory of this outbreak and what it might mean for the spread and evolution of the virus.

How bad will China’s death toll get? How long will the surge last? And what will happen to the virus as it spreads in a nation of 1.4 billion people? Definitive answers are extremely challenging to come by, in part because the Chinese government has not been transparent about the extent of the crisis. There are also scientific unknowns, including the efficacy of Chinese vaccines.

But public health officials across the planet at this point have a great deal of data about covid surges in other countries, including countries that opened up after employing a zero-covid policy. So the experts can make educated guesses about what lies in store for China in the weeks and months ahead – while being prepared to modify forecasts as reliable information trickles in.

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How big will the death toll be in China?

Outside experts observing the outbreak are predicting hundreds of thousands of deaths in the coming months. Several modelers predict more than a million covid deaths in China in 2023. The caveat: Modeling is an inexact science, and there are many variables in the equation that could push the death toll up or down.

Airfinity, a company based in the United Kingdom that analyzes data in the life sciences for its clients, has projected 1.7 million deaths by April.

“That’s 1.7 million within the space of 4 months,” said Louise Blair, who heads the company’s epidemiology team, emphasizing the “very steep growth” of cases. The company’s modeling relies heavily on the example of Hong Kong, which had a rapid explosion of illness and death in early 2022 when the omicron variant arrived. Hong Kong, which had low vaccination rates, had maintained a zero-covid policy that mirrored that of the mainland but was unable to contain omicron’s spread.

The Institute for Health Metrics and Evaluation (IHME) at the University of Washington has modeled the outbreak and forecasts 300,000 deaths by April 1, and 1.25 million by the end of the year – or as many as 1.6 million if there are no more mandates and restrictions, said institute epidemiologist Ali Mokdad.

Jeffrey Shaman, an epidemiologist at Columbia University who has been studying the pandemic from the beginning, said in an interview that he expects something like 600 million to 900 million infections in China in 2023.

The death toll depends on the infection fatality rate of the virus, which is the ratio of deaths to infections. The rate is difficult to calculate. Infections often go undetected or are misdiagnosed, and deaths can be misattributed. The rate also shifts over time depending on levels of immunity, which can rise with vaccinations or fall due to the natural waning of antibodies.

According to Shaman’s estimate, the current infection fatality rate in the United States is about 0.15 percent. If that holds true for China and his estimate of infections proves accurate, that would lead to a death count between 900,000 and 1.35 million.

But Shaman points out that there are variables that could drive the infection fatality rate higher or lower. There is lingering concern, for example, that Chinese vaccines are not as effective in preventing severe diseases as vaccines used in other countries.

“We’ve had so little information coming out of China as to what’s actually happening,” he said. “Do we really have any idea what’s going on there?”

World Health Organization officials received a briefing from Chinese health authorities on Dec. 30 about the country’s evolving strategy for managing covid. During the meeting, the WHO urged China to share information about the outbreak, including genetic sequencing data and vaccination rates, especially in vulnerable people and those over 60 years old.

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When will this covid wave peak?

The slope of the epidemic curve is likely to be steep, just as it was in the United States last winter when the highly transmissible omicron variant sickened tens of millions of people in just a few weeks and severely impacted the labor force.

Airfinity forecasts two peaks in national infection numbers, one in mid-January and one in early March. That reflects the spread of the virus from big cities – where it would drive the earlier peak – to more rural provinces. Each location in China would have just a single peak. After that, China would experience what other countries have seen: “continuous waves” of infections, Blair said.

In an email, IHME’s Mokdad said he does not believe the Chinese government will allow hospitals to be overrun, and will reimpose some of the mandates and restrictions that had been eased recently.

Moreover, people will develop their own response and are already limiting their movements, he said: “We have seen throughout the pandemic that people slow down when cases are on the rise to protect themselves and their loved ones.”

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Will China’s explosion of coronavirus infections lead to a new variant?

This virus continues to mutate and has repeatedly surprised experts, so any prediction about what it will do next is dicey. But there’s no reason to think China’s covid surge creates a special condition for the emergence of a new variant.

It is certainly possible that a new variant could emerge in China, but one could also emerge anywhere on the planet as the virus continues to spread.

“There is significant circulation of this virus globally, and the risk of further variants can come from anywhere,” Maria Van Kerkhove, an epidemiologist with the WHO, said in an email.

There are more than 500 “sub-lineages” of omicron already circulating globally, she said.

The origin of new variants is never entirely clear, but there are several ways they can emerge. One theory for the origin of omicron is that it came from an immunocompromised patient who could not clear the virus over a very long period of time. In this scenario, the virus continued to mutate to evade antibodies produced by therapeutic drugs and the natural human immune response. When omicron appeared, it already had dozens of mutations packaged together. That could happen again anywhere on the planet.

“There’s always a risk of new variants when there are a lot of infections, but that’s the least of my concerns about the situation in China,” Kristian Andersen, an immunologist at Scripps Research who has tracked the evolution of the virus, said in an email.

“I’m much more concerned about the thousands of lives (likely tens to hundreds of thousands) that will be lost as a result of this. We should put all focus on helping out China and the Chinese people, including emergency shipments of mRNA vaccines .”

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Does it make sense to impose travel restrictions on China?

Tedros Adhanom Ghebreyesus, WHO’s director general, has neither endorsed nor condemned travel restrictions, but he used the issue to skewer China for not sharing information with the rest of the world.

“In the absence of comprehensive information from [China]it is understandable that countries around the world are acting in ways that they believe may protect their populations,” he wrote on Twitter on Dec. 29.

Other experts find the restrictions unnecessary and illogical.

“It doesn’t make sense to me,” Shaman said in an email. “Travel restrictions seem intended to stop the virus at the border, which makes no sense given that the virus is already everywhere.”

Andersen echoes that, calling the fear of new China-generated variants “completely misguided.”

“What would make sense, would be to create a program to sequence wastewater from airplanes to keep an eye on variants from abroad (including China),” he said in an email. “That could then be combined with our own domestic wastewater (and clinical) surveillance for a more complete picture of circulating variants.”

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