While most countries have achieved some form of herd immunity and could relax Covid restrictions, China’s policymakers have been tightening their “dynamic zero-Covid” policies again to keep new Covid infections in check ahead of the crucial 20th Party Congress starting on 16th October. 21 million people in Sichuan’s capital city Chengdu have for instance been in complete or partial lockdown since September 1st, after 157 new cases were reported on the previous day.
Political factors no doubt play an important if not a crucial role in shaping Beijing’s Covid policy. The early success of China’s strict Covid measures that was strongly associated with Xi Jinping’s personal leadership seems to render it now difficult to abandon the strategy. And with the CCP Congress just around the corner, the rigid measures must ensure a smooth convening without a chaos that new infection clusters could cause.
Recognizing these factors, this short piece takes a deliberate look at the relevant medical and public health factors, trying to make sense of the scientific rationale behind Beijing’s policies. China’s National Health Commission (NHC) is officially talking about five factors where the medical situation needs to improve before containment measures could be relaxed.
Liang Wannian, head of the expert group of the NHC’s leading group for outbreak response and disposal, said in April that policy relaxation could be considered “when the relevant conditions are met, such as a high vaccination coverage rate, especially for the elderly and other vulnerable groups, and all regions are well prepared in terms of medical resources, quarantine beds, effective drugs, supplies (mostly food and necessity), emergency mechanisms, etc., and at the same time, effective drugs can be widely used and the virus does not appear to get worse, but rather more mild, and the risk of death is within the tolerable range.”
Factor 1: vaccination rate among the elderly: As per the NHC, by July 23, 84.7% of people older than 60 had received two jabs. The NHC considers a rate of 80% sufficient, if the other four criteria below are simultaneously met. Back in May, researchers from Shanghai’s Fudan University had calculated that at a projected 2-shot immunization of 60% among the elderly (>60), a prematurely relaxed Covid-policy could result in 1.55 million deaths within six months, 74.7% of which from the unvaccinated elderly population. Without simultaneously taking other measures, however, even with a 100% vaccination rate (2 shots) of the elderly the death toll could be only lowered from 1.6 million to 0.6 million. If accompanied by other non-pharmaceutical interventions (NPI) such as testing and quarantines, however, a 97% vaccination rate (2 shots) among the elderly could lower the mortality down to the level of a seasonal influenza.
Factor 2: quarantine beds: 400 newly constructed modular hospitals across the country and other designated quarantine facilities mean that the NHC sees itself sufficiently prepared for a possible wave of infections that need quarantining.
Factor 3: milder variant of the virus: according to NHC officials, milder variants are another medical factor to consider before relaxing measures. Omicron has shown a much lower lethality also in China compared to earlier mutations, but officials are still regularly warning the public that it is not merely a “big-sized flu”. Only a change in official rhetoric would indicate a possible relaxation of “dynamic zero-Covid” – this is not in sight yet
Factor 4: ICU capacity: As of July 2021, China can officially provide 4.4 ICU beds per 100,000 people, much less than for instance the US (34.2) or Germany (29.2). The problem: While it is relatively easy to buy the needed machines and equipment, China’s ICU doctor and nurse-to-bed ratios are 0.57:1 and 1.8:1 respectively and don’t meet the national target of 0.8:1 and 3:1 set in 2020. As per the above mentioned researchers of Fudan University, the ICU beds needed during peak demand in case of relaxed measures would correspond to 15.6 times the existing capacity, namely 1 million units. What is more, training new personnel for the ICU takes up to five years as per the NHC – a major bottleneck.
Factor 5: Covid-19 treatment medicine: Even though China has introduced Pfizer’s Paxlovid in February this year and approved the two Chinese treatment drugs Azvudine and BRII-196 + BRII-198, this is far from being sufficient. Paxlovid and BRII-196 + BRII-198 are too expensive for a nation-wide roll-out, and the production capacity for Azvudine is not sufficient and cannot quickly be ramped up. Ensuring the respective affordable capacity would take at least six months as per the NHC.
So, besides political considerations, unless Beijing substantially accelerates its vaccination campaign for the most vulnerable, which would relieve the pressure on ICU capacity and Covid-19 treatment medicine and likely also assuage popular worries of contracting Covid, only a simultaneous improvement along all five factors would allow for a policy relaxation from a medical and public health point of view.
So far, Beijing has resisted using foreign vaccines with mRNA technology. Domestic mRNA vaccines that offer better protection than inactivated vaccines, however, are still not on the market. Only a targeted vaccination campaign combined with effective accompanying measures (testing, quarantine) is likely to save as many lives as the costly and socially painful lockdowns imposed earlier in Shanghai.
Therefore, as besides financial incentives there is to date no obligation for the vulnerable to get vaccinated, it is safe to expect “dynamic zero-Covid” to remain in place well beyond the 20th Party Congress, also if just looked at from a public health perspective.