More Chinese cities have been announcing an easing of curbs following unprecedented protests against the harsh "zero-COVID" policies in China last weekend.
But loosening harsh quarantine policies brings other risks, as health experts warn China must boost vaccination rates, especially among the elderly, and prepare hospitals and medical staff or risk a massive number of deaths.
Ben Cowling, chair professor of epidemiology at the University of Hong Kong's School of Public Health, said other countries have experiences Beijing can learn from.
"Until recently, they haven't been thinking about the exit from zero-COVID. There hasn't been enough consideration for alternative strategies. That means the country now is not that well prepared for an exit."
He pointed to experiences in Taiwan and Singapore which saw a sharp rise in deaths after abandoning their zero-COVID policy of border closures, contact tracing and isolation. But hospitals there were sufficiently prepared, which helped them avoid being overwhelmed as less prepared countries were, like India.
"One thing we know from the last three years is when there's a large surge of cases, even when most cases are very mild, there's a small portion that are severe and those cases will put a lot of pressures on hospitals, whether it's oxygen supply and intensive care beds with ventilators or specialized doctors and nurses," Cowling said.
"I know they can build things very quickly in China, but for ICUs (intensive care units) it's not always finding the space and having enough beds; the problem is making sure the staff have critical care training, and I don't think it's something they can learn quickly."
Despite the recent protests against the policy in several cities in mainland China, and the economic losses and inconvenience suffered by the people, Cowling advises against ending the lockdowns immediately.
"I'm worried a transition now may be too sudden because there hasn't been an opportunity for the elderly to get their boosters and for hospitals to get prepared," he said. "It may be more rational to continue zero-COVID a little longer but alert the population and hospitals that there might be a transition in the next few months."
When hospitals are overwhelmed with patients, death rates rise. China has about the same number of hospital beds per 100,000 people as the United States, but it has far fewer intensive care unit beds. According to government statistics, there are 3.6 intensive care (ICU) beds per 100,000 people in China, compared to 11 in Singapore and 29.4 in the United States.
In Hong Kong, the mortality rate for cases with the same level of severity and similar characteristics was two to three times higher during the peak of the outbreak when the medical system was under pressure, Cowling said. Similar observations have been made in other countries.
Chan Chang-chuan, dean of National Taiwan University's College of Public Health, said China could see around 100,000 deaths if it mirrors what happened in Taiwan, where the number of deaths increased by around 16 times after it switched to coexisting with the virus.
"The cases and deaths will be much higher than before. They know that, but there's no other way," said Chan, pointing out that the experience in places which previously had tough COVID policies — Iceland, Japan, New Zealand, South Korea and Taiwan — showed it's impossible to keep out COVID-19 forever.
One Chinese academic study published in Nature Medicine in May estimated there could be as many as 1.5 million deaths if China ends its very unpopular COVID-19 lockdowns without raising vaccination rates and improving its medical response capabilities.
Avoiding overburdened hospitals
There could also be deaths caused indirectly by COVID, if hospitals can no longer treat patients with long-term illnesses or handle medical emergencies.
"I think in mainland China that will also be the case and when there's a very large COVID surge, there's a knock-on effect for people with other health conditions. If someone has a heart attack in China today, the response will be quick and the ambulance will come quickly and may save their life. In two months' time or three months' time, the ambulance line will already be full with people calling and even if you get through, the ambulance may not come," Cowling said.
The number of fatalities can be reduced if China convinces its population to get booster shots, especially if they take a dose of the more effective mRNA vaccine, Chan said.
According to the government, 90% of the population has been vaccinated with two doses of Chinese vaccines, including Sinopharm and CoronaVac, but they are made with the traditional method of using inactivated viruses, which is considered by some experts to be less effective than the mRNA method used to make the Pfizer-BioNTech and Moderna products.
A much lower percentage - 56% - of the overall population, 68% of elderly aged 60 or above, and just 40% of those 80 or older have had a booster shot, according to China's National Health Commission.
"If you want to deal with omicron, you have to have three shots," said Chan, adding that getting a fourth shot would offer even more protection.
Cowling said there was no need for the less vulnerable non-elderly people to receive more shots, given that omicron symptoms are mild for most people.
"There should be a campaign to get people who have never been vaccinated to get three doses, and for the elderly, if it's been more than six months since they were last vaccinated, to get a booster now. There's no need for everyone else to do that," he said.
Cowling also said it was not necessary for China to import the Pfizer-BioNTech or Moderna vaccines, pointing out that a study he and his colleagues conducted and published in The Lancet medical journal in October found that the Chinese vaccines were as effective as the mRNA ones if three doses are taken.
"I would say for the vaccines available in China they are highly effective against COVID - and we've proven that. … I don't think there's any need to use the other vaccines," Cowling said.
Until recently, China considered itself successful in fighting COVID-19. With a population of 1.4 billion people, the most populous country has reported around 340,000 cases and 5,200 deaths so far. But the country's biggest COVID health challenge may still be ahead.
