Nov 13, 2022Liked by Zichen Wang

Wang Zichen, this is extremely well done; congratulations on fine work.

It strikes me that if all of these instructions are put into effect, one result will be a significant impact on China's current high rate of unemployment, especially of younger people. If they can somehow be responsibly and effectively implemented by administrative organs at all levels, they will require a very large number of "workers" to maintain the system for the foreseeable future. Could these Instructions have been conceived as a response to the unemployment situation in the PRC?

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The implementation of vaccine rollout to the elderly will be key. It is far more important than any of the other announced measures.

What concerns me about the COVID measures in China is the disconnect between expert scientific opinion and the government’s implementation of anti-COVID measures. Chinese scientists are quite clear: it is imperative to vaccinate the elderly, particularly the over 80s. Let me repeat that. Vaccinate the elderly. A fantastic paper (https://www.nature.com/articles/s41591-022-01855-7), published back in May promoted such a campaign, stating that if China were to relax zero-COVID, over a million Chinese (mostly elderly and unvaccinated) would die within the first few months. However, this paper has been largely ignored at the policy level. Since then, there have been several more publications (e.g., https://weekly.chinacdc.cn/en/article/doi/10.46234/ccdcw2022.172, https://weekly.chinacdc.cn/en/article/doi/10.46234/ccdcw2022.173) that have stressed vaccination of the elderly. The original vaccine rollout was extremely tepid, failing to prioritize vaccination for over 60s. In some sense, this was understandable. The original trials of Chinese vaccines excluded over 60s. However, over the last few months, there has been significant evidence, based on outbreaks in Hong Kong and Shanghai (https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(22)00345-0/fulltext, https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-022-02606-8), showing that the inactivated vaccines in use in China are exceptionally effective even in the elderly. China must follow the broad scientific consensus and vaccinate the elderly.

At this time, if pandemic restrictions are relaxed before this happens, omicron will spread and kill over a million people. The government restrictions cannot and should not relax until a proper vaccination campaign (primary vaccination series and booster dose) nears completion, which would likely take at least 6 months. Until then, I expect no change in messaging, as this would encourage spread.

The other option is to hope for a silver bullet that can prevent transmission: a new vaccine, for example. This is a bad strategy. Firstly, there is little evidence that any vaccine at this time, whether mRNA or otherwise can do this. Furthermore, while stage III trials can evaluate odds reduction of catching COVID following vaccination, they typically do not evaluate the effects of a vaccine on transmission. Secondly, many of the second-generation vaccines are being trialed as booster doses (e.g., https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(22)00087-X/fulltext), rather than as primary vaccination series. By now, it is already near impossible to perform a phase III trial for a primary series vaccine. There are not enough cases in China to run these trials and abroad, most people have either been infected with COVID already, vaccinated, or both. Therefore, a new generation of vaccines may not help China deviate from zero-COVID since a significant number of elderly will not have received their primary series and so will not be eligible for a booster with a second generation vaccine. Furthermore, there may not be evidence that any of the vaccines prevent COVID transmission. Hence, even new vaccines cannot fully mitigate the risk needed to justify relaxing zero-COVID. The new vaccines may not offer proof that they halt transmission to the unvaccinated elderly.

In summary, there are only a few broad categories of strategy to exit the pandemic moving forward:

1) Begin to relax COVID restrictions before an appropriate vaccination campaign of the elderly. This will likely result in more than a million deaths and undo all the good work up until now. Therefore, this first approach is unlikely.

2) Hold tight until a new generation of treatments is available. The evidence that these new treatments work well on the immunologically naïve elderly in China will not be certain. The studies in which this new generation is tested will likely not be able to rule out transmission with complete certainty. They will also be unlikely to have been tested in large number of individuals who have not already been vaccinated with a primary series or already infected with COVID. Therefore, using such vaccines as part of a primary dose series will not have been rigorously tested. I think this strategy is possible, but unnecessarily risky.

3) Vaccinate the elderly now with current vaccines. This will take at least 6 months during which zero-COVID can be used to prevent spread. Re-evaluate the situation close to the end of the vaccination campaign. This is by far the best option, in my opinion. It provides the maximum amount of policy flexibility in the future. The downside is that vaccination of the elderly in large numbers may not be possible without mandates. But the pay-off would be significant. If, next year better medications and vaccines are available, these can still be used.

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Thank you for this detailed explanation of China's Zero Covid policy. I would like to know how President Xi and other Chinese officials are now going about without masks. Their doing so suggests that there has been a significant change re Covid. Would love to hear your thoughts.

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