Two years into its aggressive and mostly successful attempt to keep the COVID-19 pandemic at bay, China has begun tweaking its approach as it faces its biggest wave of infections since the first outbreak.

Fueled by Omicron and its even more rapidly spreading BA.2 subvariant, China’s current COVID-19 outbreak involves over 20,000 cases in 20 province-level areas around the country.

Public health experts tell Sixth Tone that the Chinese government now faces a conundrum: Maintain its strict “zero-COVID” policy that involves rigorous contact tracing and mass quarantining, but incur a steep economic cost due to the sheer number of cases; or loosen the reins but expose the country’s older adults, whose vaccination rates are relatively low, to heightened health risks.

The country’s health authorities are trying to find a middle path, recently introducing two changes to its handling of the virus.

People experiencing mild or asymptomatic COVID-19 infections, which are more commonly the result of the Omicron variant compared to earlier variants, will be centrally quarantined instead of being admitted to hospital, the National Health Commission announced Wednesday.

Huang Yanzhong, a China health policy expert at the Council on Foreign Relations in New York, says this change aims to free up medical resources. Many patients have mild symptoms, and healthcare workers, facilities, and medicines are better allocated elsewhere. “A major problem with the zero-COVID strategy is that it doesn’t differentiate patients,” he says. “What needs to be done is prioritize those who are really in need.”

Earlier, on March 10, the country’s health authorities for the first time allowed the private use of self-test kits, more than a year after Chinese companies began manufacturing them for export. People who use a self-test kit and find out they have been infected are called on to report the result, though no enforcement mechanism was specified. Previously, only testing at hospitals and designated facilities was allowed, but the demand for laboratory-based tests is currently too big.

Self-test kits yield results in minutes and have the added benefit of avoiding possible infections as people line up for mass testing, says Lu Hongzhou, the director of Shenzhen Third People’s Hospital. The southern metropolis recently went into a citywide lockdown due to a surge in Omicron cases.

China’s strategy for the pandemic has been to use strict measures so as to buy time for developing and administering vaccines. Though it has been effective so far in avoiding the enormous caseloads of other countries, the emergence of highly contagious virus variants that even the most effective COVID-19 vaccines fail to stop has led scientists across the globe to conclude that herd immunity is no longer achievable.

“A virus like Omicron is simply unstoppable,” says Wang Jun, a pharmacologist at the University of Arizona. A zero-tolerance approach can work when a pathogen leads to obvious symptoms, he explains. But with Omicron, many people whose symptoms are minor are spreading the virus without knowing they have been infected. “It makes stopping the spread of the disease extremely hard,” Wang says.

Before Omicron hit, Chinese health authorities appeared to have been looking for ways to loosen their restrictions, with top officials and prominent public health experts speaking openly about coexisting with the virus.

“Most virologists in the world now recognize that COVID-19 is an endemic virus and the world has to learn to live with this virus,” Zhang Wenhong, the infectious diseases expert tasked with managing Shanghai’s coronavirus response, wrote on social media last July. In the future, China would choose an approach that would allow borders to reopen and normal life to return, he wrote.

Such messages were interpreted as signs that China might roll back some of its strict COVID-19 prevention measures, says Huang. “I had thought that after experimenting with the Beijing Winter Olympics, the authorities would gradually move to relax its rules. But the Omicron outbreak in Hong Kong certainly scared them off.”

Hong Kong, whose border with the mainland has remained mostly closed during the pandemic, started to see a major uptick in cases in February. Since then, the coronavirus has infected hundreds of thousands of people and killed over 3,000 people. The surge in patients overwhelmed the city’s hospitals, leaving many waiting for treatment out on the sidewalk.

Hong Kong’s mounting death toll is largely the result of low vaccine uptake among older people, to whom COVID-19 poses a bigger health risk. According to official data, people aged 80 and above account for about 70% of the city’s fatalities.

The Chinese mainland faces a similar dilemma. Over 88% of the country’s 1.4 billion people are fully vaccinated. But half of all people aged 80 and above — some 17 million people — are not.

“China’s strict zero-COVID strategy worked so well, so many people didn’t feel the need to get vaccinated,” Wang tells Sixth Tone. “People thought the risk of getting infected is so low, then why bother dealing with the side effects of vaccines? Even my own parents were hesitant to get the shots,” he adds.

Unlike the vaccination strategy of many Western countries, China was slow in vaccinating its older citizens. For months after COVID-19 shots became available, only people between the ages of 18 to 59 were eligible for vaccination, partly due to a lack of clinical trial data from older adults.

“Protecting the most vulnerable people should have been prioritized,” Wang says. “Now the virus is everywhere, any attempt to boost vaccine uptake now would be too late.”

Using resources wisely could lower the cost of opening up, Wang says. “With fewer people needing to go to the hospital for testing and treatment, we can reserve vital resources for (older people).” New medicines also help, he adds.

In December, China approved the country’s first drug designed specifically to treat COVID-19. The company behind the monoclonal antibody treatment says it reduces the risk of hospitalization and death by 78% if administered early enough.

Last month, the country’s drug authority also approved Paxlovid, a COVID-19 antiviral pill designed by pharmaceutical giant Pfizer. The orally administered drug has been shown to reduce the risk of hospitalization and death by 89% if taken soon after the onset of symptoms.

“Zero-COVID was achieved at the cost of many people’s livelihoods and being disconnected from the rest of the world,” Wang says. “With a sluggish economy, I don’t know how much more resources China has to burn in a bid to reach this impossible goal. We are no longer helpless facing COVID-19, so our strategy needs a change.”

Editor: Kevin Schoenmakers.

Correction: A previous version of this article said testing for COVID-19 was only allowed at hospitals. It was also allowed at certain designated facilities.

(Header image: A volunteer guards a “risk area” in Xintiandi, Shanghai, March 17, 2022. VCG)