China is now facing what is likely the world's largest COVID surge of the pandemic. China's public health officials say that possibly 800 million people could be infected with the coronavirus over the next few months. And several models predict that a half million people could die, possibly more.

"Recently, the deputy director of China CDC, Xiaofeng Liang, who' s a good friend of mine, was announcing through the public media that the first COVID wave may, in fact, infect around 60% of the population," says Xi Chen, who's a global health researcher at Yale University and an expert on China's health-care system.

That means about 10% of the planet's population may become infected over the course of the next 90 days.

Epidemiologist Ben Cowling agrees with this prediction. "This surge is going to come very fast, unfortunately. That's the worst thing," says Cowling, who's at the University of Hong Kong. "If it was slower, China would have time to prepare. But this is so fast. In Beijing, there's already a load of cases and [in] other major cities because it's spreading so fast.

The fastest spread of COVID yet

Cowling says the virus is spreading faster in China than it's spread ever before anywhere during the pandemic. It also looks to be especially contagious in the Chinese population.

To estimate a virus's transmissibility, scientists often use a parameter called the reproductive number, or R number. Basically, the R number tells you on average how many people one sick person infects. So for instance, at the beginning of the COVID pandemic, in early 2020, the R number was about 2 or 3, Cowling says. At that time, each person spread the virus to 2 to 3 people on average. During the omicron surge here in the U.S. last winter, the R number had jumped up to about 10 or 11, studies have found.

Scientists at the China National Health Commission estimate the R number is currently a whopping 16 in China durng this surge. "This is a really high level of transmissibility," Cowling says. "That's why China couldn't keep their zero-COVID policy going. The virus is just too transmissible even for them."

On top of that, the virus appears to be spreading faster in China than omicron spread in surges elsewhere, Cowling adds. Last winter, cases doubled in the U.S. every three days or so. "Now in China, the doubling time is like hours," Cowling says. "Even if you manage to slow it down a bit, it's still going to be doubling very, very quickly. And so the hospitals are going to come under pressure possibly by the end of this month."

So why is the virus spreading so explosively there?

The reason is that the population has very little immunity to the virus because the vast majority of people have never been infected. Until recently, China has focused on massive quarantines, testing and travel restrictions to keep the virus mostly out of the country. So China prevented most people from getting infected with variants that came before omicron. But that means now nearly all 1.4 billion people are susceptible to an infection.

China currently has a few highly transmissible variants of omicron spreading across the country, including one called BF.7. But these variants in China aren't particularly unique, and the U.S. currently has the same ones or similar ones, including BF.7. In the U.S., however, none of the variants appear to be spreading as quickly as they are in China.

And what about vaccines? Will they stem the surge?

About 90% of the population over age 18 have been vaccinated with two shots of a Chinese vaccine. This course offers good protection against severe disease, Cowling says, but it doesn't protect against an infection. Furthermore, adults over age 60 need three shots of the vaccine to protect against severe disease, Cowling's research has found. Only about 50% of older people have received that third shot, NPR has reported. And that leaves about 11 million people still at high risk for hospitalization and death.

"There is great uncertainty about how many severe cases there will be," says Chen at Yale University. "Right now in Beijing we don't see many severe cases." However, the outbreak could look quite different outside major coastal cities like Beijing because rural areas have much poorer health-care systems.

"In China, there's such a large geographic disparity in terms of health-care infrastructure, ICU beds and medical professionals. Most of the hospitals with advanced treatment technologies are located in Beijing, Shanghai, Guangzhou, and all the big metropolitan areas."

Despite a recent effort by the government to increase ICU capacity, Chen still thinks there are way too few ICU beds in many parts of the country. "I don't quite believe the new estimate of 10 ICU beds per 100,000 people because this new number includes something they call a 'convertible.' So these are beds that are used for other treatments, such as chemotherapy and dialysis, that they are converting to an ICU bed."

Predictions about the death toll

Several models have predicted a large death toll for this initial surge, with at least a half million deaths, perhaps up to a million.

But that number, Chen says, depends a lot on two factors.

First off, people's behavior. If people at high risk continue to quarantine voluntarily, the death toll could be lower.

Second, how well the health-care system holds up under this pressure. "This is going to be a major test – and it's unprecedented," he says. "In my memory, I have never seen such a challenge to the Chinese health-care system."

No one knows for sure what's going to happen in China. But you can make some predictions based on what's happened in neighboring places faced with a similar surge. Take Hong Kong, for instance. Like China, the city had kept COVID at bay for years. But then last winter, they suffered a massive omicron surge. Over the course of only two to three months, about 3 to 4 million — or 50% of the population — caught COVID, Cowling says.

But Cowling thinks that ultimately China will still fare much better against COVID than America has.

"China has done really well to hold back the virus for three years, and ultimately, I think, the mortality rate will still be much lower than elsewhere in the world," he says, because the country has vaccinated such a high percentage of its population overall. In other words, the death toll will likely be high, given the sheer number of people infected, but it could have been much worse without the vaccinations, he explains.

"The mortality rate in China isn't going to surpass America's mortality rate [3%] at this point," he says. "But China has a really tough winter ahead."

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China appears to be facing what could be the world's largest coronavirus outbreak yet.


The country recently rolled back its zero-COVID policy, but the World Health Organization says the explosion in cases began before restrictions were lifted.

MARTÍNEZ: China's health officials say it's possible that up to 800 million people will become infected in the next few months. It's a dramatic change for residents after three years of strict testing and lockdowns.

SCHMITZ: Twenty-seven-year-old Alan Wu (ph), who lives in Beijing, says three weeks ago, he didn't know anyone in China who had ever tested positive for COVID. But a few days ago, he was infected. And he's not alone.

ALAN WU: I would say two-thirds of the people I know in Beijing are infected right now. The whole city is, like, deserted.

MARTÍNEZ: Wu says the outbreak has made daily life more difficult because so many workers are sick, and Beijing's famously quick deliveries take much longer now.

WU: You will wait two or three hours to get, you know, a bag of vegetable. I mean, it used to take, like, 10 minutes or 15 minutes.

SCHMITZ: He doesn't think the Chinese health system is prepared. He's heard from friends waiting in long lines in the cold to get medicine.

WU: This is the capital of China. Like, you know, getting medicine shouldn't be that difficult.

MARTÍNEZ: Here to tell us more about what's going on is NPR's global health correspondent Michaeleen Doucleff. Nearly 800 million people, Michaeleen, affected in China. I mean, we're talking about - what? - 90 days? That sounds crazy.

MICHAELEEN DOUCLEFF, BYLINE: Yes. You know, that's roughly 10% of the planet's population getting infected in this super short period of time. I spoke to Xi Chen. He's a global health researcher at Yale University. He says predictions from Chinese scientists are quite dire.

XI CHEN: Like, recently, the deputy director of China's CDC, Xiaofeng Liang (ph), who is a good friend of mine, and he was announcing through the public media that the first wave may infect around, like, 60% of the population.

DOUCLEFF: We haven't seen anything like this yet. You know, these numbers are big, but interestingly, official numbers out of China show cases declining there.

MARTÍNEZ: OK, how is that possible?

DOUCLEFF: Yeah, so China has changed how it tracks cases. It has stopped reporting asymptomatic cases, and it has also stopped a lot of testing. But I was talking to an epidemiologist at the University of Hong Kong, Ben Cowling, and he said cases are actually skyrocketing in many parts of China.

BEN COWLING, BYLINE: Right. In Beijing, there's already a load of cases and other major cities because it's spreading so fast. It's just extremely transmissible.

DOUCLEFF: Cowling says the virus is spreading faster in China than it spread basically ever before anywhere during this pandemic.

MARTÍNEZ: So any idea what's going on - a new variant, maybe?

DOUCLEFF: Yeah, so the variants in China are not particularly unique. They are versions of omicron, and we have the same ones and similar ones right here in the U.S. But they aren't spreading lightning fast like they are in China. And the difference is immunity. China's population has very little immunity to COVID because the vast majority of people have never been infected. Until recently, China has focused on massive quarantines, testing and travel restrictions to keep the virus mostly out. So with variants that came before omicron, China prevented most people from getting infected. But that means that now nearly 1.4 billion people in the country are susceptible to an infection.

MARTÍNEZ: So it's really that much more contagious?

DOUCLEFF: In China, it is. Scientists like Cowling use something called an R factor to estimate how contagious a pathogen is. Basically, it tells you how many people one sick person is going to infect on average. So during the omicron surge here in the U.S., the R factor was about eight. Each person who was sick spread it to about eight more people. Cowling says that in China right now, the R factor is a whopping 16.

COWLING: This is just a really high level of transmissibility. You know, and in the U.S., the early 2020, the doubling time was, like, one week. Now in China, the doubling time is, like, hours.

MARTÍNEZ: Wow, doubling in less than a day - I mean, can hospitals handle this?

DOUCLEFF: You know, Chen at Yale University says that is the big question right now. Most of the cases are expected to be mild or moderate, but there are about 11 million people at high risk for severe COVID. And Chen says that in most of the country, there are still way too few ICU beds to handle this. Many, many models now are predicting that perhaps a half a million people could die, perhaps many more. But Chen also told me that number depends a lot on people's behavior, you know, whether people at high risk continue to quarantine voluntarily and how well the health care system does hold up under this pressure. He says it is going to be a huge test for China's health care system.

MARTÍNEZ: Yeah. And, you know, earlier you said that the same variants are spreading in the U.S. Are we going to see another massive surge this winter?

DOUCLEFF: You know, the population here, it just has an enormous amount of immunity from all the previous surges and vaccines, so we are going to see cases rise here, no doubt, but not like anything we've seen before, I think.

MARTÍNEZ: NPR global health correspondent Michaeleen Doucleff, thanks a lot.

DOUCLEFF: Thank you so much. Transcript provided by NPR, Copyright NPR.

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