After three years of zero Covid policy, China is the last major economy in the world to accept "living with Covid" as a reality.
Closed borders, strict lockdowns, snap lockdowns of housing compounds, centralized quarantining, routine mass PCR testing, proof of no infection to enter restaurants, offices, public transports, and even parks were few of the widely practiced measures.
Despite it all, a less virulent but highly transmissible Omicron strain sneaked in.
Throughout 2022, a large number of people in different regions were getting infected. Mounting frustration and fatigue from the prolonged lockdowns exploded into rare outbursts of public protest in November.
This sentiment, difficulty in accurate case counting, and the assessment that Omicron poses less risk to life led to the recent decision of lifting the restrictions. The country is all set to open its borders to the inbound travellers from January 8.
China had three years to complete vaccinating all its population with boosters, ramp up hospital capacity, and stockpile antivirals just like the Western countries. Unfortunately, as the country lifts the restrictions amid a huge surge of infection, news agencies all over the world are reporting about overwhelmed hospitals, elderly people dying, and crematoriums being full.
US-based Institute of Health Metrics and Evaluation made a projection that over a million people may die from Covid in China in 2023 due the sudden lifting of regulations.
The chief epidemiologist of the Chinese CDC warned of three upcoming waves of infections till March. WHO claims, it isn't the easing of restrictions -- cases were already high in number as the country's strategy to contain the infection was inaccurate to begin with.
Many Chinese people are fleeing the country. Given the current infection wave -- Italy, the US, India, Japan, Taiwan, and Bangladesh are on alert to test Chinese travellers entering their countries.
What is it that went wrong despite China's best efforts?
The Chinese population did not develop herd immunity. China approved eight homegrown vaccines to be used for the citizens but none of them are the new technology messenger RNA (mRNA) vaccines which has brought most countries out of the pandemic.
The Chinese Sinovac and Sinopharm vaccines, also used in other countries, are traditional inactivated vaccines where a weakened or inactivated form of the virus is used to generate an immune response.
The mRNA vaccines (Pfizer and Moderna) use genetically engineered RNA that signals the host cells to make the spike proteins similar to the ones on SarsCov2 virus. This protein, unrecognized by the body, triggers the immune system to make antibodies and immune cells against the spike protein, thus preparing the body to fight the real virus when exposed to it.
Vaccine efficacy data from China is not readily available but data began to appear from other countries that used Chinese vaccines. Nature Medicine published a study on Brazil -- a big taker of the Chinese vaccines where it showed Sinovac offered 60% protection against severe disease in people aged up to 79 and 30% against people aged 80.
More concerningly, only 45% of people aged 80 and 33% of aged 90 are protected against death from Sinovac. These studies prompted Brazil to vaccinate their people over 60 with a third shot of mRNA vaccines.
Another study in Peru showed two doses of Sinopharm gave 50.4% protection against infections. Both Sinovac and Sinopharm provide little protection against Omicron but a study in Bahrain suggested that a booster with a mRNA vaccine triggers a stronger response.
Countries like Chile, Thailand, and Indonesia had switched to a different vaccine in 2021 due to renewed infection load and deaths despite using Sinovac vaccines.
Until last year, more than 80 countries were using Sinovac and Sinopharm vaccines which did provide protection against the earlier strains, but immunity seemed to wane after a few months.
Most countries have switched to Pfizer, AstraZeneca, and Moderna for booster shots. The Pfizer vaccine, now FDA approved, is being used in 156 countries and Moderna in 88 countries. A booster Pfizer shot is 70-80% effective against severe disease and a booster Moderna is 88- 99% effective against hospitalization from Omicron.
What is the outcome of ‘mix and match' Vaccines?
Studies done in the UK, Germany, and Spain showed mix and match vaccines give higher protection against Covid. Inactivated vaccines (AstraZeneca, Sinovac, and Sinopharm) induce strong T-cell mediated immune response whereas mRNA vaccines (Pfizer and Moderna) induce very high levels of antibodies.
Combinations of both have proven to induce the best T-cell response which is important in longer protection and for people whose immune systems are compromised.
Older people have weaker immune systems and require stronger vaccines and boosters for protection. Two model studies published in Nature Medicine suggested that the predicted high death rate in China can be prevented if 85% of the population gets a fourth dose of a different vaccine, preferably a mRNA one to slow down the infection rate and reduce death and severe infection.
Along with this, antiviral drugs given to people aged 60 and older and to individuals at high risk of developing severe disease, could reduce deaths by up to 35%.
Interestingly the study also revealed that among the more than 260 million people in China older than 60, only 70% aged 60 and older, and only 40% aged 80 and up, have received a third dose till December 2022.
So, the concern remains over China's large pool of susceptible individuals of 80 and older who received less doses of less effective vaccines and are at the greatest risk of severe disease.
If we draw a comparison with Bangladesh, is it safe to say that Bangladesh has always been more life and livelihood driven whereas China was not?
China promotes self-reliance and despite nodding to the Pfizer vaccine more than a year ago, they have yet to approve it for use. mRNA vaccine development is built on decades of research by Western countries, and while China is yet to develop their own version, their people will benefit from getting the booster shots with the Western version as it has shown to provide strong protection against Omicron.
The German government after seeing the protests in China, advised the country to start using the Western mRNA vaccines to come out of the pandemic in November 2022. Only recently, China approved emergency use of Pfizer's Paxlovid, the Covid-19 pill. The strict lockdowns also prevented people from developing cross immunity and natural immunity which makes it crucial to bring reliable vaccines.
Bangladesh on the other hand, under Prime Minister Sheikh Hasina's direction, was on pandemic alert from the very beginning.
It is one of the earliest countries in South Asia to procure vaccines and has fully vaccinated the entire population for free.
By now, 44% of the population have already received the third booster shot and the fourth booster is also given to 88,346 people.
WHO had advised to start giving any vaccine that was available and Bangladesh followed that strategy. The government purchased AstraZeneca from India, Sinopharm from China, and received generous numbers of Pfizer, Moderna, Johnson & Johnson, and AstraZeneca from the COVAX initiative donated mainly by the US and Japan.
Vaccine administration strategy was also prioritized depending on age and vulnerability by vaccinating the elderly and immunocompromised first, then the middle aged, finally saving the safest vaccines for the children.
The decades of successful EPI programs helped roll out the large Covid vaccination program smoothly. Bangladesh has a youthful population and there were uncountable asymptomatic infections. A study showed that 60-70% people had Covid antibodies which might be a result of those asymptomatic cases.
The three separate lockdown phases in Bangladesh till 2021 successfully broke the chain of infections each time.
While in lockdown the government and private sector hospitals ramped up their capacity to increase oxygen supply, add critical care units, expand testing capacities, generate massive awareness on masking, circulate updated treatment protocol, and accelerate the production of the lifesaving antiviral drugs by the pharmaceutical companies.
On top of these, the prime minister extended a stimulus package of Tk131,000 crore to support the businesses and livelihood of people. The digital connectivity was leveraged for vaccine registration, online education, telemedicine, daily office work, grocery shopping, mobile banking, and even the judicial system.
While China's relation to “living with Covid” policy was short-lived with the recent infection waves, Bangladesh is once again on alert ever since the arrival of four Covid cases from China last week.
Whenever there is a scare of a fresh breakout, the PM herself alerts the officials to remain vigilant. It is admirable that for a resource constrained country like Bangladesh, the leadership saved people by taking the right decision at the right time. Bangladesh has rightfully been repeatedly lauded in the international platform for beating the pandemic.
China might reconsider their strategy and take a more pragmatic approach for safeguarding their people in the current situation. The world is waiting for this pandemic to be over everywhere.
Dr Maliha Mannan Ahmed is the Founder and Executive Director of Organikare. She has an MBBS, MBA, and a Master's in Health Care Leadership.
