1 Introduction
Coronavirus disease 2019 (COVID-19), an infectious disease caused by novel coronavirus SARS-CoV-2, significantly challenged the healthcare, social, and economic system in China and other countries across the world since December 2019 [
1]. In January 8, 2023, after more than 3 years combating against COVID-19, Chinese government downgraded the management of COVID-19 from Category B but with measures for Category A to Category B and removed it from quarantinable infectious disease management [
2]. During the past three years, although having experienced several waves of COVID-19 outbreak, China always adopted evidence-based prevention and control strategy and did the best to minimize the cost. Under the strong leadership of the Chinese central government, China put people and their lives first, meanwhile ensured sustainable socio-economic development. While taking the most strict and precise non-pharmaceutic intervention (NPI) in 2020, and launching the biggest ever vaccination campaign since July 2020, a much lower overall infection and mortality rate was achieved from January 2020 to November 2022, compared to some developed countries (Fig.1 and Fig.2). Chinese people’s health has thus been largely protected during the high virulence period of the SARS-CoV-2, and nation’s gross domestic product (GDP) maintained positive growth at an average annual rate of 4.5% over the period of 2020–2022, higher than the world’s average [
3] and compared to some developed countries (Fig.3 and Fig.4).
The World Health Organization (WHO) declared an end to COVID-19 as a global public health emergency on May 5, 2023. However, the end of pandemic does not mean that COVID-19 is no longer a health threat. Experiences from China’s fighting against COVID-19 should be learned to drive a better preparedness for future public health emergency. Previous literature indicated that the transition from evidence to policy for emerging infectious disease went through the following stages: the data obtaining stage, mainly collecting clinical and epidemiological data; the risk factor finding stage, mainly based on the comprehensive analysis and judgment of social and economic development; the design and testing strategies stage, involving the prediction and analysis of policies through modeling and other approaches; the policy uptake stage, which required the government departments continue to discuss, review, and optimize strategies [
4]. This article systematically reviews the epidemiologic features of COVID-19 pandemic in China and explores the science-based evidence for critical prevention and management policy-making, in order to share valuable lessons with international partners to build a global community of health for all.
2 China’s general experiences of the control and management of COVID-19 outbreak
COVID-19 was identified as the world’s largest pandemic since the 21st century. It represented an extraordinary challenge for the society to respond to the unprecedented infectious disease and extensive test of the country’s governance system, especially in the early phase of outbreak. Over the past three more years, China has gained a series of remarkable experiences in pandemic response and control. First, the strong leadership of the Chinese central government is the fundamental organizational guarantee for the overall success of the battle against the pandemic. A Joint Prevention and Control Mechanism of the State Council against COVID-19 (JPCM) was established on January 20, 2020 to coordinate across various sectors at central government level, which ensured efficient and comprehensive response to the emergencies and exerted leadership role to the local authorities. Second, the principle of “putting people and their lives first” ensured that all infected individuals received proper care and free medical treatment, maintaining well-being, value, and dignity of every individual. Third, China has established the world’s largest medical and health service system, medical security system, and pharmaceutical supply system. The selfless and tireless work of medical workers played the leading role in safeguarding the health of over 1.4 billion people. Medical and technological innovations contributed to the development of effective traditional Chinese medicine (TCM) formulas and domestically developed small molecule drugs for COVID-19, meeting the urgent needs of clinical treatment. Fourth, the popularization of vaccine administration provided people of different ages with immune barriers against the transmission of infection or reduced the severity of the disease. Meanwhile, taking into consideration of the appearance of variants of concern (VOCs) due to viral mutations of SARS-CoV-2 and based on practical effects, the implementation of measures for prevention and control was continuously optimized through dynamic adjustments [
5,
6]. Ten editions of “Chinese National Prevention and Control Protocol (CNPCP) for COVID-19” and “Chinese National Diagnosis and Treatment Protocol (CNDTP) for COVID-19” were issued, continuously improving measures such as investigation, isolation, and treatment of high-risk individuals, regional control of high-risk areas, and classification of infected individuals for appropriate treatment. Policies regarding monitoring and early warning, pandemic response, and patient treatment were also continuously refined. Fifth, international cooperation was essential for combatting the COVID-19. From the very beginning, China shared the SARS-CoV-2 viral genome sequence and epidemiological data to WHO and international societies. While benefitting the aid from many countries, particularly for personal protection equipment (PPE) at the early phase, China provided huge aid of PPEs, vaccines, and other medical products to 120 countries and regions once the production and supply chains were restored since March 2020 and sent expert teams to more than 40 countries [
7]. The last but not the least, China’s successful management of COVID-19 was attributable to the grassroots governance system and the concerted efforts of the entire population. Grassroots organizations and community social workers played a crucial role in providing material and mental health support to the household, especially the vulnerable people. Moreover, the successful implementation of every prevention and control strategy would not be possible without the strong sense of responsibility, self-discipline, dedication, and mutual support heroically exhibited by the 1.4 billion Chinese people.
3 Distinct stages of response to COVID-19 pandemic in China
China’s experience of fighting against COVID-19 pandemic can be divided into four stages by comprehensively incorporating key aspects of pandemic influenza risk, transmissibility, severity of disease, virology, epidemiological and clinical data, and national action plans (Fig.5). During Stage I (December 2019 to May 2020), after an overall assessment of the epidemic caused by the novel coronavirus infection, decisive measures were made to put the management of COVID-19 at a very high level of legally notifiable infectious disease, namely, Category B but with measures for Category A. The channels of exit from and entry into the epicenter, Wuhan City and Hubei Province, were closed while basic livelihood needs of the local residents were ensured as much as possible, thanks to the support from all other provinces, autonomous regions, and municipalities, and unprecedented large-scale public health response measures were implemented nationwide [
8]. Within about three months, the epidemic was under control, which also provided valuable time for other regions to prepare for the disease and made significant contributions to the global fight against the pandemic [
9]. During the second stage (May 2020 to December 2021), after the epidemic entered a normalized prevention and control stage in April 2020, China adhered to the strategy on “preventing external importation and internal resurgence of SARS-CoV-2 infections” and the “dynamic zero” principle, which effectively protected Chinese people from the impact of five imported global waves of outbreak. In November 2021, the emergence of the Omicron variant and its sublineages were observed, and the transmissibility of COVID-19 continued to rise. During stage III (January 2022 to December 2022), by continuing to adhere to the strategy of “dynamic zero,” China made every effort to ensure the health and safety of the people, and the outbreak of the BA.1, BA.2, BA.4, and BA.5 variants were effectively prevented or controlled. In November 2022, the more transmissible Omicron variant BA.5.2 and BF.7 began to spread in China, and scientific evidence increasingly indicated a weakened pathogenicity of the Omicron variant. In response, during stage IV (December 2022 to February 2023), Chinese government optimized and adjusted management measures, downgrading COVID-19 to Category B infectious disease management on January 8, 2023. After more than three years’ combating with COVID-19, China achieved remarkable success in protecting people’s life and maintained a relatively stable operation of the society.
3.1 Stage I: Action against initial outbreak in Wuhan (December 2019 to May 2020)
The action against initial outbreak in Wuhan refers to the actions to save people’s lives against the initial outbreak of the COVID-19 epidemic from late December 2019 to the end of April 2020 in Wuhan and other cities of Hubei Province. Winning the battle against initial outbreak in Wuhan and Hubei Province laid a solid foundation for the later actions against the pandemic.
3.1.1 Early rational deployment of healthcare strength and social mobilization to cope with outbreak
On December 27, 2019, aggregated cases of pneumonia of unknown cause were reported, while a cluster of patients with similar situations were observed in other hospitals in Wuhan [
8]. Continuous monitoring, detection, and exploration on the uncertain pathogen and related disease were conducted by local government and research institutions, as early treatment for patients and response to the disease prevention were also implemented. Research and professional institutions worked day and night to determine the pathogen of infection and its transmission pattern, and strengthen monitoring. In parallel to domestic coordination, Chinese government also released epidemic information timely and established deep cooperation with WHO and other international communities, which provided valuable information and time for the global preparedness for the novel coronavirus.
3.1.2 Strict traffic restriction to prevent the virus from spreading
In the following two days, the cumulative infected cases were rapidly increasing in Wuhan. On January 22, 2020, 131 newly confirmed cases were reported in 24 provinces across the country, with a total of 25 provinces reporting COVID-19 cases, and the epidemic was spreading rapidly [
10]. At that time, there were no effective drugs or vaccines for COVID-19, and 13.8% of COVID-19 population suffered from severe case and 6.1% suffered from critical case, while the mortality rate was approximately 5% [
8,
11]. To prevent the virus from spreading across the country by population transportation during Chinese Spring Festival, it was necessary to restrict the population movement in Wuhan City and Hubei Province, control traffic channels and isolate infected cases. Therefore, on January 23, 2020, Wuhan declared temporary closure of the city’s outbound routes.
The traffic control was a crucial measure during that critical period, preventing the spread of COVID-19 within and outside the city. A study conducted in Wuhan with a sample of 32 583 patients demonstrated that after implementing the restriction on traffic and channels of exit in Hubei and Wuhan, the R
0 value of SARS-CoV-2 virus, a basic reproduction number indicating the probability of infection per contact, decreased from 3.88 to 1.25 [
12]. WHO also commented that the strict restriction on traffic channels in Wuhan and Hubei reduced the probability of the epidemic spreading and was very appropriate and important [
11]. Similar conclusion was also proved by the following experiences from other countries. Data from Germany and Italy also reported the effectiveness of social distancing interventions, with restriction on traffic channels implemented around March 23, 2020, followed by a decrease in the R
0 value to around 1 [
12].
3.1.3 Integration of medical resources to save lives
To effectively address the urgent need of medical workforce, from January 24 to March 8, 2020, a total of 346 medical teams including 42 600 medical staff were sent to assist the response in the virus-hit Wuhan and other cities in Hubei Province [
13]. Together with 540 000 local healthcare professionals, all 590 000 doctors, nurses, public health specialists from different institutions were effectively integrated and coordinated to protect every people, treat every infected case, and save every human life [
8]. More attentions were attached to critically ill patients, especially those at real risk of death. On January 23, 2020, the JPCM decided to urgently build special hospital for critical cases and the design plans for Wuhan Huoshenshan Hospital were completed on the next day. Only 10 days later, a new hospital with 33 900 m
2, 1000 beds of intensive care units, severe cases wards, and general wards was completed and officially delivered for use, which also included para-clinical departments such as intra-hospital infection control, laboratory medicine, specialized diagnosis, and imaging. On February 5, 2020, another special hospital named Leishenshan was also completed and put in use for critical patient care [
1].
Thanks to the selfless and tireless work of healthcare workers and the strong political commitment of Chinese government, with the extraordinary courage of people in Wuhan City and Hubei Province, the proportion of critical cases in Wuhan dropped from 31.6% on February 11 to 22.4% on February 27, 2020, and the mortality rate dropped from 9.0% on January 26 to 4.4% on February 27, 2020 [
14].
3.1.4 Construction of temporary shelter hospitals to care mild cases
The combined capacity of Huoshenshan and Leishenshan Hospitals was only 2600 beds, limited to treating critical cases, and thus unable to meet the urgent treatment needs of the increasing number of mild patients in Wuhan. Therefore, on February 3, 2020, it was decided to redecorate large venues such as sports stadiums, exhibition centers, and training centers into “Fangcang hospitals,” a kind of temporary shelter hospital for mild cases, providing quarantine and treatment for free [
15]. By March 10, 2020, 16 Fangcang hospitals provided care to about 12 000 patients. This allowed mild patients to receive medical care while being quarantined to prevent the spreading of disease. After that, the Rt value, representing the average number of people that can be transmitted per infected person after a period of epidemic prevention and control interventions, in Wuhan dropped to 0.32 on February 17, and 0.1 on March 8, 2020, and the newly confirmed cases dropped to single number at that time. Eventually, there were no new confirmed cases in Wuhan [
10].
3.1.5 Efficient socio-economic recovery
From February to March 2020, the newly confirmed cases gradually decreased from high level to low level. From February 2 to 14, the number of newly confirmed cases fluctuated between 1000 and 2000 per day. From February 15 to March 5, it fluctuated between 100 and 1000 per day. And this number entered the range of 10 to 100 on March 6 and 7 [
8]. From 0:00 to 24:00 on March 18, there were zero new confirmed cases and zero new suspected cases of COVID-19 in Wuhan, achieving the first “double zero” in the past three months [
10].
After more than 10 days’ strict surveillance of pandemic, Chinese central government believed that it was time to ensure both pandemic control and socio-economic development, to minimize the potential impact of COVID-19 on people’s daily life, and to maintain the general order of society. In April 2020, China took great efforts to expand domestic demand, support the resumption of production, and ensure employment. Although the GDP in the first quarter of 2020 witnessed a negative growth, China strived to achieve the economic and social development goals of the year, while giving top priority to the medical care and disease prevention. At the end of April 2020, China entered the stage of normalized prevention and control of COVID-19 epidemic. The management measures of COVID-19 changed from emergency response to regular prevention and control.
3.2 Stage II: Targeted routine prevention and control for COVID-19 (May 2020 to December 2021)
During the period from May 2020 to December 2021, several waves of out-boarder importation of COVID-19 cases were detected and a few domestic cases were confirmed. The cluster outbreaks of COVID-19 were occasionally reported, but almost all of them could be rapidly and effectively controlled in 1–3 incubation periods, eliminating the potential impact on people’s daily life and socio-economic development. During that one and half years, holding high the principle of “putting people and their lives first,” China optimized COVID-19 management strategy into targeted routine prevention and control, adhering to two crucial policies, including “prevent external importation and internal resurgence” and “dynamic zero” [
16].
3.2.1 Prevent external importation and internal resurgence
After winning the action against COVID-19 in Wuhan, the pandemic mainly occurred in border port cities, with contaminated containers and imported frozen productions as the main sources of transmission, leading to a relatively high proportion of asymptomatic infection cases [
16]. In response to this, from May 2020 to August 2021, China timely adjusted the prevention and control measures to “prevent external importation and internal resurgence,” with the assistance of nucleic acid testing to enhance prevention.
Under the strategy of “prevent external importation,” a closed-loop management system was implemented to ensure the simultaneous prevention of people, goods, and the environment from SARS-CoV-2 infection or contamination. According to the China Center for Disease Control and Prevention (CDC) Weekly Report from May 2020 to November 2021, a total of 11 local clusters of cases occurred. Among them, 5 cases (45.45%) were workers at port, dock, or airport cargo, and 2 cases (18.18%) were airport staff. In terms of the source of infection, 2 cases (18.2%) were caused by imported frozen products’ packaging, and 3 cases (27.27%) were caused by close contact with infected individuals [
17]. Each of these events was closely related to infections among high-risk populations who were working in cross boarder transportation or cold chain product trade. This highlighted the importance of the joint prevention and control of people, goods, and the environment, as well as the implementation of closed-loop management.
Under the strategy of “preventing internal resurgence,” regions in China were categorized by the risk of the pandemic into three levels—low, medium, and high, and differentiated and precise measures were implemented based on the classification, minimizing the negative influence of COVID-19 prevention on people’s daily life and social sustainability. Low-risk areas focused on the prevention of external importation, medium-risk areas on preventing external importation and internal spread, and only high-risk areas were strictly controlled to prevent internal spread and external exportation [
18].
With a series of effective measures, China’s economy quickly recovered from the impact of the pandemic and regained its development vitality. According to data from the National Bureau of Statistics of China, only the first quarter’s GDP in 2020 decreased by 6.8% year-on-year, but then quickly rebounded with a 3.2% year-on-year growth in the second quarter. In the following two quarters of 2020, China’s GDP continued to maintain positive growth, with year-on-year growth rates of 4.9% and 6.4% (Fig.3), respectively. The comprehensive GDP for China in 2020 reached a growth of 2.2% compared to 2019 (Fig.4). In contrast to the global economy, which was greatly impacted by the pandemic, with significant declines, and a substantial shrinkage in GDP for many countries, China’s economy accounted for a significant 17% share of the world’s total GDP [
19]. In terms of prevention and control policies, the differentiated and precise approaches in various regions according to the classification of disease risk provided policy guarantees for resuming work, production, and education, effectively coordinating pandemic prevention with economic and social life.
In addition, a large proportion of infection was transmitted by asymptomatic infected individuals at that time, thus, China promptly proposed the strategy of “expanding prevention with the assistance of nucleic acid test.” Asymptomatic individuals referred to those who test positive for the COVID-19 viral pathogen but did not exhibit related clinical symptoms [
20]. Research indicated that the proportion of asymptomatic individuals ranged from 1.0% to 87.9% [
21]. Moreover, the viral load in the upper respiratory tract of asymptomatic individuals was comparable to that of symptomatic individuals, and the viral shedding was highest before the onset of symptoms, making asymptomatic individuals one of the important sources of COVID-19 transmission [
22,
23]. Therefore, expanding prevention by adopting nucleic acid test was an effective measure. In terms of the effectiveness, asymptomatic individuals were difficult to identify according to clinical manifestations, but their respiratory specimens would be tested positive for the SARS-CoV-2 pathogen. As for the cost-effectiveness of nucleic acid test, one study showed that in a city with 18.67 million residents during an outbreak of COVID-19, conducting large-scale nucleic acid test reduced 13 confirmed cases, compared to the control, ended the pandemic 20 days earlier, and brought a net benefit of 22.182 billion RMB. The cost-benefit ratio was 24.23, much larger than 1, demonstrating the value of large-scale nucleic acid test [
24].
3.2.2 “Dynamic zero” policy
From August 2021 to December 2021, the Delta variant emerged and spread across China. In response to the new VOCs, China established the general policy for COVID-19 prevention and control—“dynamic zero” policy, aiming to effectively control the pandemic within one incubation period. This policy was based on coordinated targeted routine prevention measures and localized emergency response. It focused on newly confirmed local cases, implementing comprehensive measures to break the transmission chain and achieve effective pandemic control in a more precise way.
Compared to previous strains, the Delta variant had some new epidemiological characteristics: the viral loads was approximately 1260 times higher than the prevalent strains in 2020 [
25], with an average incubation period of 4.4 days, an average generational interval of 2.9 days, and an average sequence interval of 2.3 days, much shorter than previous variants [
26]. More importantly, the Delta variant had more rapid transmission speed between generations, higher R
0, and stronger transmissibility, with a nearly 60% increase in transmissibility compared to the Alpha variant. The R
0 value reached to approximately 5–8. A study estimated that when the R
0 of Delta variant was 6, it would potentially infect 60.46 million people after 10 generations of transmission [
27]. Based on the characteristics of the Delta variant, equipped with rapid advancements in biological technology and widespread use of big data, China adjusted the policy for COVID-19 management into the “dynamic zero” policy [
28], a multi-dimensional approach employed to achieve maximum effectiveness with minimal cost.
Taking Shanghai City as an example, the “dynamic zero” policy and related measures showed remarkable results. In terms of pandemic prevention and control, based on precise management, the cumulative number of people screened for nucleic acid in the nine COVID-19 outbreaks only accounted for approximately 1.7% of the total population in 2021 [
29]. An estimation study also indicated that if China were to adopt the prevention and control strategies similar with countries such as the United States, the UK, Spain, and France, the number of daily new infections would reach hundreds of thousands, with severe cases reaching 10 000 [
30].
During the targeted routine response to the variant strains, the value of China’s universal vaccination policy should be highlighted. To ensure people’s safety, in July 2020, China following WHO rules, urgently launched COVID-19 vaccination to high-risk personnels, such as frontline medical and pandemic prevention professionals, port workers, and city’s fundamental operation support staff, under the principle of informed consent and voluntary administration. In December 2020, China’s first COVID-19 vaccine was conditionally approved for market. Subsequently, the nationwide COVID-19 vaccination campaign began, with arrangements to make vaccine more accessible for special populations such as the elderly and children. Research showed that the infection rate of the Delta variant was higher among individuals who had not been vaccinated. A cross-sectional study in India found that unvaccinated individuals accounted for 72.4% of the total cases infected with the Delta variant [
31]. Statistics from Public Health England also demonstrated that among 300 010 reported cases of Delta variant infection from February 1 to August 2, 2021, unvaccinated individuals accounted for 50.35% [
32]. These studies demonstrated the practical value of China’s universal vaccination policy.
3.3 Stage III: Response to Omicron (January 2022 to December 2022)
In November 2021, the Omicron variant was discovered in multiple countries and was classified as a VOC by WHO at the same month. In January 2022, Omicron replaced the Delta variant as the predominant strain globally and continued to spread since then. It entered Hong Kong, China on November 27, 2021, and then Chinese mainland on December 9, 2021, leading subsequently to multiple waves of local outbreaks. For example, the outbreaks in Tianjin City in January 2022, in Shenzhen City, Guangdong Province in February–March 2022, in Shanghai City and Jilin Province in March 2022, and in Hainan Province in August 2022 were all caused by the Omicron variant. During this stage, the nationwide outbreaks caused by Omicron exhibited the characteristics of being widespread, frequent, and occurring in multiple locations. Compared to previous variants, Omicron exhibited the following characteristics: (1) significantly increased transmissibility, much higher than the Delta variant [
33], with a R
0 reaching 8–10 [
34] and an incubation period of 2–4 days [
35]; (2) reduced pathogenicity [
36], posing a relatively smaller threat to the lungs and having a shorter duration of illness; (3) enhanced immune escape capability, making it more likely to evade immunity in vaccinated individuals or those with previous SARS-CoV-2 infection [
37,
38]; (4) rapid mutation rate [
39], with the emergence of various sublineages such as BA.2, BA.3, BA.4, BA.5, BF.7, and BA.2.12.1. During this stage, China continued to firmly adhere to the strategy of “preventing external importation and internal resurgence” and the “dynamic zero” policy, but also attached more attention to the potential side effects. The ninth edition of CNPCP for COVID-19 was issued to guide the disease prevention, whereas the “nine non-permissions” policy, including the prohibition of measures taken by some local administration impacting people’s daily life, was enacted to balance the pandemic control and socio-economic development. Due to the fast spread of the Omicron variant, prevention and control measures focused on acting early and acting quickly. The entire chain of pandemic prevention and control was accelerated, and speed was emphasized as a requirement throughout the entire process of pandemic response. At the same time, China conducted one-month pilot programs in seven cities, including Dalian, Suzhou, Ningbo, Xiamen, Qingdao, Guangzhou, and Chengdu, between April and May, to optimize the prevention and control strategies. The study summarized a wealth of scientific evidence, contributing to the optimization and adjustment of COVID-19 diagnosis and treatment, prevention and control protocols.
By the end of 2021, the full immunization rate of COVID-19 vaccine in China was 85%, however, the rate in the elderly in China was still low, with less than 30% in the elderly over 80 years old and less than 50% in the elderly over 70 years old in some provinces and cities. At the same time, the overall vaccination rate in the United States was about 60%, but the rate among people aged 65 years and older reached 86.1%. Similarly, according to the official data of Japan, the proportion of people aged 60–64, 65–69, 70–79, and over 80 years old who had completed the full vaccination accounted for 86.5%, 87.83%, 92.62%, and 94.35% of the same population, respectively [
40]. It was obviously that the immunity level of the elderly in China was relatively low.
Leveraging data from the United States [
41], the UK [
42], Hong Kong SAR [
43], and Singapore [
44], we conducted the analysis considering the infection rate, hospitalization, ICU admission, and death rate associated with the Omicron variant, adjusting for vaccination rates and age distribution within the population. The projected outcomes suggested that abandoning the dynamic zero-COVID policy could lead to daily increases in cases and significant strain on medical resources. It is estimated that the peak daily outpatient and emergency department visits could reach 2.26 million, exceeding the system’s full capacity by 111.16%. Additionally, according to international data on severe cases and mortality, patients infected by the Omicron strain would occupy 145.8% of the total ICU beds across China in a short period, and a projected deaths of nearly one million could occur, with individuals aged 60 and over comprising approximately 41.3% of these fatalities.
Therefore, the purpose of the great efforts China made from January to September 2022 to control the Omicron outbreak, especially the costly Shanghai Campaign, was really to win the time to increase the vaccination rate of COVID-19 vaccine in Chinese population, especially in the older adults, to increase the manufacturing and storage of anti-viral medicines, to increase the ICU number for severe/critical cases, and to strengthen the training of the general practitioners in both urban and rural areas for COVID-19 patients treatment and management. In October 2022, the vaccination rate in the whole population had been increased and people aged 60 and older who acquired COVID-19 vaccines were more than 90% [
45]. Moreover, continuous monitoring and analysis on the COVID-19 confirmed cases indicated that the proportion of severe and critical illness patients decreased from 16.47% in 2020 to 3.32% in 2021, and as of December 5, 2022, the ratio was 0.18% [
46]. That meant the proportion of severe and critical illness was decreasing year by year, and the mortality rate was also gradually decreasing while the viral transmissibility was rocket-rising.
3.4 Stage IV: Downgradation of COVID-19 management from Category B but with measures of Category A to Category B (December 2022 to February 2023)
The threats of the novel coronavirus, the immunity levels of the population, the capacity of the healthcare system, and the effectiveness of social public health interventions were the core factors considered when formulating pandemic prevention and control policies in China. Based on these considerations, in November 2022, the JPCM assessed the then pandemic situation and emphasized the need to optimize and adjust COVID-19 prevention and control policy and measures adapted to the decreased pathogenicity of the virus, high vaccination rates in Chinese population, and effective coordination between pandemic prevention and control and socio-economic development. Subsequently, based on the experience and assessment data from pandemic control practices in multiple regions, 20 measures were further optimized and promulgated. In December 2022, the JPCM announced the “New Ten Measures” to optimize the implementation of pandemic prevention and control. On January 8, 2023, after three years of the pandemic, the novel coronavirus infection was officially downgraded from Category B with measures for Category A to a Category B management disease.
With the change in the pandemic prevention and control stage and the impact of the highly transmissible Omicron variant, the number of infected individuals rapidly increased within a short period. To address the challenges during this stage, China took the following measures: forward deployment to strengthen the protection of vulnerable populations; rapid triage to strengthen hierarchical diagnosis and treatment; coordinated allocation of medical resources, making every effort to treat severe/critical patients; and strengthened guarantee to ensure an adequate supply of medications.
After November 2022, the number of visits in fever clinics, emergency departments and critical/severe illness patients across the country sequentially peaked [
47]. On December 23, 2022, the number of fever clinics visits reached a peak of 2.867 million, and continued to decline, falling back to 477 000 on January 12, 2023. The number of visits in emergency department peaked on January 2, 2023, and on January 12, 2023, the positive infection detection of SARS-CoV-2 in emergency department dropped to 2.9%. On January 5, 2023, the number of hospitalized critically/severely ill COVID-19 patients reached peak at 128 000, and until January 12, 2023, the number declined to 105 000. In general, after January 12, 2023, China passed the peak of the outbreak stage.
As of February 9, 2023, there have been a total of 88 385 deaths related to SARS-CoV-2 infection in China. Among them, the number of deaths was 5235 by December 8, 2022, the mortality rate was 1.48%, which was a little bit higher than the world average mortality rate at 1.04% [
48]. From December 8, 2022, to January 12, 2023, the number of deaths was 59 938, the critical/severe illness rate of patients hospitalized with COVID-19 was 8.19%, and the in-hospital mortality rate was 4.72%. From January 12 to February 9, 2023, the number of deaths was 23 212, the proportion of hospitalized critical/severe cases was about 8.05%, and the in-hospital mortality dropped to 2.82%. Moreover, critical/severe cases and deaths at that time were more likely to be elderly population and with underlying disease. Taking the data of January 12, 2023 as an example, 89.6% of the critical/severe patients hospitalized with COVID-19 were aged 60 years and above, and the average age was 75.5 years. Among these patients, 40.7% had one underlying disease, 24.6% had two underlying diseases, and 34.8% had three or more underlying diseases [
47].
4 Strengths and shortcomings in China’s fight against COVID-19
China has achieved remarkable innovations in the early stages of the COVID-19 outbreak, especially in the identification of signs and diagnosis as well as the epidemiology and transmission characteristics of the disease [
49,
50]. This rapid identification of signs and symptoms helped in the early detection of patients and isolation of suspected cases, thus effectively curbing the spread of the virus. Chinese researchers isolated and sequenced the genetic sequence of the novel coronavirus, and shared this information with other international research institutions, which provided a basis for global researchers to detect and diagnose novel coronavirus. In the response to the COVID-19 pandemic, China promoted the detection technology to the level of molecular medicine, mainly using fluorescence quantitative PCR for nucleic acid detection, which were used as an important basis for the diagnosis of COVID-19 patients and large-scale rapid screening [
51]. Since the outbreak of COVID-19, the National Health Commission of the People’s Republic of China had issued ten editions of the CNDTP for COVID-19, which provided scientific and standardized basis for the diagnosis and treatment of COVID-19 from the aspects of epidemiological characteristics, pathology, clinical manifestations, diagnosis, classification, key populations, treatment, nursing, and prevention [
52].
In spite of the great achievements in China’s combatting COVID-19, there were some shortcomings which are worth mentioning. The direct reporting system from grassroots level health professional to both local health authorities and Chinese CDC, established in China after SARS outbreak, could be better used at the initial stage of the outbreak. The quality control of the clinical trials for anti-COVID-19 drugs and technologies could be improved. Risk communication with the public on the essential role of vaccination, especially among elderly, could be raised to a higher level. The psychological social service to the people, especially the young, was not sufficient in some places. The stockpiling of people’s daily life goods was not enough in some cities before lockdown. And the anti-viral drugs and other medicines upon the adjustment of prevention and control policies could be much better prepared in some provinces and cities. All these lessons learned can be integrated into the amendment of laws or regulations for prevention and control of infectious diseases, particularly the protocols of preparedness for emerging new infectious diseases or re-emerging infectious diseases.
5 Conclusions and recommendations
During the past three years and more, China achieved extraordinary success against the most serious pandemic over the last century, giving top priority of people and their lives, while ensuring the stable development of the society and economy, which reflected the excellent governance system, the great responsibility of political leadership, and strong courage of the people. However, the struggle between human beings and virus is a long historical process. Although China downgraded the management of COVID-19 to Category B and the WHO declared the end of global public health emergency, the threats of COVID-19 and other emerging virus to global health still exist. The management of COVID-19 cannot be simply lifted, instead it should be optimized and adjusted based on scientific evidence. Measures to protect vulnerable population, such as the elderly and children should be continued. It is necessary to make science-based plan of booster vaccinations and the development of effective medications, according to the virus variation and the effect of vaccine protection, especially for the elderly populations. The hierarchical medical system should be strengthened and the distribution of medical resources should be optimized to ensure the optimal treatment for severe and critical cases. The capability of primary health care system should be enhanced, serving as the gatekeeper of population health.
We must learn lessons from the past experiences and enhance the capability and preparedness for potential public health emergencies as well. The public health system and discipline should be strengthened and the capability of emergency response and on-site judgment of public health personnel need to be promoted. It is crucial to enhance our capacity of epidemic surveillance, early warning, timely information reporting and emergency response. While coordinating and deeply integrating the medical and prevention system in China is also of great significance, international cooperation and coordination are urgently needed to boost the world economic recovery and build a global community of health for all.
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