To the Editor — To date, mainland China has promptly blocked hundreds of COVID-19 outbreaks that are associated with imported cases, enabling it to maintain the zero-COVID policy for more than 20 months1. Although tremendously costly, this zero-case policy could have saved an estimated one million lives, compared with the global average mortality of COVID-19 (as of 16 February 2022)1. Many people in China and around the world are wondering if and when mainland China will change its zero-case policy to one of living with SARS-CoV-2. We believe that this change will happen sooner or later, as SARS-CoV-2 will probably become a seasonal infection in 2022 and circulate in humans indefinitely2,3.

There are several reasons why this change could be feasible in 2022 (Table 1). The number of fatal cases in China has been low. Of the total 24,249 new COVID-19 cases confirmed in mainland China from 15 May 2020 to 15 February 2022, only two people died before 15 March 2022 (case fatality rate (CFR) of 0.008%), although many had pneumonia1. This low CFR can mitigate any social panic. Indeed, the global CFR of SARS-CoV-2, which was around 80 times higher than that of seasonal influenza (~0.12%) in April 2020, will be likely less than 2 times higher than that of seasonal influenza in 2022 (ref. 3) due to the effects of mass vaccination, immunity from infection and the highly transmissible but relatively low-pathogenicity Omicron variant. Furthermore, COVID-19 vaccination coverage reached more than 85% in mainland China, with each person inoculated with around 2.2 doses on average1.

Table 1 Key factors to consider in ending China’s zero-COVID policy

The change from a zero-COVID approach will come with many advantages, but also great challenges (Table 1). The change should better balance the control of COVID-19 versus other socioeconomic issues. The change should also better balance the control of COVID-19 versus other diseases, as the zero-COVID approach has occupied vast public health resources. Moreover, living with the virus in a highly vaccinated population can lead to robust herd immunity against various SARS-CoV-2 variants through repeated natural mild infections2,3,4.

The greatest challenge of moving away from the zero-COVID approach in populous mainland China is that SARS-CoV-2 cases could surge rapidly, with high case numbers for months after stringent control measures are lifted. The rising cases could overwhelm healthcare systems (Table 1), which could greatly increase the COVID-19 CFR.

SARS-CoV-2 is currently circulating in Japan, South Korea and Hong Kong at high levels1, which should be observed closely as natural pilot experiments to evaluate the risk of the change in mainland China. It should be noted that the COVID-19 vaccination rate is low in Hong Kong, particularly in elderly people, which may render the COVID-19 outbreak there more severe than in mainland China.

To prepare for the end of the zero-COVID policy, we propose that development of online healthcare services should be widely and rapidly promoted, so that mild COVID-19 cases can be seen at home. This could prevent hospitals from being overwhelmed and greatly reduce the risk of nosocomial infections, including to healthcare workers5. By June 2021, mainland China had constructed more than 1,600 online hospitals with more than 239 million users6, providing a solid foundation for the rapid development of online healthcare services.

Local healthcare workers in community clinics are critical to control the COVID-19 pandemic. By 2021, 970,036 community hospitals had been established in mainland China, employing more than 3 million healthcare workers (around 1 community hospital for every 1,400 residents)6. These millions of local healthcare workers can be trained to provide better online and offline healthcare services for mild COVID-19 cases7.

Mainland China should also stockpile antivirals, personal protective equipment, N95 masks and ventilators, particularly at community hospitals. Traditional Chinese medications should also be considered, as they have a profound role in Chinese society and may help relieve mild respiratory symptoms.

It is our view that mainland China should consider changing stepwise from the zero-COVID approach in April or May 2022. By this time, vaccination immunity will not have declined much and most parts of the country will be warm. There is some evidence that SARS-CoV-2 is less transmissable in warmer months8, when co-infection with other respiratory pathogens will also be less frequent.

Regardless of when the zero-COVID policy changes, preparations should be implemented in advance to confront the challenges.