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Excess mortality in Mainland China after the end of the Zero COVID policy: A systematic review

Published online by Cambridge University Press:  06 February 2026

Isaac Chun-Hai Fung*
Affiliation:
Department of Biostatistics, Epidemiology and Environmental Health Sciences, Jiann-Ping Hsu College of Public Health, Georgia Southern University, USA
Hai Liang
Affiliation:
School of Journalism and Communication, The Chinese University of Hong Kong, Hong Kong
Kelli J. Pierce
Affiliation:
Department of Biostatistics, Epidemiology and Environmental Health Sciences, Jiann-Ping Hsu College of Public Health, Georgia Southern University, USA
Alicia N. M. Kraay
Affiliation:
Gates Foundation, USA
Kin On Kwok
Affiliation:
The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong Hong Kong Institute of Asia-Pacific Studies, The Chinese University of Hong Kong, Hong Kong Department of Infectious Disease Epidemiology, Imperial College London, UK
Andrei R. Akhmetzhanov
Affiliation:
Institute of Epidemiology and Preventive Medicine, National Taiwan University College of Public Health, Taiwan
Frank E. Baiden
Affiliation:
Office of the Dean, University of Health and Allied Sciences School of Public Health, Ghana
H. Juliette T. Unwin
Affiliation:
School of Mathematics, The University of Bristol, UK
Francis B. Kengne
Affiliation:
Department of Biostatistics, Epidemiology and Environmental Health Sciences, Jiann-Ping Hsu College of Public Health, Georgia Southern University, USA
Faharudeen Alhassan
Affiliation:
Department of Population Health Sciences, School of Public Health, Georgia State University, USA
Gerardo Chowell*
Affiliation:
Department of Population Health Sciences, School of Public Health, Georgia State University, USA Department of Applied Mathematics, College of Applied Sciences, Kyung Hee University, Korea
*
Corresponding authors: Isaac Chun-Hai Fung and Gerardo Chowell; Emails: cfung@georgiasouthern.edu; gchowell@gsu.edu
Corresponding authors: Isaac Chun-Hai Fung and Gerardo Chowell; Emails: cfung@georgiasouthern.edu; gchowell@gsu.edu
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Abstract

After the Zero COVID policy ended on December 7, 2022, ~90% of mainland Chinese were infected in a COVID-19 wave. This systematic review synthesized research estimating excess mortality during that wave in mainland China. We searched seven databases in May 2024 and updated our search in July–August 2025. Peer-reviewed research (Chinese or English), published since January 1, 2023, estimating excess deaths in the COVID-19 wave post-Zero-COVID was included. Risk of bias was assessed using a modified Newcastle-Ottawa Scale. Two authors independently conducted abstract screening, full-text review, data extraction, and risk-of-bias assessment. Seven articles were included. Two studies analysed the death records of a town and a district in Shanghai, estimating the excess mortality rates of 153.6% and 174.3%, respectively. Using indirect methods, four studies estimated national excess mortality (range: 0.71–1.87 million). Another study estimated excess mortality in Taiyuan. Studies used diverse methods to estimate excess deaths, resulting in widely varying and uncertain estimates. Choice of reference period, seasonality, and other factors affect expected mortality estimates.

Information

Type
Review
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited.
Copyright
© The Author(s), 2026. Published by Cambridge University Press
Figure 0

Figure 1. Schematic presenting the steps taken to identify literature for this systematic review: the database search, deduplication, abstract screening, full-text review, and inclusion and exclusion of literature. Panels A and B present the process and results of our first (2024) and second (2025) search, respectively. Search updated July–August 2025; no additional inclusions. PRISMA counts reconcile with Supplementary Text S1.

Figure 1

Table 1. Data sources of the seven included articles, their reference period (with which the expected number of deaths was derived), and the time period in which excess deaths were calculated

Figure 2

Table 2. Location (population) of the excess death estimates, reported/estimated number of deaths, expected number of deaths, and excess deaths reported in the 7 included articles

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