A fast-spreading COVID-19 outbreak in China has researchers predicting a surge in virus-related deaths next year, with several analyses forecasting more than 1 million fatalities in a country that until now has largely kept the coronavirus in check.

Earlier this month, China dramatically loosened its strict “zero COVID” policies following a wave of protests in towns and cities where residents were fed up with years of stringent lockdowns, mass testing and centralized quarantines. The demonstrations marked the most significant show of public dissent in China in years.

But many of China’s 1.4 billion people remain vulnerable to the virus because of limited exposure, low vaccination rates and poor investment in emergency care. And now, funeral homes and crematoriums in Beijing, the capital, are struggling to keep up with demand, Reuters reported.

On Friday, the Institute for Health Metrics and Evaluation, a global health research institute at the University of Washington in Seattle, projected that China’s COVID-19 death toll would spike to more than 322,000 by April. An analysis of the report by Reuters found that China could see more than 1 million coronavirus deaths in 2023 – up from an official toll now of just 5,235.

That would put China’s death toll on par with the United States, where 1.1 million people have died of COVID-19 since the pandemic began.

“However way we look at it, it’s very likely that the next few months are going to be quite challenging for China,” IHME director Christopher Murray said in a video statement earlier this month. “The populations at greatest risk in the world are those that have avoided a lot of transmission and have gaps in vaccination. And that’s exactly the case for China.”

The virus first emerged in the Chinese city of Wuhan in December 2019 – and quickly spread around the globe. But after that initial outbreak, Chinese authorities embarked on a hard-line strategy to prevent transmission, closing the country’s borders, isolating patients and their contacts, and in some cases locking down entire cities to keep the virus from circulating.

As new, more infectious variants appeared – including omicron and its offshoots – the strategy became less effective, experts say, while angering residents who watched as the rest of the world opened up.

The virus was already spreading “intensively” in China before authorities relaxed restrictions on Dec. 7, the World Health Organization said last week.

“There’s a narrative at the moment that China lifted the restrictions and all of a sudden the disease is out of control,” the WHO’s emergencies director, Mike Ryan, said at a news conference Wednesday. “The disease was spreading intensively because I believe the control measures in themselves were not stopping the disease. And I believe China decided strategically that was not the best option anymore.”

Still, a separate study published last week by researchers in Hong Kong predicted that 684 people per million would die if China reopened without a mass vaccination booster campaign and other measures. According to a Bloomberg News analysis, that would add up to about 964,000 deaths over the course of the reopening.

China’s official coronavirus vaccination rate is 90 percent, which includes two doses of its domestically produced vaccines. But those shots, which use older technology, have lower efficacy rates than messenger RNA vaccines and offer weaker protection against new variants, experts say. Another problem in China is vaccine hesitancy, particularly among the elderly. Just 40 percent of Chinese older than 80 have received a booster shot.

China’s “vaccine induced immunity has waned over time and with low booster uptake and no natural infections, the population is more susceptible to severe disease,” said Airfinity, a London-based health analytics firm.

Airfinity’s own models, released in late November, projected between 1.3 million and 2.1 million deaths in China if the government abruptly ended its zero-COVID policy.

Other estimates have been even bleaker. Also in November, epidemiologists led by Zhou Jiatong, the head of the Center for Disease Control in China’s Guangxi region, estimated that more than 2 million people could die if the country suffered a COVID-19 surge similar to the one that hit Hong Kong in the spring.

Because China stopped publicizing asymptomatic cases – and appeared to tighten its definition of a COVID death – earlier this month, the IHME and others used Hong Kong’s omicron outbreak to inform their models. The variant ripped through the densely populated region, and within three months, the population of just 7.4 million saw more than a million new coronavirus cases and some 7,000 deaths.

Now, the severity of China’s coronavirus surge is being reported largely anecdotally, with stories of deserted streets, strained hospitals and funeral homes, and pharmacies being emptied of fever medication and traditional remedies.

Murray, the IHME director, said China has several options. It could slow the transition away from zero COVID to avoid overwhelming hospitals. It could also change course and try to inoculate residents with mRNA vaccines or increase access to antiviral medications such as Paxlovid.

Last week, Pfizer signed an agreement with the state-owned China Meheco Group Co. to import and distribute Paxlovid on the mainland, Bloomberg News reported.

The Hong Kong-based researchers also wrote that waiting a month to reopen and using that time to increase booster and antiviral coverage could reduce cumulative deaths in China by 26 percent.

“Although the surge of disease burden posed by reopening in December 2022 – January 2023 would likely overload most local health systems nationwide, a reopening strategy that combines vaccination, antiviral treatment and [public health and social measures] could allow China to exit zero-COVID more safely,” they wrote.

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