After China abruptly dropped its COVID-zero measures earlier this month, a surge in infections across the country was expected.
But many observers are casting a questioning eye over the reported low case numbers.
"In China, what's been reported is relatively low numbers of cases in ICUs, but anecdotally ICUs are filling up," the World Health Organization's emergencies director Mike Ryan said on Wednesday.
"I wouldn't like to say that China is actively not telling us what's going on. I think they're behind the curve."
Reuters reported this week that dozens of hearses were seen lining up outside a designated COVID-19 crematorium in Beijing while workers in hazmat suits carried the dead inside the facility.
Despite this, China has reported just seven deaths in the three weeks since the COVID-zero policy ended on December 3.
This week a Chinese health official said only deaths from respiratory illness, such as pneumonia, would be counted in China's official COVID-19 death toll.
Dr Ryan suggested that definition was too narrow, as many people die of COVID due to organ systems failures from the severity of infection.
"So limiting a diagnosis of death from COVID to someone with a COVID positive test and respiratory failure will very much underestimate the true death toll associated with COVID," he said.
Systems under strain
While Reuters could not confirm if the hearses all contained people who died of COVID, there are other indications that the pressure on the hospital system is building.
In a post on its official WeChat page, one hospital in Shanghai estimated there were 5.43 million positive cases in the city and that 12.5 million would be infected by the end of the year in the commercial hub.
"In this tragic battle, the entire Greater Shanghai will fall, and we will infect all the staff of the hospital! We will infect the whole family! Our patients will all be infected! We have no choice, and we cannot escape."
In a public notice, authorities in Tongchuan, a city of 700,000, called for all medical workers who retired in the past five years to join the battle against COVID, saying "medical institutions at all levels in the city are under great pressure".
According to local media reports, some sports stadiums have been turned into makeshift fever clinics in Beijing, Shanghai and other major cities to deal with the increasing number of patients.
State media also said local governments were trying to tackle drug shortages, while pharmaceutical companies were working extra-time to boost supplies.
On Thursday, 3,030 new daily cases were reported in China, a country of 1.4 billion.
That's far fewer than the most recent seven-day average recorded in Australia, which was 15,956.
Internet users in China are sceptical.
"The number is definitely bigger," one Weibo user posted on the Chinese social media platform.
Health modelling from various researchers predicted China could see between 1 million and 2 million COVID deaths if it loosened restrictions too quickly without ramping up vaccinations.
The Chinese National Health Commission didn't respond to the ABC's enquiries about COVID figures.
PCR testing stopped
Experts say it is difficult to have a clear picture of what's happening in China at the moment as PCR testing has been mostly stopped.
Professor Ben Cowling, an epidemiologist at Hong Kong University, suggested that due to the absence of PCR tests, the daily numbers of confirmed COVID infections and deaths in China are not reflective of the true figures.
"With the reduction in PCR testing rates, which is entirely understandable because of the cost of testing, it is difficult to interpret the current case numbers," he said.
Following a series of anti-lockdown protests taking place in various cities in China last month, mass PCR testing has been gradually abandoned by the government.
Most PCR testing facilities that used to be available on street corners in big cities have been removed and people are no longer required to provide negative PCR results to enter most public spaces.
"Even in hospitals PCR testing is not being done," Professor Cowling said.
"It's not that it's impossible [to do PCR testing], just that there's no reason for hospitals to test.
"At the moment all patients with COVID-like symptoms will probably have COVID and will be managed accordingly."
Avoiding mass panic
Dr Huang Yanzhong, a senior fellow for Global Health at the Council on Foreign Relations, agreed it's difficult to know what's actually going on in China right now.
Dr Huang said there was a dearth of reliable data on the infections, severe cases and deaths.
"As a result, we can only rely on anecdotal evidence to gauge the extent of the crisis," he said.
Apart from mandatory PCR testing being dropped, Dr Huang suggested the lack of data may also be part of attempts to reduce mass panic that may threaten social stability.
The sharp turn in COVID policies and fast spread of the virus have sparked public concern, he added.
"Lack of reliable data on the spread of COVID in the country will undermine the government's ability to monitor and track the virus, as well as the ability to mobilise resources and modify policy to flatten the curve and reduce severe cases [and] deaths," he said.
Managing public trust
A TV broadcaster in Shanghai reported on Tuesday that the city's mental health hotline has received an increasing number of calls recently regarding the COVID situation.
The top question from callers was: "What should I do if people around me all test positive?"
Jin Jin, a local mental health expert interviewed by the broadcaster, told viewers that these people should feel relieved and lucky that they are still not testing positive and they should continue wearing masks to protect themselves.
Edmund Lee, assistant director at the Centre for Information Integrity and the Internet at the Nanyang Technological University, Singapore, said moving forward, one of the challenges would be managing the public's trust in the Chinese government.
He said that included managing expectations when people see the COVID numbers increase.
"So the main rhetoric from the Chinese authorities is that previously, there was a need for a lot of strict regulations and lockdowns for the protection of the public. And I think by and large, people do accept that to a certain extent," he said.
"It will be a challenge for the Chinese government to develop trust in the citizens who are still sceptical that it has not really pivoted away from its original stance."
Dr Lee said even when governments had all the information at hand, they had to think about how to disseminate it at a pace that would be readily accepted by the public.
"They have been so used to seeing low COVID numbers and low COVID deaths, and to see a drastic increase in the coming days – it might be alarming for some people," Dr Lee said.
"We do not want any government to be deliberately withholding and manipulating facts and data.
"But in terms of achieving transparency and accountability, we understand that sometimes data needs to be released at different points in time for the message to be effective."
According to Professor Cowling, the full numbers of PCR confirmed cases are being revealed in China, they are just not a true reflection of the level of infections and deaths because testing has mostly stopped.
"There will not be many confirmed COVID deaths in China this winter. Most of the COVID deaths that occur will not be PCR confirmed," Professor Cowling said.
The WHO has received no data from China on new COVID-19 hospitalisations since Beijing lifted its zero-COVID policy.
US Secretary of State Antony Blinken said all countries, including China, needed to share information on COVID-19.
"It's also very important for all countries — including China — to focus on people getting vaccinated, making testing and treatment available, and importantly, sharing information with the world about what they're experiencing," Mr Blinken said.
"Again, because it has implications not just for China, but for the entire world."
