TAIPEI, Taiwan (AP) — Lu Muying died on April 1 in a government quarantine facility in Shanghai, with her family on the phone as doctors tried to resuscitate her. She had tested positive for COVID-19 in late March and was moved there in line with government policy that all coronavirus cases be centrally isolated.

But the 99-year-old, who was just two weeks shy of her 100th birthday, was not counted as a COVID-19 death in Shanghai’s official tally. In fact, the city of more than 25 million has only reported 25 coronavirus deaths despite an outbreak that has spanned nearly two months and infected hundreds of thousands of people in the world’s third-largest city.

Lu’s death underscores how the true extent of the virus toll in Shanghai has been obscured by Chinese authorities. Doctors told Lu’s relatives she died because COVID-19 exacerbated her underlying heart disease and high blood pressure, yet she still was not counted.

Interviews with family members of patients who have tested positive, a publicly released phone call with a government health official and an internet archive compiled by families of the dead all raise issues with how the city is counting its cases and deaths, almost certainly resulting in a marked undercount.

The result is a blurred portrait of an outbreak that has sweeping ramifications for both the people of Shanghai and the rest of the world, given the city’s place as an economic, manufacturing and shipping hub.

An Associated Press examination of the death toll sheds light on how the numbers have been clouded by the way Chinese health authorities tally COVID-19 statistics, applying a much narrower, less transparent, and at times inconsistent standard than the rest of the world.

In most countries, including the United States, guidelines stipulate that any death where COVID-19 is a factor or contributor is counted as a COVID-related death.

But in China, health authorities count only those who died directly from COVID-19, excluding those, like Lu, whose underlying conditions were worsened by the virus, said Zhang Zuo-Feng, an epidemiologist at the University of California, Los Angeles.

“If the deaths could be ascribed to underlying disease, they will always report it as such and will not count it as a COVID-related death, that’s their pattern for many years,” said Jin Dong-yan, a virologist at the University of Hong Kong’s medical school.

That narrower criteria means China’s COVID-19 death toll will always be significantly lower than those of many other nations.

Both Jin and Zhang said this has been China’s practice since the beginning of the pandemic and is not proof of a deliberate attempt to underreport the death count.

However, Shanghai authorities have quietly changed other standards behind the scenes, in ways that have violated China’s own regulations and muddied the virus’ true toll.

During this outbreak, Shanghai health authorities have only considered virus cases where lung scans show a patient with evidence of pneumonia as “symptomatic,” three people, including a Chinese public health official, told the AP. All other patients are considered “asymptomatic” even if they test positive and have other typical COVID-19 symptoms like sneezing, coughing or headaches.

This way of classifying asymptomatic cases conflicts with China’s past national guidelines. It’s also a sharp change from January, when Wu Fan, a member of Shanghai’s epidemic prevention expert group, said that those with even the slightest symptoms, like fatigue or a sore throat, would be “strictly” classified as a symptomatic case.

Further adding to the confusion, the city has overlapping systems to track whether someone has the virus. City residents primarily rely on what’s called their Health Cloud, a mobile application that allows them to see their COVID-19 test results. However, the Shanghai health authorities have a separate system to track COVID-19 test results, and they have the sole authority to confirm cases. At times, the data between the systems conflict.

In practice, these shifting and inconsistent processes give China’s Centers for Disease Control and Prevention “wiggle room” to determine COVID-related deaths, said the Chinese health official, allowing them to rule out the coronavirus as being the cause of death for people who didn’t have lung scans or positive test results logged on their apps. The official spoke on condition of anonymity to discuss the sensitive topic.

In response to questions about Shanghai’s COVID-19 figures, China’s top medical authority, the National Health Commission, said in a fax that there is “no basis to suspect the accuracy of China’s epidemic data and statistics.” Shanghai’s city government did not respond to a faxed request for comment.

Statements from the authorities are little comfort to the relatives of the dead. Chinese internet users, doubting the official figures, have built a virtual archive of the deaths that have occurred since Shanghai’s lockdown based on firsthand information posted online. They have recorded 170 deaths so far.

Chinese media reports on the unrecorded COVID-19 deaths have been swiftly censored, and many criticisms of Shanghai’s stringent measures expunged online. Instead, state media has continued to uphold China’s zero-COVID approach as proof of the success of its political system, especially as the world’s official death toll climbs past 6.2 million.

Earlier this month, doubts over the data burst into public view when a Shanghai resident uploaded a recording of a phone conversation he had with a CDC officer in which he questioned why city health authorities told his father he had tested positive for COVID-19 when data on his father’s mobile application showed up as negative.

“Didn’t I tell you to not look at the Health Cloud?” said the official, Zhu Weiping, referring to the app. “The positive cases are only from us notifying people.”

Others skeptical of the data include relatives of Zong Shan, an 86-year-old former Russian translator who died March 29. Despite testing positive and being moved to a government quarantine facility, online test results showed Zong supposedly was negative for COVID-19 on the day of her death.

“My relative, like most of the other people in Shanghai who were notified as positive, all reported negative results” on the Health Cloud app, one of Zong’s relatives said, declining to be named for fear of retribution.

Zong was taken to a government quarantine facility from the Donghai Elderly Care Hospital on March 29, and died there that night. The family was told by hospital staff she was being transferred after she tested positive for COVID-19. But they didn’t think the virus was the biggest threat to her health — rather, it was the dearth of nursing care at the quarantine facility. Zong needed to be fed liquids and couldn’t eat without assistance.

She had been in stable condition before the transfer, said a relative. When the family asked for the cause of death, doctors didn’t give a clear answer.

“They gave me very vague answers. One minute they said it was stroke, then they said this was also just a hypothesis,” said the relative. “But on one point, they were very clear, they said it had nothing to do with COVID. Her lungs were clear.”

Lu, who was also transferred from the Donghai hospital, would have celebrated her 100th birthday April 16; her relatives had ordered a cake and gotten permission to host a small celebration Thursday. But when she tested positive, the family made mental preparations for her death, acknowledging she had lived a long life.

But the strange thing, a relative said, was the night before she died, the doctor had specifically called the family to let them know Lu was now testing negative for COVID-19. Ultimately, the doctor said she died because the virus had worsened her underlying illnesses, said the relative, speaking on condition of anonymity to discuss the issue.

Further, the family knew of another patient from the same hospital, a neighbor, who died the day after being transferred to a quarantine facility on March 25 and also had not been counted.

Jin, the Hong Kong virologist, noted the potential political benefits of Shanghai’s low official COVID-19 death toll.

“They might claim this is their achievement, and this is is their victory,” Jin said.

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Story: Huizhong Wu and Dake Kang. Kang reported from Beijing. Associated Press video producer Olivia Zhang contributed from Beijing.

BEIJING (AP) — Shanghai allowed 4 million more people out of their homes Wednesday as coronavirus rules that shut down China’s largest city eased and some factories resumed operation.

A total of almost 12 million people in the city of 25 million are allowed to go outdoors following the first round of easing last week, health official Wu Ganyu said at a news conference. Wu said the virus was “under effective control” for the first time in some parts of the city.

Shanghai shut down businesses and confined most of its population to their homes starting March 28 after a spike in infections. That led to complaints about lack of access to supplies of food and medicine. People in Shanghai who test positive but have no symptoms have been ordered into quarantine centers set up in exhibition halls and other public buildings.

The shutdown of Shanghai and other industrial centers to fight outbreaks has prompted fears global manufacturing and trade might be disrupted. Official data this week showed economic activity in the first three months of this year declined compared with the final quarter of 2021.

China’s case numbers in its latest infection surge are relatively low, but the ruling Communist Party is enforcing a “zero-COVID” strategy that has shut down major cities to isolate every case.

On Wednesday, the government reported 19,927 new cases in China’s mainland, all but 2,761 of which had no symptoms. Shanghai accounted for 95% of the total, or 18,902 cases, of which only 2,495 had symptoms.

The government reported 26,760 people who tested positive but had no symptoms were released on Wednesday from observation. That included 25,411 in Shanghai, where some residents of quarantine centers have complained they are unsanitary.

Other major industrial and trading centers including Changchun, Jilin and Shenyang in the northeast, the port of Tianjin east of Beijing and Shenzhen and Guangzhou in the south have shut down businesses, imposed travel restrictions or told told residents to stay home.

That forced global automakers and other manufacturers to reduce or stop production because their suppliers couldn’t deliver.

Volkswagen AG announced this week its Changchun factory resumed production and the automaker was considering when its Shanghai facility would reopen. BMW AG said its factory in Shenyang reopened.

Under the latest changes, the status of areas with more than 4 million people shifted from closed to controlled, said Wu, the health official. He some are not allowed to leave their neighborhoods and large gatherings were prohibited.

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Story: Joe McDonald.

BEIJING (AP) — Shanghai authorities on Monday reported the first COVID-19 deaths in the latest outbreak in China’s most populous and wealthiest city.

All three people who died were elderly, had underlying diseases such as diabetes and hypertension and had not been vaccinated against the coronavirus, city Health Commission inspector Wu Ganyu told journalists.

“After entering hospital, their conditions grew worse and they died after attempts to save them were unsuccessful,” Wu said.

The deaths raise to 4,641 the number of people that China says have succumbed to the disease since the virus was first detected in the central city of Wuhan in late 2019.

While China has an overall vaccination rate of around 90%, a low rate among the elderly remains a concern. Only 62% of Shanghai residents over age 60 have been vaccinated, according to the latest data available. Some experts say China needs to raise that rate before it can safely live with the virus.

While highly contagious, the omicron BA.2 variant driving the Shanghai outbreak is less lethal than the previous delta variant. However, China’s low death toll from COVID-19, which is blamed for more than 988,000 deaths in the United States, has raised questions about how China’s authoritarian and often highly secretive government counts such fatalities.

Most of Shanghai’s 25 million residents are being confined to their homes for a third week as China continues to employ a “zero-tolerance” strategy to curb the outbreak, demanding isolation of anyone possibly infected.

China on Monday said 23,362 people had tested positive for the virus over the previous 24 hours, most of them showing no symptoms and almost all of them in Shanghai.

The city has reported more than 300,000 cases since late March. Shanghai began easing restrictions last week, although officials have warned that the city doesn’t have its outbreak under control.

Shanghai, which is home to China’s biggest port and most important stock exchange, appeared unprepared for such a massive undertaking.

Residents have run short of food and other daily necessities while enduring lockdown conditions, and tens of thousands of people put under medical observation have been sequestered in crowded facilities where lights are always on, garbage bins overflow, food is inadequate and hot showers nonexistent.

Anyone who tests positive but has few or no symptoms is required to spend one week in a quarantine facility.

Concerns have risen about the economic impact of the government’s hard-line policy.

China’s economic growth edged up to a still-weak 4.8% over a year earlier in the first three months of 2022 as lockdowns cut production in major industrial cities. Official data showed growth accelerated from the previous quarter’s 4%.

At a meeting Monday, Vice Premier Liu He, President Xi Jinping’s top economic adviser, pledged increased spending to stabilize supply chains and provide financial support for health workers and others on the pandemic front lines.

While the ruling Communist Party has urged more targeted prevention measures, local officials have routinely adopted stringent regulations, possibly for fear of being fired or penalized over outbreaks in their areas.

In the city of Wenzhou, which has seen only a handful of cases, authorities have authorized rewards of up to 50,000 yuan ($7,800) for information about people who falsify their health status, online news site The Paper reported.

BEIJING (AP) — Beibei sleeps beside thousands of strangers in rows of cots in a high-ceilinged exhibition center. The lights stay on all night, and the 30-year-old real estate saleswoman has yet to find a hot shower.

Beibei and her husband were ordered into the massive National Exhibition and Convention Center in Shanghai last Tuesday after spending 10 days isolated at home following a positive test. Their 2-year-old daughter, who was negative, went to her grandfather, while her nanny also went into quarantine.

Residents show “no obvious symptoms,” Beibei, who asked to be identified only by her given name, told The Associated Press in an interview by video phone.

“There are people coughing,” she said. “But I have no idea if they have laryngitis or omicron.”

The convention center, with 50,000 beds, is one of more than 100 quarantine facilities set up in China’s most populous city for those such as Beibei who test positive but have few or no symptoms. It’s part of official efforts to contain China’s biggest coronavirus outbreak since the 2-year-old pandemic began. But it’s also testing patience of people increasingly fed up with China’s harsh “zero-COVID” policy that aims to isolate every case.

“At the beginning people were frightened and panicked,” Beibei said. “But with the publication of daily figures, people have started to accept that this particular virus is not that horrible.”

Beibei was told she was due to be released Monday after two negative tests while at the convention center.

Most of Shanghai shut down starting March 28 and its 25 million people were ordered to stay home. That led to complaints about food shortages and soaring economic losses.

Anyone who tests positive but shows few or no symptoms is required to spend one week in a quarantine facility. Beibei said she had a stuffy nose and briefly lost part of her senses of taste and smell, but those symptoms passed in a few days.

On Sunday, China reported 26,155 new cases, all but 3,529 of which had no symptoms. Shanghai accounted for 95% of the total, or 24,820, including 3,238 with no symptoms.

The city has reported more than 300,000 cases since late March. Shanghai began easing restrictions last week, though a health official warned the city didn’t have its outbreak under control.

At the convention center, residents are checked twice a day for fever and told to record health information on mobile phones, according to Beibei. Most people pass the time by reading, square dancing, taking online classes or watching videos on mobile phones.

The 420,000-square-meter (4.6 million-square-foot) exhibition center is best known as the site of the world’s biggest auto show. Other quarantine sites include temporary prefabricated buildings.

Residents of other facilities have complained about leaky roofs, inadequate food supplies and delays in treatment for medical problems.

“We haven’t found a place with a hot shower,” Beibei said. “Lights are on all night, and it’s hard to fall asleep.”

A video obtained by AP showed wet beds and floors due a leaky roof in a different facility in a prefabricated building.

“Bathrooms are not very clean,” Beibei said. “So many people use them, and volunteers or cleaners can’t keep up.”