ZHUOZHOU, China — China only counts deaths from pneumonia or respiratory failure in its official COVID-19 death toll, a Chinese health official said, a narrow definition that limits the number of deaths being reported as the virus surges following the easing of pandemic-related restrictions.

Deaths that occur in patients with pre-existing illnesses are not counted as COVID-19 deaths, said Wang Guiqiang, the head of infectious disease at Peking University’s No. 1 Hospital.

China has always been conservative in how it counts illnesses, whether the flu or COVID-19. In most countries, including the United States, guidelines stipulate that any death in which COVID-19 is a factor or contributor is counted as a COVID-19-related death.

In effect, Wang’s comments on Tuesday clarified publicly what the country has been doing throughout the pandemic.

On Wednesday, China reported no new COVID-19 deaths and subtracted one death from its overall toll, lowering it to 5,241, according to a daily tally issued by the National Health Commission, which did not explain the decrease.

The clarification of how China officially records COVID-19 deaths comes as cases have soared across the country amid the loosening of restrictions. Yet the overall count remains blurry, as China has stopped requiring daily PCR tests and many people are testing at home. Anecdotally, many people have fallen ill in cities such as Beijing and Shanghai.

WHO emergencies chief Dr. Michael suggested China’s definition of COVID-19 deaths was too narrow.

“People who die of COVID die from many different (organ) systems’ failures, given the severity of infection,” Ryan said at a media briefing Wednesday. “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.”

Earlier this year, Shanghai was hit by an omicron-driven outbreak. Multiple people told the AP then that their elderly family members who tested positive for COVID-19 and died were not counted in the city’s official death toll. When patients had underlying diseases, the deaths were attributed to those.

An AP investigation then showed that numbers have been clouded by the way health authorities tally COVID-19 statistics, applying a much narrower, less transparent and at times shifting standard, as Shanghai changed how it defined positive cases.

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

An Associated Press reporter saw multiple bodies being wheeled out of funeral homes in Beijing last week, and two relatives said their loved ones had died after testing positive for COVID-19. Last week, however, the country did not report any deaths due to COVID-19.

Medical resources in smaller cities and rural communities, which are home to about 500 million of China’s 1.4 billion people, lag far behind those of large cities such as Beijing and Shanghai. The rural medical infrastructure includes 17,000 county-level hospitals, many of which lack even a single ICU bed, 35,000 township health centers and 599,000 village clinics.

To Beijing’s southwest, hospital emergency wards in smaller cities are being overwhelmed. On Wednesday, AP journalists witnessed dozens of elderly patients in critical condition being wheeled into crowded wards in Zhuozhou, in China’s industrial Hebei province.

Two funeral shop keepers and one crematorium worker in Zhuozhou said deaths have been spiking since the government loosened COVID-19 restrictions. One of the shopkeepers, who didn’t give his name because of the sensitivity of the issue, added that the city’s crematorium was burning 20 to 30 bodies a day, up from 3 to 4 before COVID-19 restrictions were lifted.

Different countries count cases and deaths differently, and patchy testing means that direct comparisons are often misleading.

But experts have repeatedly advised that authorities should err on the side of caution while counting deaths. The World Health Organization states in guidelines that “probable” COVID-19 cases and deaths where COVID-19 was a contributing factor should also be counted as COVID-19 deaths. Problems in death counts have raised questions in countries ranging from South Africa to Russia.

WHO estimated in May that nearly 15 million people died from COVID-19 or due to overwhelmed health systems in the first two years of the pandemic. That is significantly more than the official death toll of over 6 million for that period.

Officials at the U.N. health agency said they were concerned about China’s current outbreak and that its lagging vaccination could risk more vulnerable people getting infected.

“WHO is very concerned over the evolving situation in China with increasing reports of severe disease,” WHO Director-General Tedros Adhanom Ghebreyesus said at the media briefing.

Ryan said the explosive surge of cases in China was not exclusively due to the easing of “zero-COVID” and that it was impossible to stop omicron, the most highly infectious variant yet. Some scientists have warned that China’s outbreak could fuel new variants, which might unravel progress made globally to contain the pandemic.

“Vaccination is the exit strategy from omicron,” he said.

He said vaccination rates among people over age 60 in China lagged behind many other countries and that the efficacy of the Chinese-made vaccines was about 50%.

“That’s just not adequate protection in a population as large as China, with so many vulnerable people,” Ryan said. He added that while China has dramatically increased its capacity to vaccinate people in recent weeks, it’s unclear whether that will be enough.