China says its official COVID-19 vaccination rate is around 90%, but it's not hard to find people who have been avoiding the jab.

Take Faye Fei, for example. She's a 32-year-old lifestyle blogger who lives in the city of Hangzhou, about an hour from Shanghai by high-speed train.

"I have an advantage in that I don't go to an office to work. I don't have a job at a company or in a government agency and don't really come into contact with a lot of people," she says. "Also I think I protect myself pretty well."

On top of that, she says she's young, she's not afraid of COVID-19 anymore, she doesn't feel the need to get a shot until China re-opens to the world and she believes the virus is changing too quickly for the vaccines available in China — all of them made in China — to have decent efficacy.

People like Fei signal a potential problem for the government in the days ahead.

A weekend of angry street protests last month against Beijing's hardline pandemic control policy, known as "dynamic zero COVID," seems to have nudged the authorities to take more risks. The authorities on Wednesday announced fresh steps to roll back some of the policy's strict elements.

Health experts say increasing vaccinations is a key part of the way forward if the government hopes to minimize the impact as the virus inevitably spreads.

The least vaccinated are the elderly

The problem of under-vaccination is most acute among the elderly. The government announced a little over a week ago that around 30% of people aged 60 and up — or roughly 80 million people — were not vaccinated and boosted as of Nov. 11. Among those 80 or older, the ratio was closer to 60%.

Experts on Chinese health care say several factors have contributed to the low vaccination rates among older adults. COVID vaccination campaigns focused initially on essential workers, and efficacy data was not focused on the elderly. The government has almost exclusively enforced "zero COVID" policies to keep the virus out and douse flareups rather than moving to ramp up vaccinations when outbreaks were limited.

Plus, there's deep-seated vaccine hesitancy.

For many, it has its roots in product quality issues that have for years plagued manufacturing in China — including its production of pharmaceuticals. Cases like Tan Hua's resonate.

In 2014, Tan, then 34 years old, was bitten by a dog. She saw a doctor and was given a shot of what her mother, Hua Xiuzhen, says they were told was the best rabies vaccine on the market. But it didn't go well.

"That very night she got a headache and dizziness. Her memory declined sharply. She had convulsions. She couldn't see; everything was dark for her. She couldn't walk straight," Hua told NPR by phone.

They got emergency help. But Tan never fully recovered.

"She's disabled. She can't work. She spends the whole day lying in a bed," Hua says.

They blame the vaccine, and Hua has been on a crusade for justice ever since. She also now avoids all vaccines — including those for COVID-19, of which China has approved 12.

"I'm scared to think about it. And none of my neighbors have been vaccinated either as far as I know," she says.

It wasn't always like this, according to Mary Brazelton, an expert in the history of science and medicine in China at the University of Cambridge.​ In the months after the Communist takeover in 1949, the Chinese government launched several successful vaccination campaigns, taking on smallpox, tuberculosis, diphtheria and other diseases.

"If you look at earlier periods in the People's Republic of China's history ... what you see is in some ways almost the opposite in terms of really strong vaccination programs that work quite hard to convince people, particularly elderly people, to receive vaccines against infectious diseases," Brazelton says.

But lax oversight and corruption during recent decades of breakneck economic growth has led to a string of product quality scandals in China — from baby formula cut with industrial chemicals to contaminated blood thinner and tainted vaccines.​

"To me, that kind of helps explain the degrees of hesitancy," Brazelton says.

China experts say there's also been weak messaging around Chinese COVID vaccines.

China has not imported any foreign-made vaccines, which are widely seen inside the country to be more effective than China's homegrown jabs. And data on the Chinese vaccines has been conflicting. In March, scientists in Hong Kong reported that made-in-China Sinovac boosters can effectively prevent serious illness in old people. This month, though, Singapore-based scientists concluded that three or four doses of mRNA vaccines offered better protection for people over 60 than China's inactivated virus vaccines for COVID-19.

Yanzhong Huang, a China health care expert at Seton Hall University, says the government has done a bad job of messaging around the virus and debunking myths — despite near total control of the media environment in the country.​

"Many of those, the vaccine skeptics, are liberal-minded people. They just don't trust the Chinese vaccines and the government narrative on the effectiveness of the Chinese vaccines," he says.

Jerry, a real estate executive in Shanghai, is 33 years old — and a good example of that. He did not want his full name used because of the sensitivity of the topic.

Jerry reckons COVID-19 is "kind of a flu thing" these days; nothing too serious. He hasn't gotten the vaccine and he believes – despite science to the contrary – there's no point.

"I just think the virus is changing so fast. So not a single vaccine can help," he says, focusing on vaccines' ability to prevent transmission rather than stave off serious illness and death.

Jerry estimates that the vaccination rate among his friends — educated, 30-somethings in China's most cosmopolitan city — may be as low as 60%. He says couples trying to get pregnant are particularly fearful of possible side-effects.

The government is now redoubling efforts to get more people vaccinated, especially the elderly. The stakes are high.

Only about half of people aged 60 and up in Hong Kong were vaccinated when the omicron variant hit in the spring. Hospitals were quickly swamped and the rate of deaths-per-100,000 people spiked to the highest in the world. Nearly all of those who died were over 60 and not fully vaccinated.

To be sure, China has the state capacity to force the population to get vaccinated. After all, it has put entire cities with tens of millions of people into strict lockdowns.

But Huang, of Seton Hall, says the government may be better off bolstering the incentives for people to get the vaccine, and offering assurances of support in case something goes wrong.

They're just not quite there yet.

"They still they have not sent a clear message ... convincing the elderly that you need to get a vaccine, it's good for you," he says.

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