COVID-19 pandemic

COVID‑19 pandemic
COVID-19 Outbreak World Map per Capita.svg
Confirmed cases per 100,000 population
as of 28 October 2020
  •   >3,000
  •   1,000–3,000
  •   300–1,000
  •   100–300
  •   30–100
  •   0–30
  •   None or no data
Total cases per country
COVID-19 Outbreak World Map.svg
As of 28 October 2020
  •   >1,000,000
  •   100,000–999,999
  •   10,000–99,999
  •   1,000–9,999
  •   100–999
  •   1–99
  •   None or no data
Deaths per capita
COVID-19 Outbreak World Map Total Deaths per Capita.svg
Per million population
as of 19 October 2020
Daily new cases
Daily new cases COVID-19 map.svg
As of 29 September 2020
(7 day rolling average)
A nurse caring for a patient with COVID‑19 in an intensive care unit
Meeting of the Italian government task force to face the coronavirus outbreak, 23 February 2020
Taiwanese 33rd Chemical Corps spraying disinfectant on a street in Taipei, Taiwan
Burial in Hamadan, Iran
Workers unloading boxes of medical supplies at Villamor Air Base
Clockwise from top:
Disease Coronavirus disease 2019 (COVID‑19)
Virus strain Severe acute respiratory syndrome
coronavirus 2
(SARS‑CoV‑2)[a]
Source Possibly via bats, pangolins, or both[1][2]
Location Worldwide
First outbreak Wuhan, China[3]
Index case Wuhan, Hubei, China
30°37′11″N 114°15′28″E / 30.61972°N 114.25778°E / 30.61972; 114.25778
Arrival date Between 6 October 2019 and 11 December 2019[4]
Date 31 December 2019 (2019-12-31)[3] – present
(10 months, 4 weeks and 1 day)
Confirmed cases 45,126,200[5]
Active cases 13,597,214[5] (28.1% of confirmed cases as of 24 September)
Suspected cases Estimated in early Oct at c. 770 million[6]
Recovered 30,346,618[5]
Deaths
1,182,368[5]
Territories
190[5]
Suspected cases have not been confirmed as being due to this strain by laboratory tests, although some other strains may have been ruled out.

The COVID-19 pandemic, also known as the coronavirus pandemic, is an ongoing pandemic of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), first identified in December 2019 in Wuhan, China. The outbreak was declared a Public Health Emergency of International Concern in January 2020 and a pandemic in March 2020. As of 30 October 2020, more than 45.1 million cases have been confirmed, with more than 1.18 million deaths attributed to COVID-19.[5]

Common symptoms include fever, cough, fatigue, breathing difficulties, and loss of smell and taste. Complications may include pneumonia and acute respiratory distress syndrome. The incubation period is typically around five days but may range from one to 14 days.[11] There are several vaccine candidates in development, although none have completed clinical trials. There is no known specific antiviral medication, so primary treatment is currently symptomatic.[12]

Recommended preventive measures include hand washing, covering one's mouth when sneezing or coughing, social distancing, wearing a face mask in public, ventilation and air-filtering, disinfecting surfaces, and monitoring and self-isolation for people exposed or symptomatic. Authorities worldwide have responded by implementing travel restrictions, lockdowns, workplace hazard controls, and facility closures. Many places have also worked to increase testing capacity and trace contacts of the infected.

The responses have caused global social and economic disruption, including the largest global recession since the Great Depression.[13] It has led to the postponement or cancellation of events, widespread supply shortages exacerbated by panic buying, famines affecting hundreds of millions of people, and decreased emissions of pollutants and greenhouse gases. Educational institutions have been partially or fully closed. Misinformation has circulated through social media and mass media. There have been incidents of xenophobia and discrimination against Chinese people and against those perceived as being Chinese or as being from areas with high infection rates.[14]

Epidemiology

For country-level data, see:
732-bar-chart
Cases
45,126,200
Deaths
1,182,368
As of 30 October 2020 [5]

Background

Although it is still unknown exactly where the outbreak first started, several early infected people had visited Huanan Seafood Wholesale Market, located in Wuhan, Hubei, China.[15] On 11 February 2020, the World Health Organisation (WHO) named the disease "COVID-19", short for coronavirus disease 2019.[16][17] The virus that caused the outbreak is known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a newly discovered virus closely related to bat coronaviruses,[18] pangolin coronaviruses,[19][20] and SARS-CoV.[21] The scientific consensus is that COVID-19 has a natural origin.[22][23] The probable bat-to-human infection may have been among people processing bat carcasses and guano in the production of traditional Chinese medicines.[24]

The earliest known person with symptoms was later discovered to have fallen ill on 1 December 2019, and that person did not have visible connections with the later wet market cluster.[25][26] Of the early cluster of cases reported that month, two-thirds were found to have a link with the market.[27][28][29] There are several theories about when and where the very first case (the so-called patient zero) originated.[30] On 13 March 2020, an unverified report from the South China Morning Post (SCMP) suggested a case traced back to 17 November 2019 (a 55-year-old person from Hubei) may have been the first person infected.[31][32] Phylogenic estimates in genetic studies conducted in early 2020 indicate that SARS-CoV-2 likely passed onto humans sometime between 6 October 2019 and 11 December 2019.[4]

Epidemiological studies estimate each infection results in 5.7 new ones when no members of the community are immune and there are no preventive measures taken.[33][clarification needed]

An aerial view of the market, looking like a construction site.
The Huanan Seafood Wholesale Market in March 2020, after it was closed down.

Cases

Official case counts refer to the number of people who have been tested for COVID-19 and whose test has been confirmed positive according to official protocols.[34][35] Many countries, early on, had official policies to not test those with only mild symptoms.[36][37] An analysis of the early phase of the outbreak up to 23 January estimated 86 percent of COVID-19 infections had not been detected, and that these undocumented infections were the source for 79 percent of documented cases.[38] Several other studies, using a variety of methods, have estimated that numbers of infections in many countries are likely to be considerably greater than the reported cases.[39][40]

On 9 April 2020, preliminary results found that 15 percent of people tested in Gangelt, the centre of a major infection cluster in Germany, tested positive for antibodies.[41] Screening for COVID-19 in pregnant women in New York City, and blood donors in the Netherlands, has also found rates of positive antibody tests that may indicate more infections than reported.[42][43] Seroprevalence based estimates are conservative as some studies shown that persons with mild symptoms do not have detectable antibodies.[44] Some results (such as the Gangelt study) have received substantial press coverage without first passing through peer review.[45]

Analysis by age in China indicates that a relatively low proportion of cases occur in individuals under 20.[46] It was not clear whether this was because young people were less likely to be infected, or less likely to develop serious symptoms and seek medical attention and be tested.[47] A retrospective cohort study in China found that children and adults were just as likely to be infected.[48]

Initial estimates of the basic reproduction number (R0) for COVID-19 in January were between 1.4 and 2.5,[49] but a subsequent analysis concluded that it may be about 5.7 (with a 95 percent confidence interval of 3.8 to 8.9).[50] R0 can vary across populations and is not to be confused with the effective reproduction number (commonly just called R), which takes into account effects such as social distancing and herd immunity. By mid-May 2020, the effective R was close to or below 1.0 in many countries, meaning the spread of the disease in these areas at that time was stable or decreasing.[51]

Deaths

Deceased in a 16 m (53 ft) "mobile morgue" outside a hospital in Hackensack, New Jersey

Official deaths from COVID-19 generally refer to people who died after testing positive according to protocols. This may ignore deaths of people who die without having been tested.[53] Conversely, deaths of people who had underlying conditions may lead to over-counting.[54] Comparison of statistics for deaths for all causes versus the seasonal average indicates excess mortality in many countries.[55][56] This may include deaths due to strained healthcare systems and bans on elective surgery.[57] The first confirmed death was in Wuhan on 9 January 2020.[58] The first reported death outside of China occurred on 1 February in the Philippines,[59] and the first reported death outside Asia was in the United States on 6 February.[60]

More than 95% of the people who contract COVID-19 recover. Otherwise, the time between symptoms onset and death usually ranges from 6 to 41 days, typically about 14 days.[61] As of 30 October 2020, more than 1.18 million[5] deaths had been attributed to COVID-19. In China, as of 14 June, about 80% of deaths were recorded in those over 60, and 75% had pre-existing health conditions including cardiovascular disease and diabetes.[62] Individuals of any age with underlying health conditions are at increased risk of severe illness.[63]

On 24 March 2020, the Centers for Disease Control and Prevention (CDC) changed criteria for attributing deaths to COVID-19 to include those marked "probable"/"likely." The CDC said, "It is not likely that [the National Center for Health Statistics (NCHS)] will follow up on these cases" and that while the "underlying cause depends upon what and where conditions are reported on the death certificate, … the rules for coding and selection of the ... cause of death are expected to result in COVID–19 being the underlying cause more often than not."[64]

On 16 April, the World Health Organisation (WHO) created two codes for classifying deaths: UO7.1, "confirmed by laboratory testing irrespective of severity of clinical signs or symptoms"; and UO7.2, "diagnosed clinically or epidemiologically but laboratory testing is inconclusive or not available". The WHO "recognized that in many countries detail as to the laboratory confirmation… will not be reported [and] recommended, for mortality purposes only, to code COVID-19 provisionally to code U07.1 unless it is stated as 'probable' or 'suspected'."[65][66] It was also noted that the WHO "does not distinguish" between infection by SARS-CoV-2 and COVID-19.[67]

Multiple measures are used to quantify mortality.[68] These numbers vary by region and over time, influenced by testing volume, healthcare system quality, treatment options, government response,[69][70][71] time since the initial outbreak, and population characteristics, such as age, sex, and overall health.[72] Countries like Belgium include deaths from suspected cases of COVID-19, regardless of whether the person was tested, resulting in higher numbers compared to countries that include only test-confirmed cases.[73]

The death-to-case ratio reflects the number of deaths attributed to COVID-19 divided by the number of diagnosed cases within a given time interval. Based on Johns Hopkins University statistics, the global death-to-case ratio is 2.6 percent (1,182,368 deaths for 45,126,200 cases) as of 30 October 2020.[5] The number varies by region.[74]

The most important metric in assessing death rate is the infection fatality rate (IFR),[76][c] which is deaths attributed to disease divided by individuals infected (including all asymptomatic and undiagnosed) to-date.[78] In March, a peer-reviewed analysis of pre-serology data from mainland China yielded an overall IFR of 0.66% (with age-bracketed values ranging from 0.00161% for 0–9 years to 0.595% for 50–59 years to 7.8% for > 80 years).[79]

In April, an IFR range of 0.12–1.08% was derived from non-peer-reviewed serology surveys, with the upper bound characterized as much more credible and the range indicated as from 3 to 27 times deadlier than influenza (0.04%).[80]

In July, the CDC adopted the IFR as a "more directly measurable parameter for disease severity for COVID-19" and computed an overall 'best estimate' for planning purposes for the U.S. of 0.65%.[81][82] In September, the CDC computed an age-bracketed ‘best estimate’ for the U.S. of 0.003% for 0–19 years; 0.02% for 20–49 years; 0.5% for 50–69 years; and 5.4% for 70+ years.[83][d]

In August, the WHO reported serology testing for three locations in Europe (with some data through 2 June) that showed IFR overall estimates converging at approximately 0.5-1%.[77] A systematic review article in The BMJ advised that "caution is warranted … using serological tests for … epidemiological surveillance" and called for higher quality studies assessing accuracy with reference to a standard of "RT-PCR performed on at least two consecutive specimens, and, when feasible, includ[ing] viral cultures."[85][86] CEBM researchers have called for in-hospital 'case definition' to record "CT lung findings and associated blood tests"[87] and for the WHO to produce a "protocol to standardise the use and interpretation of PCR" with continuous re-calibration.[88]

In September, a Bulletin of the World Health Organization article by John Ioannides estimated global IFR inferred from seroprevalence data at 0.23%[e] overall and 0.05% for people < 70 years, much lower than estimates made earlier in the pandemic. Ioannides criticized prior "average IFR … irresponsibly circulated widely in media and social media" as "probably extremely flawed as they depended on erroneous modeling assumptions, and/or focused only on selecting mostly studies from countries high death burden (that indeed have higher IFRs), and/or were done by inexperienced authors who used overtly wrong meta-analysis methods in a situation where there is extreme between-study heterogeneity.[89] As the data for his analysis was drawn "predominantly from hard-hit epicenters", Ioannides indicates that even lower "average values of 0.15–0.25% … and 0.03–0.04% for <70 years) as of October 2020 are plausible."[89][90] He also notes that in European countries with a large numbers of cases and deaths[91] and in the U.S.,[92] "many, and in many cases most, deaths occurred in nursing homes”.[93]

On 6 October, Dr. Mike Ryan, director of the WHO's Health Emergencies Programme announced "Our current best estimates tell us that about 10% of the global population may have been infected by this virus."[94] Also in October, the Centre for Evidence-Based Medicine (CEBM) reported a 'presumed estimate' of global IFR at between 0.10% to 0.35%, noting that this will vary between populations due to differences in demographics.[95] These researchers noted a decrease in IFR in England over time;[96][f] and, for the UK and Italy (the two Europeans nations worst hit by COVID-19), attribute the rise in daily cases, stability in daily deaths, and shift of cases to a younger population to waning viral circulation, misapplication of testing, and misinterpretation of test results rather than to prevention, treatment, or virus mutation.[97]

Another metric in assessing death rate is the case fatality rate (CFR),[g] which is deaths attributed to disease divided by individuals diagnosed to-date. This metric can be misleading because of delay between symptom onset and death and because testing focuses on individuals with symptoms (and particularly on those manifesting more severe symptoms).[67] On 4 August, WHO indicated "at this early stage of the pandemic, most estimates of fatality ratios have been based on cases detected through surveillance and calculated using crude methods, giving rise to widely variable estimates of CFR by country – from less than 0.1% to over 25%."[77]

Transmission

Signs and symptoms

Symptoms of COVID-19 [103]

Symptoms of COVID-19 can be relatively non-specific; the two most common symptoms are fever (88 percent) and dry cough (68 percent). Less common symptoms include fatigue, respiratory sputum production (phlegm), loss of the sense of smell, loss of taste, shortness of breath, muscle and joint pain, sore throat, headache, chills, vomiting, coughing out blood, diarrhea, and rash.[104][105][106]

Among those who develop symptoms, approximately one in five may become more seriously ill and have difficulty breathing.[107] Emergency symptoms include difficulty breathing, persistent chest pain or pressure, sudden confusion, difficulty waking, and bluish face or lips; immediate medical attention is advised if these symptoms are present.[106] Further development of the disease can lead to complications including pneumonia, acute respiratory distress syndrome, sepsis, septic shock, and kidney failure.[105]

Cause

Virology

Illustration of SARSr-CoV virion

Diagnosis

Demonstration of a swab for COVID-19 testing

COVID-19 can provisionally be diagnosed on the basis of symptoms and confirmed using reverse transcription polymerase chain reaction (RT-PCR) testing of infected secretions or CT imaging of the chest.[120][121]

On 29 September, a letter in Lancet highlighted the increasing likelihood of overestimating of COVID-19 incidence as more asymptomatic people are included in RT-PCR testing with consequent "misdirection of policies regarding lockdowns and school closures," noting that the false-positive rate in the UK is currently unknown, with "preliminary estimates … somewhere between 0·8% and 4·0%".[122][123] The letter called for "stricter standards … in laboratory testing, … and pretest probability assessments … [including] symptoms, previous medical history of COVID-19 or presence of antibodies, any potential exposure to COVID-19, and likelihood of an alternative diagnosis."[124]

Viral testing

The standard test for presence of SARS-CoV-2 uses RNA testing of respiratory secretions collected using a nasopharyngeal swab, though it is possible to test other samples. This test uses real-time rRT-PCR which detects the presence of viral RNA fragments.[125] As this test detects RNA but not infectious virus, its "ability to determine duration of infectivity of patients is limited."[126] Positive tests have been shown not to correlate with future excess deaths.[127]

A number of laboratories and companies have developed serological tests, which detect antibodies produced by the body in response to infection.[128] Several have been evaluated by Public Health England and approved for use in the UK.[129]

On 22 June 2020, UK health secretary Matt Hancock announced the country would conduct a new "spit test" for COVID-19 on 14,000 key workers and their families in Southampton, having them spit in a pot, which was collected by Southampton University, with results expected within 48 hours. Hancock said the test was easier than using swabs and could enable people to conduct it at home.[130]

The University of Oxford's CEBM has pointed to mounting evidence[131][132] that "a good proportion of 'new' mild cases and people re-testing positives after quarantine or discharge from hospital are not infectious, but are simply clearing harmless virus particles which their immune system has efficiently dealt with" and have called for "an international effort to standardize and periodically calibrate testing"[133] On 7 September, the UK government issued "guidance for procedures to be implemented in laboratories to provide assurance of positive SARS-CoV-2 RNA results during periods of low prevalence, when there is a reduction in the predictive value of positive test results."[134]

In October 2020, the US diplomats and security officials raised a warning for Las Vegas against the use of Chinese test kits donated by the United Arab Emirates. In partnership with Group 42, Nevada was receiving donations of hundreds of thousands of test kits costing from between $15 million to $20 million, which raised concerns around patient privacy and test accuracy. Earlier, there were doubts that UAE's Group 42 could get access to US citizens through tests data.[135][136]

Imaging

A CT scan of a person with COVID-19 shows lesions (bright regions) in the lungs.

Characteristic imaging features on chest radiographs and computed tomography (CT) of people who are symptomatic include asymmetric peripheral ground-glass opacities without pleural effusions.[137] Many groups have created COVID-19 datasets that include imagery such as the Italian Radiological Society which has compiled an international online database of imaging findings for confirmed cases.[138] Due to overlap with other infections such as adenovirus, imaging without confirmation by rRT-PCR is of limited specificity in identifying COVID-19.[137] A large study in China compared chest CT results to PCR and demonstrated that though imaging is less specific for the infection, it is faster and more sensitive.[121]

Prevention

Infographic by the U.S. Centers for Disease Control and Prevention (CDC), describing how to stop the spread of germs

Strategies for preventing transmission of the disease include social distancing, wearing of masks, washing hands, avoiding touching the eyes, nose, or mouth with unwashed hands, and coughing or sneezing into a tissue, and putting the tissue directly into a waste container.[139][140][141][142]

Social distancing

Social distancing measures on public ground

Social distancing (also known as physical distancing) includes infection control actions intended to slow the spread of the disease by minimising close contact between individuals. Methods include quarantines; travel restrictions; and the closing of schools, workplaces, stadiums, theatres, or shopping centres. Individuals may apply social distancing methods by staying at home, limiting travel, avoiding crowded areas, using no-contact greetings, and physically distancing themselves from others.[140][143][144] Many governments are now mandating or recommending social distancing in regions affected by the outbreak.[145][146] Non-cooperation with distancing measures in some areas has contributed to the further spread of the pandemic.[147]

The maximum gathering size recommended by U.S. government bodies and health organisations was swiftly reduced from 250 people (if there were no known COVID-19 spread in a region) to 50 people, and later to 10.[148] On 22 March 2020, Germany banned public gatherings of more than two people.[149] A Cochrane review found that early quarantine with other public health measures are effective in limiting the pandemic, but the best manner of adopting and relaxing policies are uncertain, as local conditions vary.[144]

Older adults and those with underlying medical conditions such as diabetes, heart disease, respiratory disease, hypertension, and compromised immune systems face increased risk of serious illness and complications and have been advised by the CDC to stay home as much as possible in areas of community outbreak.[150][151]

In late March 2020, the WHO and other health bodies began to replace the use of the term "social distancing" with "physical distancing", to clarify that the aim is to reduce physical contact while maintaining social connections, either virtually or at a distance. The use of the term "social distancing" had led to implications that people should engage in complete social isolation, rather than encouraging them to stay in contact through alternative means.[152][153] Some authorities have issued sexual health guidelines for the pandemic, which include recommendations to have sex only with someone you live with, and who does not have the virus or symptoms of the virus.[154][155]

Face masks and respiratory hygiene

The CDC and WHO advise that masks reduce the spread of coronavirus by asymptomatic and pre-symptomatic individuals ( Taiwan President Tsai Ing-wen pictured wearing a surgical mask)

The CDC and WHO recommend individuals wear non-medical face coverings in public settings where there is an increased risk of transmission and where social distancing measures are difficult to maintain.[156][157][158] This recommendation is meant to reduce the spread of the disease by asymptomatic and pre-symtomatic individuals and is complementary to established preventive measures such as social distancing.[157][159] Face coverings limit the volume and travel distance of expiratory droplets dispersed when talking, breathing, and coughing.[157][159] Many countries and local jurisdictions encourage or mandate the use of face masks or cloth face coverings by members of the public to limit the spread of the virus.[160][161]

Masks are also strongly recommended for those who may have been infected and those taking care of someone who may have the disease.[162] When not wearing a mask, the CDC recommends covering the mouth and nose with a tissue when coughing or sneezing and recommends using the inside of the elbow if no tissue is available.[139] Proper hand hygiene after any cough or sneeze is encouraged.[139] Healthcare professionals interacting directly with COVID-19 patients are advised to use respirators at least as protective as NIOSH-certified N95 or equivalent, in addition to other personal protective equipment.[163]

Self-isolation

Without pandemic containment measures—such as social distancing, vaccination, and use of face masks—pathogens can spread exponentially. [164] This graphic shows how early adoption of containment measures tends to protect wider swaths of the population.

Self-isolation at home has been recommended for those diagnosed with COVID-19 and those who suspect they have been infected. Health agencies have issued detailed instructions for proper self-isolation.[165][166]

Many governments have mandated or recommended self-quarantine for entire populations.[167][168] The strongest self-quarantine instructions have been issued to those in high-risk groups.[169] Those who may have been exposed to someone with COVID-19 and those who have recently travelled to a country or region with the widespread transmission have been advised to self-quarantine for 14 days from the time of last possible exposure.[107][170][171]

Ventilation and air filtration

The CDC recommends ventilation in public spaces to help clear out infectious aerosols, as well several others, including those regarding air filtration.[172][173]

Hand washing

Hand hygiene is extremely important to prevent the spread of SARS-CoV-2.[174] The CDC recommends that people wash hands often with soap and water for at least twenty seconds, especially after going to the toilet or when hands are visibly dirty; before eating; and after blowing one's nose, coughing, or sneezing. This is because outside the human body, the virus is killed by household soap, which bursts its protective bubble.[175] In addition, soap and water disrupts the sticky bond between pathogens and human skin which causes the coronavirus pathogen to slide off the hands/body.[176] CDC has recommended using an alcohol-based hand sanitiser with at least 60 percent alcohol by volume when soap and water are not readily available.[139] The WHO advises people to avoid touching the eyes, nose, or mouth with unwashed hands.[140][177] It is not clear whether washing hands with ash, if soap is not available, is effective at reducing the spread of viral infections.[178]

Surface cleaning

Surfaces may be decontaminated with a number of solutions (within one minute of exposure to the disinfectant for a stainless steel surface), including 62–71 percent ethanol, 50–100 percent isopropanol, 0.1 percent sodium hypochlorite, 0.5 percent hydrogen peroxide, and 0.2–7.5 percent povidone-iodine. Other solutions, such as benzalkonium chloride and chlorhexidine gluconate, are less effective.[179] Ultraviolet germicidal irradiation may also be used.[172] The CDC recommends that if a COVID-19 case is suspected or confirmed at a facility such as an office or day care, all areas such as offices, bathrooms, common areas, shared electronic equipment like tablets, touch screens, keyboards, remote controls, and ATM machines used by the ill persons should be disinfected.[180]

Vaccine

Mitigation

Screening, containment and mitigation

Goals of mitigation include delaying and reducing peak burden on healthcare ( flattening the curve) and lessening overall cases and health impact. [186] [187] Moreover, progressively greater increases in healthcare capacity ( raising the line) such as by increasing bed count, personnel, and equipment, help to meet increased demand. [188]
Mitigation attempts that are inadequate in strictness or duration—such as premature relaxation of distancing rules or stay-at-home orders—can allow a resurgence after the initial surge and mitigation. [186] [189]

Strategies in the control of an outbreak are screening, containment (or suppression), and mitigation. Screening is done with a device such as a thermometer to detect the elevated body temperature associated with fevers caused by the coronavirus.[190] Containment is undertaken in the early stages of the outbreak and aims to trace and isolate those infected as well as introduce other measures to stop the disease from spreading. When it is no longer possible to contain the disease, efforts then move to the mitigation stage: measures are taken to slow the spread and mitigate its effects on the healthcare system and on society. A combination of both containment and mitigation measures may be undertaken at the same time.[191] Suppression requires more extreme measures so as to reverse the pandemic by reducing the basic reproduction number to less than 1.[192]

Part of managing an infectious disease outbreak is trying to delay and decrease the epidemic peak, known as flattening the epidemic curve.[186] This decreases the risk of health services being overwhelmed and provides more time for vaccines and treatments to be developed.[186] Non-pharmaceutical interventions that may manage the outbreak include personal preventive measures such as hand hygiene, wearing face masks, and self-quarantine; community measures aimed at physical distancing such as closing schools and cancelling mass gathering events; community engagement to encourage acceptance and participation in such interventions; as well as environmental measures such surface cleaning.[193]

More drastic actions aimed at containing the outbreak were taken in China once the severity of the outbreak became apparent, such as quarantining entire cities and imposing strict travel bans.[194] Other countries also adopted a variety of measures aimed at limiting the spread of the virus. South Korea introduced mass screening and localised quarantines and issued alerts on the movements of infected individuals. Singapore provided financial support for those infected who quarantined themselves and imposed large fines for those who failed to do so. Taiwan increased face mask production and penalised hoarding of medical supplies.[195]

Simulations for Great Britain and the United States show that mitigation (slowing but not stopping epidemic spread) and suppression (reversing epidemic growth) have major challenges. Optimal mitigation policies might reduce peak healthcare demand by two-thirds and deaths by half, but still result in hundreds of thousands of deaths and overwhelmed health systems. Suppression can be preferred but needs to be maintained for as long as the virus is circulating in the human population (or until a vaccine becomes available), as transmission otherwise quickly rebounds when measures are relaxed. Long-term intervention to suppress the pandemic has considerable social and economic costs.[192]

Mandatory traveller information collection for use in COVID-19 contact tracing at New York City's LaGuardia Airport in August 2020

Contact tracing is an important method for health authorities to determine the source of infection and to prevent further transmission.[196] The use of location data from mobile phones by governments for this purpose has prompted privacy concerns, with Amnesty International and more than a hundred other organisations issuing a statement calling for limits on this kind of surveillance.[197]

Several mobile apps have been implemented or proposed for voluntary use, and as of 7 April 2020 more than a dozen expert groups were working on privacy-friendly solutions such as using Bluetooth to log a user's proximity to other cellphones.[197] (Users are alerted if they have been near someone who subsequently tests positive.)[197]

On 10 April 2020, Google and Apple jointly announced an initiative for privacy-preserving contact tracing based on Bluetooth technology and cryptography.[198][199] The system is intended to allow governments to create official privacy-preserving coronavirus tracking apps, with the eventual goal of integration of this functionality directly into the iOS and Android mobile platforms.[200] In Europe and in the U.S., Palantir Technologies is also providing COVID-19 tracking services.[201]

Health care

An army-constructed field hospital outside Östra sjukhuset ( Eastern hospital) in Gothenburg, Sweden, contains temporary intensive care units for COVID-19 patients.

Increasing capacity and adapting healthcare for the needs of COVID-19 patients is described by the WHO as a fundamental outbreak response measure.[202] The ECDC and the European regional office of the WHO have issued guidelines for hospitals and primary healthcare services for shifting of resources at multiple levels, including focusing laboratory services towards COVID-19 testing, cancelling elective procedures whenever possible, separating and isolating COVID-19 positive patients, and increasing intensive care capabilities by training personnel and increasing the number of available ventilators and beds.[202][203] In addition, in an attempt to maintain physical distancing, and to protect both patients and clinicians, in some areas non-emergency healthcare services are being provided virtually.[204][205][206]

Due to capacity limitations in the standard supply chains, some manufacturers are 3D printing healthcare material such as nasal swabs and ventilator parts.[207][208] In one example, when an Italian hospital urgently required a ventilator valve, and the supplier was unable to deliver in the timescale required, a local startup received legal threats due to alleged patent infringement after reverse-engineering and printing the required hundred valves overnight.[209][210][211] On 23 April 2020, NASA reported building, in 37 days, a ventilator which is currently undergoing further testing. NASA is seeking fast-track approval.[212][213]

Treatment

An exhausted anaesthesiologist in Pesaro, Italy, March 2020

Antiviral medications are under investigation for COVID-19, though none have yet been shown to be clearly effective on mortality in published randomised controlled trials.[214] However, remdesivir may affect the time it takes to recover from the virus.[215] Emergency use authorisation for remdesivir was granted in the U.S. on 1 May, for people hospitalised with severe COVID-19.[216] The interim authorisation was granted considering the lack of other specific treatments, and that its potential benefits appear to outweigh the potential risks.[216][217]

Taking over-the-counter cold medications,[218] drinking fluids, and resting may help alleviate symptoms.[139] Depending on the severity, oxygen therapy, intravenous fluids, and breathing support may be required.[219] The safety and effectiveness of convalescent plasma as a treatment option requires further research.[220]

Other trials are investigating whether existing medications can be used effectively against COVID-19 or the immune reaction to it.[214][221] On 16 June, the RECOVERY Trial group released a statement that their preliminary results show low dose dexamethasone reduces mortality in patients receiving respiratory support,[222] though previous reviews had suggested the use of steroids may worsen outcomes.[223] Demand for dexamethasone surged after publication of the preprint.[224] On 2 September, the WHO recommended treatment with systemic steroids for patients with severe and critical symptoms, but continued to advise against their use for other patients.[225]

A study of major hospitals in the U.S. found that abnormal liver tests occurred in most hospitalized patients with COVID-19 and may be associated with poorer clinical outcomes.[226] Tocilizumab was significantly associated in the relationship between the drugs used to treat the disease and abnormal liver tests, which prompted studies to determine whether abnormal results were due to coronavirus or drug-induced liver injury, according to Michael Nathanson, director of the Yale Liver Center and co-author of the study.[227]

History

2019

Cumulative per capita confirmed COVID-19 cases
Cumulative per capita confirmed COVID-19 cases
Desc-i.svg
Interactive timeline map of confirmed cases per million people
(drag circle to adjust; may not work on mobile devices)

Based on the retrospective analysis, starting from December, the number of coronavirus cases in Hubei gradually increased, reaching 60 by 20 December and at least 266 by 31 December.[31] That same day, the WHO received reports of a cluster of viral pneumonia cases of an unknown cause in Wuhan,[228] and an investigation was launched at the start of January 2020.[229]

According to official Chinese sources, these early cases were mostly linked to the Huanan Seafood Wholesale Market, which also sold live animals.[230] However, in May 2020, George Gao, the director of the Chinese Center for Disease Control and Prevention, said animal samples collected from the seafood market had tested negative for the virus, indicating the market was not the source of the initial outbreak.[231]

On 24 December, Wuhan Central Hospital sent a bronchoalveolar lavage fluid (BAL) sample from an unresolved clinical case to sequencing company Vision Medicals. On 27 and 28 December, Vision Medicals informed the Wuhan Central Hospital and the Chinese CDC of the results of the test, showing a new coronavirus.[232] A pneumonia cluster of unknown cause was observed on 26 December and treated by the doctor Zhang Jixian in Hubei Provincial Hospital, who informed the Wuhan Jianghan CDC on 27 December.[233]

On 30 December 2019, a test report addressed to Wuhan Central Hospital, from company CapitalBio Medlab, stated that there was an erroneous positive result for SARS, causing a group of doctors at Wuhan Central Hospital to alert their colleagues and relevant hospital authorities of the result. Eight of those doctors, including Li Wenliang (who was also punished on 3 January),[234] were later admonished by the police for spreading false rumours; and another doctor, Ai Fen, was reprimanded by her superiors for raising the alarm.[235] That evening, the Wuhan Municipal Health Commission issued a notice to various medical institutions about "the treatment of pneumonia of unknown cause".[236] The next day, the Wuhan Municipal Health Commission made the first public announcement of a pneumonia outbreak of unknown cause, confirming 27 cases[228][237][238]—enough to trigger an investigation.[229]

2020

Chinese medics in the city of Huanggang, Hubei on 20 March 2020

During the early stages of the outbreak, the number of cases doubled approximately every seven and a half days.[239] In early and mid-January 2020, the virus spread to other Chinese provinces, helped by the Chinese New Year migration and Wuhan being a transport hub and major rail interchange.[240] On 20 January, China reported nearly 140 new cases in one day, including two people in Beijing and one in Shenzhen.[241] A retrospective official study published in March found that 6,174 people had already developed symptoms by 20 January (most of them would be diagnosed later)[242] and more may have been infected.[243] A report in The Lancet on 24 January indicated human transmission, strongly recommended personal protective equipment for health workers, and said testing for the virus was essential due to its "pandemic potential".[27][244]

On 30 January, with 7,818 confirmed cases across 19 countries, the WHO declared the outbreak a Public Health Emergency of International Concern (PHEIC),[245][246] and then a pandemic on 11 March 2020[247][248] as Italy, Iran, South Korea, and Japan reported increasing numbers of cases. Later that month, the number of cases outside of China quickly surpassed the number of cases inside China.

On 31 January 2020, Italy had its first confirmed cases, two tourists from China.[249] As of 13 March 2020, the WHO considered Europe the active centre of the pandemic.[250] On 19 March 2020, Italy overtook China as the country with the most reported deaths.[251] By 26 March, the United States had overtaken China and Italy with the highest number of confirmed cases in the world.[252] Research on coronavirus genomes indicates the majority of COVID-19 cases in New York came from European travellers, rather than directly from China or any other Asian country.[253] Retesting of prior samples found a person in France who had the virus on 27 December 2019[254][255] and a person in the United States who died from the disease on 6 February 2020.[256]

On 11 June 2020, after 55 days without a locally transmitted case being officially reported,[257] the city of Beijing reported a single COVID-19 case, followed by two more cases on 12 June.[258] As of 15 June 79 cases were officially confirmed.[259] Most of these patients went to Xinfadi Wholesale Market.[257][260]

On 29 June 2020, WHO warned that the spread of the virus is still accelerating as countries reopen their economies, although many countries have made progress in slowing down the spread.[261]

On 15 July 2020, one COVID-19 case was officially reported in Dalian in more than three months. The patient did not travel outside the city in the 14 days before developing symptoms, nor did he have contact with people from "areas of attention."[262]

In October 2020, the WHO stated, at a special meeting of WHO leaders, that one in ten people around the world may have been infected with COVID-19. At the time, that translated to 780 million people being infected, while only 35 million infections had been confirmed.[263]

As of 30 October 2020, more than 45.1 million cases have been reported worldwide; more than 1.18 million people have died and more than 30.3 million have recovered.[5]

National responses

A total of 190[5] countries and territories have had at least one case of COVID-19 so far. Due to the pandemic in Europe, many countries in the Schengen Area have restricted free movement and set up border controls.[264] National reactions have included containment measures such as quarantines and curfews (known as stay-at-home orders, shelter-in-place orders, or lockdowns).[265] The WHO's recommendation on curfews and lockdowns is that they should be short-term measures to reorganize, regroup, rebalance resources, and protect health workers who are exhausted. To achieve a balance between restrictions and normal life, the long-term responses to the pandemic should consist of strict personal hygiene, effective contact tracing, and isolating when ill.[266]

By 26 March, 1.7 billion people worldwide were under some form of lockdown,[267] which increased to 3.9 billion people by the first week of April—more than half the world's population.[268][269]

By late April, around 300 million people were under lockdown in nations of Europe, including but not limited to Italy, Spain, France, and the United Kingdom, while around 200 million people were under lockdown in Latin America.[270] Nearly 300 million people, or about 90 percent of the population, were under some form of lockdown in the United States,[271] around 100 million people in the Philippines,[270] about 59 million people in South Africa,[272] and 1.3 billion people have been under lockdown in India.[273][274] On 21 May 100,000 new infections occurred worldwide, the most since the start of the pandemic, while overall 5 million cases were surpassed.[275]

Asia

As of 30 April 2020,[276] cases have been reported in all Asian countries except for Turkmenistan and North Korea, although these countries likely also have cases.[277][278] Despite being the first area of the world hit by the outbreak, the early wide-scale response of some Asian states, particularly Mongolia,[279] South Korea,[280] Taiwan,[281] and Vietnam,[282] has allowed them to fare comparatively well.

A temporary hospital constructed in Wuhan in February

As of 14 July 2020, there are 83,545 cases confirmed in China— excluding 114 asymptomatic cases, 62 of which were imported, under medical observation; asymtomatic cases have not been reported prior to 31 March 2020— with 4,634 deaths and 78,509 recoveries,[283] meaning there are only 402 cases. Hubei has the most cases, followed by Xinjiang.[284]

Indian officials conducting temperature checks at the Ratha Yatra Hindu festival on 23 June

The first case of COVID-19 in India originated from China and was reported on 30 January 2020. India ordered a nationwide lockdown for the entire population starting 24 March,[285] with a phased unlock beginning 1 June. Six cities account for around half of all reported cases in the country—Mumbai, Delhi, Ahmedabad, Chennai, Pune and Kolkata.[286]

As of September 2020, India had the largest number of confirmed cases in Asia;[287] and the second-highest number of confirmed cases in the world,[288] behind the United States,[289] with the number of total confirmed cases breaching the 100,000 mark on 19 May,[290] 1,000,000 on 16 July[291] and 5,000,000 confirmed cases on 16 September 2020.[292] On 30 August, India surpassed the US record for the most cases in a single day, with more than 78,000 cases,[293] and set a new record on 16 September, with almost 98,000 cases reported that day.

On 10 June, India's recoveries exceeded active cases for the first time.[294] As of 30 August, India's case fatality rate is relatively low at 2.3%, against the global 4.7%.[295]

Disinfection of Tehran Metro trains against coronavirus. Similar measures have also been taken in other countries. [296]

Iran reported its first confirmed cases of SARS-CoV-2 infections on 19 February in Qom, where, according to the Ministry of Health and Medical Education, two people had died that day.[297][298] Early measures announced by the government included the cancellation of concerts and other cultural events,[299] sporting events,[300] Friday prayers,[301] and closures of universities, higher education institutions, and schools.[302] Iran allocated 5 trillion rials (equivalent to US$120,000,000) to combat the virus.[303] President Hassan Rouhani said on 26 February there were no plans to quarantine areas affected by the outbreak, and only individuals would be quarantined.[304] Plans to limit travel between cities were announced in March,[305] although heavy traffic between cities ahead of the Persian New Year Nowruz continued.[306] Shia shrines in Qom remained open to pilgrims until 16 March.[307][308]

Iran became a centre of the spread of the virus after China during February.[309][310] More than ten countries had traced their cases back to Iran by 28 February, indicating the outbreak may have been more severe than the 388 cases reported by the Iranian government by that date.[310][311] The Iranian Parliament was shut down, with 23 of its 290 members reported to have had tested positive for the virus on 3 March.[312] On 15 March, the Iranian government reported a hundred deaths in a single day, the most recorded in the country since the outbreak began.[313] At least twelve sitting or former Iranian politicians and government officials had died from the disease by 17 March.[314] By 23 March, Iran was experiencing fifty new cases every hour and one new death every ten minutes due to coronavirus.[315] According to a WHO official, there may be five times more cases in Iran than what is being reported. It is also suggested that U.S. sanctions on Iran may be affecting the country's financial ability to respond to the viral outbreak.[316] On 20 April, Iran reopened shopping malls and other shopping areas across the country.[317] After reaching a low in new cases in early May, a new peak was reported on 4 June, raising fear of a second wave.[318] On 18 July, President Rouhani estimated that 25 million Iranians had already become infected, which is considerably higher than the official count.[319] Leaked data suggest that 42,000 people had died with COVID-19 symptoms by 20 July, nearly tripling the 14,405 officially reported by that date.[320]

A drive-through test centre at the Gyeongju Public Health Centre

COVID-19 was confirmed to have spread to South Korea on 20 January 2020 from China. The nation's health agency reported a significant increase in confirmed cases on 20 February,[321] largely attributed to a gathering in Daegu of the Shincheonji Church of Jesus.[321][322] Shincheonji devotees visiting Daegu from Wuhan were suspected to be the origin of the outbreak.[323][324] By 22 February, among 9,336 followers of the church, 1,261 or about 13 percent reported symptoms.[325] South Korea declared the highest level of alert on 23 February 2020.[326] On 29 February, more than 3,150 confirmed cases were reported.[327] All South Korean military bases were quarantined after tests showed three soldiers had the virus.[323] Airline schedules were also changed.[328][329]

South Korea introduced what was considered the largest and best-organised programme in the world to screen the population for the virus, isolate any infected people, and trace and quarantine those who contacted them.[280][330] Screening methods included mandatory self-reporting of symptoms by new international arrivals through mobile application,[331] drive-through testing for the virus with the results available the next day,[332] and increasing testing capability to allow up to 20,000 people to be tested every day.[333] Despite some early criticisms of President Moon Jae-in's response to the crisis,[334] South Korea's programme is considered a success in controlling the outbreak without quarantining entire cities.[280][335][336]

On 23 March, it was reported that South Korea had the lowest one-day case total in four weeks.[333] On 29 March it was reported that beginning 1 April all new overseas arrivals will be quarantined for two weeks.[337] Per media reports on 1 April, South Korea has received requests for virus testing assistance from 121 different countries.[338] Persistent local groups of infections in the greater Seoul area continued to be found, which led to Korea's CDC director saying in June that the country had entered a second wave of infections,[339] although a WHO official disagreed with that assessment.[340]

Europe

Cases of COVID-19 per 100,000 residents in Europe. The numbers are not comparable, as the testing strategy differs among countries and time periods.

On 21 August, it was reported the COVID-19 cases were climbing among younger individuals across Europe.[349]

Although it was originally thought the pandemic reached France on 24 January 2020, when the first COVID-19 case in Europe was confirmed in Bordeaux, it was later discovered that a person near Paris had tested positive for the virus on 27 December 2019 after retesting old samples.[254][255] A key event in the spread of the disease in the country was the annual assembly of the Christian Open Door Church between 17 and 24 February in Mulhouse, which was attended by about 2,500 people, at least half of whom are believed to have contracted the virus.[350][351]

On 13 March, Prime Minister Édouard Philippe ordered the closure of all non-essential public places,[352] and on 16 March, French President Emmanuel Macron announced mandatory home confinement, a policy which was extended at least until 11 May.[353][354][355] As of 14 September, France has reported more than 402,000 confirmed cases, 30,000 deaths, and 90,000 recoveries,[356] ranking fourth in number of confirmed cases.[357] In April, there were riots in some Paris suburbs.[358] On 18 May, it was reported that schools in France had to close again after reopening, due to COVID-19 case flare-ups.[359]

The outbreak was confirmed to have spread to Italy on 31 January, when two Chinese tourists tested positive for SARS-CoV-2 in Rome.[249] Cases began to rise sharply, which prompted the Italian government to suspend all flights to and from China and declare a state of emergency.[360] An unassociated cluster of COVID-19 cases was later detected, starting with 16 confirmed cases in Lombardy on 21 February.[361]

Civil Protection volunteers conduct health checks at the Guglielmo Marconi Airport in Bologna on 5  February.

On 22 February, the Council of Ministers announced a new decree-law to contain the outbreak, including quarantining more than 50,000 people from eleven different municipalities in northern Italy.[362] Prime Minister Giuseppe Conte said, "In the outbreak areas, entry and exit will not be provided. Suspension of work activities and sports events has already been ordered in those areas."[363][364]

On 4 March, the Italian government ordered the full closure of all schools and universities nationwide as Italy reached a hundred deaths. All major sporting events were to be held behind closed doors until April,[365] but on 9 March all sport was suspended completely for at least one month.[366] On 11 March, Prime Minister Conte ordered stoppage of nearly all commercial activity except supermarkets and pharmacies.[367][368]

On 6 March, the Italian College of Anaesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) published medical ethics recommendations regarding triage protocols.[369][370][371] On 19 March, Italy overtook China as the country with the most coronavirus-related deaths in the world after reporting 3,405 fatalities from the pandemic.[372][373] On 22 March, it was reported that Russia had sent nine military planes with medical equipment to Italy.[374] As of 14 September, there were 287,753 confirmed cases, 35,610 deaths, and 213,634 recoveries in Italy, with the majority of those cases occurring in the Lombardy region.[5] A CNN report indicated that the combination of Italy's large elderly population and inability to test all who have the virus to date may be contributing to the high fatality rate.[375] On 19 April, it was reported that the country had its lowest deaths at 433 in seven days and some businesses are asking for a loosening of restrictions after six weeks of lockdown.[376] On 13 October 2020, the Italian government again issued restrictive rules to contain a rise in infections.[377]

Residents of Valencia, Spain, maintaining social distancing while queueing

Sweden differed from most other European countries in that it mostly remained open.[401] Per the Swedish Constitution, the Public Health Agency of Sweden has autonomy which prevents political interference and the agency's policy favoured forgoing a lockdown. The Swedish strategy focused on measures that could be put in place over a longer period of time, based on the assumption that the virus would start spreading again after a shorter lockdown.[402][403] The New York Times said that, as of May 2020, the outbreak had been far deadlier there but the economic impact had been reduced as Swedes have continued to go to work, restaurants, and shopping.[401][404] On 19 May, it was reported that the country had in the week of 12–19 May the highest per capita deaths in Europe, 6.25 deaths per million per day.[405] In the end of June, Sweden no longer had excess mortality.[406]

The "Wee Annie" statue in Gourock, Scotland, was given a face mask during the pandemic.

Devolution in the United Kingdom meant that each of the four countries of the UK had its own different response to COVID-19, and the UK government, on behalf of England, moved quicker to lift restrictions.[407] The UK government started enforcing social distancing and quarantine measures on 18 March 2020[408][409] and was criticised[by whom?] for a perceived lack of intensity in its response to concerns faced by the public.[410][411] On 16 March, Prime Minister Boris Johnson advised against non-essential travel and social contact, suggesting people work from home and avoid venues such as pubs, restaurants, and theatres.[412][413] On 20 March, the government announced that all leisure establishments to close as soon as possible,[414] and promised to prevent unemployment.[415] On 23 March, Johnson banned gatherings of multiple people and restricting non-essential travel and outdoor activity. Unlike previous measures, these restrictions were enforceable by police through fines and dispersal of gatherings. Most unessential businesses were ordered to close.[416]

On 24 April it was reported that a promising vaccine trial had begun in England; the government pledged more than £50 million towards research.[417] A number of temporary critical care hospitals were built.[418] The first operating was the 4000-bed NHS Nightingale Hospital London, constructed for over nine days.[419] On 4 May, it was announced that it would be placed on standby and remaining patients transferred to other facilities;[420] 51 patients had been treated in the first three weeks.[421]

On 16 April it was reported that the UK would have first access to the Oxford vaccine, due to a prior contract; should the trial be successful, some 30 million doses in the UK would be available.[422]

North America

The hospital ship USNS Comfort arrives in Manhattan on 30 March.

South America

Argentina was among the Latin American countries that earned the best grades for their response to the pandemic. [449]
The National Congress of Brazil, projecting the words "Solidariedade Salva Vidas," meaning "Solidarity Saves Lives."

On 20 May it was reported that Brazil had a record 1,179 deaths in a single day, for a total of almost 18,000 fatalities. With a total number of almost 272,000 cases, Brazil became the country with the third-highest number of cases, following Russia and the United States.[457] On 25 May, Brazil exceeded the number of reported cases in Russia when they reported that 11,687 new cases had been confirmed over the previous 24 hours, bringing the total number to over 374,800, with more than 23,400 deaths. President Jair Bolsonaro has created a great deal of controversy referring to the virus as a "little flu" and frequently speaking out against preventive measures such as lockdowns and quarantines. His attitude towards the outbreak has so closely matched that of U.S. President Donald Trump he has been called the "Trump of the Tropics".[458] Bolsonaro later tested positive for the virus.[459]

In June 2020, the government of Brazil attempted to conceal the actual figures of the COVID-19 active cases and deaths, as it stopped publishing the total number of infections and deaths. On 5 June, Brazil's health ministry took down the official website reflecting the total numbers of infections and deaths. The website was live on 6 June, with only the number of infections of the previous 24 hours. The last official numbers reported about 615,000 infections and over 34,000 deaths.[460] On 15 June, it was reported that the worldwide cases had jumped from seven to eight million in one week, citing Latin America, specifically Brazil as one of the countries where cases are surging, in this case, towards 1 million cases.[461]

Africa

Oceania

On 19 May 2020, Australia filed a motion with the UN for an inquiry into the origins of the virus, and the response of the UN and governments. More than 100 countries supported this motion, and it was passed unanimously.[471][472]

International responses

Travel restrictions

As a result of the pandemic, many countries and regions imposed quarantines, entry bans, or other restrictions, either for citizens, recent travellers to affected areas,[473] or for all travellers.[474] Together with a decreased willingness to travel, this had a negative economic and social impact on the travel sector. Concerns have been raised over the effectiveness of travel restrictions to contain the spread of COVID-19.[475] A study in Science found that travel restrictions had only modestly affected the initial spread of COVID-19, unless combined with infection prevention and control measures to considerably reduce transmissions.[476] Researchers concluded that "travel restrictions are most useful in the early and late phase of an epidemic" and "restrictions of travel from Wuhan unfortunately came too late".[477]

The European Union rejected the idea of suspending the Schengen free travel zone and introducing border controls with Italy,[478][479] a decision which has been criticised by some European politicians.[480][481]

Evacuation of foreign citizens

Ukraine evacuates Ukrainian and foreign citizens from Wuhan, China.

Owing to the effective lockdown of Wuhan and Hubei, several countries evacuated their citizens and diplomatic staff from the area, primarily through chartered flights of the home nation, with Chinese authorities providing clearance. Canada, the United States, Japan, India,[482] Sri Lanka, Australia, France, Argentina, Germany, and Thailand were among the first to plan the evacuation of their citizens.[483] Brazil and New Zealand also evacuated their own nationals and some other people.[484][485] On 14 March, South Africa repatriated 112 South Africans who tested negative for the virus from Wuhan, while four who showed symptoms were left behind to mitigate risk.[486] Pakistan said it would not evacuate citizens from China.[487]

On 15 February, the U.S. announced it would evacuate Americans aboard the cruise ship Diamond Princess,[488] and on 21 February, Canada evacuated 129 Canadian passengers from the ship.[489] In early March, the Indian government began evacuating its citizens from Iran.[490][491] On 20 March, the United States began to partially withdraw its troops from Iraq due to the pandemic.[492]

United Nations response measures

The United Nations response to the pandemic has been led by its Secretary-General and can be divided into formal resolutions at the General Assembly and at the Security Council (UNSC), and operations via its specialized agencies.

In June 2020, the Secretary-General launched its 'UN Comprehensive Response to COVID-19'.[493] The United Nations Conference on Trade and Development (UNSC) has been criticized for a slow coordinated response, especially regarding the UN's global ceasefire, which aims to open up humanitarian access to the world's most vulnerable in conflict zones.[494]

Protests against governmental measures

In several countries, protests have risen against governmental restrictive responses to the COVID-19 pandemic.

Impact

Economics

The outbreak is a major destabilising threat to the global economy. Agathe Demarais of the Economist Intelligence Unit has forecast that markets will remain volatile until a clearer image emerges on potential outcomes. One estimate from an expert at Washington University in St. Louis gave a $300+ billion impact on the world's supply chain that could last up to two years.[496] Global stock markets fell on 24 February due to a significant rise in the number of COVID-19 cases outside China.[497][498] On 27 February, due to mounting worries about the coronavirus outbreak, U.S. stock indexes posted their sharpest falls since 2008, with the Dow falling 1,191 points (the largest one-day drop since the financial crisis of 2007–08)[499] and all three major indexes ending the week down more than 10 percent.[500] On 28 February, Scope Ratings GmbH affirmed China's sovereign credit rating but maintained a Negative Outlook.[501] Stocks plunged again due to coronavirus fears, the largest fall being on 16 March.[502]

Lloyd's of London has estimated that the global insurance industry will absorb losses of US$204 billion, exceeding the losses from the 2017 Atlantic Hurricane season and 9/11, suggesting the COVID-19 pandemic will likely go down in history as the costliest disaster ever in human history.[503]

A highway sign on the Gardiner Expressway in Toronto discouraging non-essential travel

Tourism is one of the worst affected sectors due to travel bans, closing of public places including travel attractions, and advice of governments against travel. Numerous airlines have cancelled flights due to lower demand, and British regional airline Flybe collapsed.[504] The cruise line industry was hard hit,[505] and several train stations and ferry ports have also been closed.[506] International mail between some countries stopped or was delayed due to reduced transportation between them or suspension of domestic service.[507]

The retail sector has been impacted globally, with reductions in store hours or temporary closures.[508] Visits to retailers in Europe and Latin America declined by 40 percent. North America and Middle East retailers saw a 50–60 percent drop.[509] This also resulted in a 33–43 percent drop in foot traffic to shopping centres in March compared to February. Shopping mall operators around the world imposed additional measures, such as increased sanitation, installation of thermal scanners to check the temperature of shoppers, and cancellation of events.[510]

"Those who can, put something in; those who can't, help yourself." Bologna, April 2020.

Hundreds of millions of jobs could be lost globally.[511][512] More than 40 million Americans lost their jobs and filed unemployment insurance claims.[513] The economic impact and mass unemployment caused by the pandemic has raised fears of a mass eviction crisis,[514][515] with an analysis by the Aspen Institute indicating between 30 and 40 million Americans are at risk for eviction by the end of 2020.[516][517] According to a report by the Yelp, about 60% of U.S. businesses that have closed since the start of the pandemic will stay shut permanently.[518]

According to a United Nations Economic Commission for Latin America estimate, the pandemic-induced recession could leave 14–22 million more people in extreme poverty in Latin America than would have been in that situation without the pandemic.[519] According to the World Bank, up to 100 million more people globally could fall into extreme poverty due to the shutdowns.[520][521] The International Labour Organization (ILO) informed that the income generated in first nine months of 2020 from work across the world dropped by 10.7 per cent, or $3.5 trillion, amidst the coronavirus outbreak.[522]

Coronavirus fears have led to panic buying of essentials across the world, including toilet paper, dried and instant noodles, bread, rice, vegetables, disinfectant, and rubbing alcohol.

The outbreak has been blamed for several instances of supply shortages, stemming from globally increased usage of equipment to fight outbreaks, panic buying (which in several places led to shelves being cleared of grocery essentials such as food, toilet paper, and bottled water), and disruption to the factory and logistic operations.[523] The spread of panic buying has been found to stem from perceived threat, perceived scarcity, fear of the unknown, coping behaviour and social psychological factors (e.g. social influence and trust).[524] The technology industry, in particular, has warned of delays to shipments of electronic goods.[525] According to the WHO director-general Tedros Adhanom, demand for personal protection equipment has risen a hundredfold, leading to prices up to twenty times the normal price and also delays in the supply of medical items of four to six months.[526][527] It has also caused a shortage of personal protective equipment worldwide, with the WHO warning that this will endanger health workers.[528]

The impact of the coronavirus outbreak was worldwide. The virus created a shortage of precursors (raw material) used in the manufacturing of fentanyl and methamphetamine. The Yuancheng Group, headquartered in Wuhan, is one of the leading suppliers.[529] Price increases and shortages in these illegal drugs have been noticed on the street of the UK.[530] U.S. law enforcement also told the New York Post Mexican drug cartels were having difficulty in obtaining precursors.[531]

The pandemic has disrupted global food supplies and threatens to trigger a new food crisis.[532][533] David Beasley, head of the World Food Programme (WFP), said "we could be facing multiple famines of biblical proportions within a short few months."[534] Senior officials at the United Nations estimated in April 2020 that an additional 130 million people could starve, for a total of 265 million by the end of 2020.[535][534][536]

In early February 2020, Organization of the Petroleum Exporting Countries (OPEC) "scrambled" after a steep decline in oil prices due to lower demand from China.[537] On Monday, 20 April, the price of West Texas Intermediate (WTI) went negative and fell to a record low (minus $37.63 a barrel) due to traders' offloading holdings so as not to take delivery and incur storage costs.[538] June prices were down but in the positive range, with a barrel of West Texas trading above $20.[538]

Culture

Closed entrance to the Shah Abdol-Azim Shrine in Ray, Iran

The performing arts and cultural heritage sectors have been profoundly affected by the pandemic, impacting organisations' operations as well as individuals—both employed and independent—globally. Arts and culture sector organisations attempted to uphold their (often publicly funded) mission to provide access to cultural heritage to the community, maintain the safety of their employees and the public, and support artists where possible. By March 2020, across the world and to varying degrees, museums, libraries, performance venues, and other cultural institutions had been indefinitely closed with their exhibitions, events and performances cancelled or postponed.[539] In response there were intensive efforts to provide alternative services through digital platforms.[540][541][542]

A man wearing purple vestments and standing at an altar uses a mobile phone camera to record himself. Empty pews are visible in the background.
An American Catholic military chaplain prepares for a live-streamed Mass in an empty chapel at Offutt Air Force Base in March 2020.

Holy Week observances in Rome, which occur during the last week of the Christian penitential season of Lent, were cancelled.[541] Many dioceses have recommended older Christians stay home rather than attend Mass on Sundays; services have been made available via radio, online live streaming and television, though some congregations have made provisions for drive-in worship.[543][544][541] With the Roman Catholic Diocese of Rome closing its churches and chapels and St. Peter's Square emptied of Christian pilgrims,[541] other religious bodies also cancelled in-person services and limited public gatherings in churches, mosques, synagogues, temples and gurdwaras.[541] Iran's Health Ministry announced the cancellation of Friday prayers in areas affected by the outbreak and shrines were later closed,[301][308] while Saudi Arabia banned the entry of foreign pilgrims as well as its residents to holy sites in Mecca and Medina.[545][546] The 2020 Hajj was limited to around 1,000 selected pilgrims, in contrast to the usual number of over 2 million.[547]

The pandemic has caused the most significant disruption to the worldwide sporting calendar since the Second World War. Most major sporting events have been cancelled or postponed, including the 2019–20 UEFA Champions League,[548] 2019–20 Premier League,[549] UEFA Euro 2020, 2019–20 NBA season,[550] and 2019–20 NHL season.[551] The outbreak disrupted plans for the 2020 Summer Olympics in Tokyo, Japan, which were originally scheduled to start at 24 July 2020, and were postponed by the International Olympic Committee to 23 July 2021.[552][553][554]

The entertainment industry has also been affected, with many music groups suspending or cancelling concert tours.[555][556] The Eurovision Song Contest, which was due to be held in Rotterdam, the Netherlands in May, was cancelled; however, the Netherlands was retained as host for 2021.[557][558] Many large theatres such as those on Broadway also suspended all performances.[559] Some artists have explored ways to continue to produce and share work over the internet as an alternative to traditional live performance, such as live streaming concerts[560] or creating web-based "festivals" for artists to perform, distribute, and publicise their work.[561] Online, numerous COVID-19-themed Internet memes have spread as many turn to humour and distraction amid the uncertainty.[562]

Politics

The pandemic has affected the political systems of multiple countries, causing suspensions of legislative activities,[563] isolations or deaths of multiple politicians,[564] and rescheduling of elections due to fears of spreading the virus.[565] Starting in late May, large-scale protests against police brutality in at least 200 U.S. cities and later worldwide in response to the killing of George Floyd raised concerns of a resurgence of the virus.[566]

Although they have broad support among epidemiologists, social distancing measures have been politically controversial in many countries. Intellectual opposition to social distancing has come primarily from writers of other fields, although there are a few heterodox epidemiologists.[567]

On 23 March 2020, United Nations Secretary-General António Manuel de Oliveira Guterres issued an appeal for a global ceasefire in response to the pandemic;[568][569] 172 UN Member States and Observers signed a non-binding statement in support of the appeal in June,[570] and the UN Security Council passed a resolution supporting it in July.[571][572]

Chinese Communist Party general secretary Xi Jinping (left) with State Council Premier Li Keqiang

The Chinese government has been criticised by the United States government,[573] UK Minister for the Cabinet Office Michael Gove,[574] and others[575] for its handling of the pandemic. A number of provincial-level administrators of the Communist Party of China were dismissed over their handling of the quarantine measures in China, a sign of discontent with their response to the outbreak. Some commentators believed this move was intended to protect Chinese Communist Party general secretary Xi Jinping from the controversy.[576] The U.S. intelligence community says China intentionally under-reported its number of coronavirus cases.[577] The Chinese government maintains it has acted swiftly and transparently.[578][579]

In early March, the Italian government criticised the European Union's lack of solidarity with coronavirus-affected Italy[580][581]—Maurizio Massari, Italy's ambassador to the EU, said "only China responded bilaterally", not the EU.[582] On 22 March, after a phone call with Italian Prime Minister Giuseppe Conte, Russian president Vladimir Putin had the Russian army send military medics, disinfection vehicles, and other medical equipment to Italy.[583] President of Lombardy Attilio Fontana and Italian Foreign Minister Luigi Di Maio expressed their gratitude for the aid.[584] Russia also sent a cargo plane with medical aid to the United States.[585] Kremlin spokesman Dmitry Peskov said "when offering assistance to U.S. colleagues, [Putin] assumes that when U.S. manufacturers of medical equipment and materials gain momentum, they will also be able to reciprocate if necessary."[586] In early April, Norway and EU states like Romania and Austria started to offer help by sending medical personnel and disinfectant,[587] and Ursula von der Leyen offered an official apology to the country.[588]

Several hundred anti-lockdown protesters rallied at the Ohio Statehouse 20 April. [589]

The outbreak prompted calls for the United States to adopt social policies common in other wealthy countries, including universal health care, universal child care, paid sick leave, and higher levels of funding for public health.[590][591][592] Political analysts anticipated it may negatively affect Donald Trump's chances of re-election.[593][594] Beginning in mid-April 2020, there were protests in several U.S. states against government-imposed business closures and restricted personal movement and association.[595] Simultaneously, protests ensued by essential workers in the form of a general strike.[596] In early October 2020, Donald Trump and many other government officials were diagnosed with COVID-19, further disrupting the country's politics.[597] The president, while still infected with the novel coronavirus, returned to the Oval Office on 7 October 2020. White House chief of staff Mark Meadows had previously ensured safety precautions to accommodate the president's request to return to work as soon as possible. Meadows claimed that the staffers and personnel working in direct contact with the president wore "full PPE, masks, goggles, and the like."[598]

The planned NATO "Defender 2020" military exercise in Germany, Poland, and the Baltic states, the largest NATO war exercise since the end of the Cold War, will be held on a reduced scale.[599][600] The Campaign for Nuclear Disarmament's general secretary Kate Hudson criticised the exercise, saying "it jeopardises the lives not only of the troops from the U.S. and the many European countries participating but the inhabitants of the countries in which they are operating."[601]

The Iranian government has been heavily affected by the virus, with about two dozen parliament members and fifteen current or former political figures infected.[311][602] Iran's President Hassan Rouhani wrote a public letter to world leaders asking for help on 14 March 2020, saying they were struggling to fight the outbreak due to a lack of access to international markets from the United States sanctions against Iran.[603] Saudi Arabia, which launched a military intervention in Yemen in March 2015, declared a ceasefire.[604]

Diplomatic relations between Japan and South Korea worsened due to the pandemic.[605] South Korea criticised Japan's "ambiguous and passive quarantine efforts" after Japan announced anyone coming from South Korea would be placed in quarantine for two weeks at government-designated sites.[606] South Korean society was initially polarised on President Moon Jae-in's response to the crisis; many Koreans signed petitions either calling for Moon's impeachment or praising his response.[334]

Some countries have passed emergency legislation in response to the pandemic. Some commentators have expressed concern that it could allow governments to strengthen their grip on power.[607][608] In the Philippines, lawmakers granted president Rodrigo Duterte temporary emergency powers during the pandemic.[609] In Hungary, the parliament voted to allow the prime minister, Viktor Orbán, to rule by decree indefinitely, suspend parliament as well as elections, and punish those deemed to have spread false information about the virus and the government's handling of the crisis.[610] In some countries, including Egypt,[611] Turkey,[612] and Thailand,[609] opposition activists and government critics have been arrested for allegedly spreading fake news about the COVID-19 pandemic.[613]

Agriculture and food systems

The COVID-19 pandemic has disrupted agricultural and food systems worldwide.[614] COVID-19 hit at a time when hunger or undernourishment was once again on the rise in the world, with an estimated 690 million people already going hungry in 2019.[615] Based on the latest UN estimates, the economic recession triggered by the pandemic may lead to another 83 million people, and possibly as many as 132 million, going hungry in 2020.[615][616][617][618] This is mainly due to a lack of access to food – linked to falling incomes, lost remittances and, in some cases, a rise in food prices. In countries that already suffer from high levels of acute food insecurity, it is no longer an issue of access to food alone, but increasingly also one of food production.[614][615]

Famine

The pandemic, alongside lockdowns and travel restrictions, has prevented movement of aid and greatly impacted food production. As a result, several famines are forecast, which the United Nations called a crisis "of biblical proportions,"[619] or "hunger pandemic."[620] It is estimated that without intervention 30 million people may die of hunger, with Oxfam reporting that "12,000 people per day could die from COVID-19 linked hunger" by the end of 2020.[621][619][622] This pandemic, in conjunction with the 2019–20 locust infestations and several ongoing armed conflicts, is predicted to form the worst series of famines since the Great Chinese Famine, affecting between 10 and 20 percent of the global population in some way.[623] 55 countries are reported to be at risk, with three dozen succumbing to crisis-level famines or above in the worst-case scenario.[624] 265 million people are forecast to be in famine conditions, an increase of 125 million due to the coronavirus pandemic.[621]

Education

Other health issues

Environment and climate

Xenophobia and racism

Since the start of the outbreak, heightened prejudice, xenophobia, and racism have been documented around the world toward people of Chinese and East Asian descent.[652][653][654] Reports from February (when most cases were confined to China) documented racist sentiments expressed in groups worldwide about Chinese people 'deserving' the virus.[655][656][657] Chinese people and other Asian in the United Kingdom and United States have reported increasing levels of racist abuse and assaults.[658][659][660] U.S. President Donald Trump has been criticised for referring to the coronavirus as the "Chinese Virus" and "Kung Flu", which has been widely condemned as racist and xenophobic.[661][662][663] On 14 March, an Asian family, including a two-year-old girl, was attacked at knifepoint in Texas in what the FBI has called a COVID-19 related hate crime.[664]

Following the progression of the outbreak to new hotspot countries, people from Italy (the first country in Europe to experience a serious outbreak of COVID-19) were also subjected to suspicion and xenophobia,[665][666] as were people from hotspots in other countries. Discrimination against Muslims in India escalated after public health authorities identified an Islamic missionary (Tablighi Jamaat) group's gathering in New Delhi in early March 2020 as a source of spread.[667] Paris has seen riots break out over police treatment of ethnic minorities during the coronavirus lockdown.[668] Racism and xenophobia towards southern and south east Asians increased in the Arab states of the Persian Gulf.[669][670][671] South Korea's LGBTQ community was blamed by some for the spread of COVID-19 in Seoul.[672][673] In China, some people of African descent were evicted from their homes and told to leave China within 24 hours, due to disinformation that they and other foreigners were spreading the virus.[674] This racism and xenophobia was criticised by foreign governments and diplomatic corps and the Chinese ambassador to Zimbabwe.[675]

Information dissemination

Ongoing COVID-19 research is indexed and searchable in the NIH COVID-19 Portfolio.[676] Some newspaper agencies removed their online paywalls for some or all of their coronavirus-related articles and posts,[677] while scientific publishers made scientific papers related to the outbreak available with open access.[678] Some scientists chose to share their results quickly on preprint servers such as bioRxiv.[679]

Misinformation

U.S. president Donald Trump suggested at a press briefing on 23  April that disinfectant injections or exposure to ultraviolet light might help treat COVID-19. There is no evidence that either could be a viable method. [680] (1:05 min)

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