COVID-19 pandemic

COVID-19 pandemic
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Map of confirmed deaths per capita as of 3 June 2020
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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
Passengers at Linate Airport in Milan have their temperatures taken
Almost empty supermarket aisle in Melbourne, Australia
Top to bottom:
Disease Coronavirus disease 2019 (COVID-19)
Virus strain Severe acute respiratory syndrome
coronavirus 2
(SARS‑CoV‑2)[a]
Source Probably bats, possibly via pangolins[2][3]
Location Worldwide
First outbreak China[4]
Index case Wuhan, Hubei, China
30°37′11″N 114°15′28″E / 30.61972°N 114.25778°E / 30.61972; 114.25778
Date December 1, 2019 (2019-12-01)[4] – present
(6 months and 2 days)
Confirmed cases 6,395,328[5][b]
Active cases 3,272,442[5]
Recovered 2,742,306[5]
Deaths
380,580[5]
Territories
188[5]

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).[1] The outbreak was first identified in Wuhan, China, in December 2019.[4][6] The World Health Organization declared the outbreak a Public Health Emergency of International Concern on 30 January, and a pandemic on 11 March.[7][8] As of 3 June 2020, more than 6.39 million cases of COVID-19 have been reported in more than 188 countries and territories, resulting in more than 380,000 deaths; more than 2.74 million people have recovered.[5]

Common symptoms include fever, cough, fatigue, shortness of breath, and loss of sense of smell.[9][13][14] Complications may include pneumonia and acute respiratory distress syndrome.[15] The time from exposure to onset of symptoms is typically around five days but may range from two to fourteen days.[16][17] There is no known vaccine or specific antiviral treatment.[9] Primary treatment is symptomatic and supportive therapy.[18]

Recommended preventive measures include hand washing, covering one's mouth when coughing, maintaining distance from other people, wearing a face mask in public settings, and monitoring and self-isolation for people who suspect they are infected.[9][19] 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 infected persons.

The pandemic has caused global social and economic disruption,[20] including the largest global recession since the Great Depression.[21] It has led to the postponement or cancellation of sporting, religious, political, and cultural events,[22] widespread supply shortages exacerbated by panic buying,[23][24][25] and decreased emissions of pollutants and greenhouse gases.[26][27] Schools, universities, and colleges have been closed either on a nationwide or local basis in 177 countries, affecting approximately 98.6 percent of the world's student population.[28] Misinformation about the virus has spread through social media and the mass media.[29] 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.[30][31][32]

Video summary ( script) on the coronavirus disease (4:12 min)

Epidemiology

Background

On 31 December 2019, health authorities in China reported to the World Health Organization (WHO) a cluster of viral pneumonia cases of unknown cause in Wuhan, Hubei,[316][317] and an investigation was launched in early January 2020.[318] On 30 January, the WHO declared the outbreak a Public Health Emergency of International Concern (PHEIC)—7,818 cases confirmed globally, affecting 19 countries in five WHO regions.[319][320]

Several of the early cases had visited Huanan Seafood Wholesale Market[321] and so the virus is thought to have a zoonotic origin.[322] The virus that caused the outbreak is known as SARS‑CoV‑2, a newly discovered virus closely related to bat coronaviruses,[323] pangolin coronaviruses,[324][325] and SARS-CoV.[326] The scientific consensus is that COVID-19 has a natural origin.[327][328] The probable bat-to-human infection may have been among people processing bat carcasses and guano in the production of traditional Chinese medicines.[329]

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.[330][331] Of the early cluster of cases reported that month, two-thirds were found to have a link with the market.[332][333][334] On 13 March 2020, an unverified report from the South China Morning Post suggested a case traced back to 17 November 2019 (a 55-year-old from Hubei) may have been the first person infected.[335][336]

The WHO recognized the spread of COVID-19 as a pandemic on 11 March 2020.[337] Italy, Iran, South Korea, and Japan reported surging cases. The total numbers outside China quickly passed China's.[338]

Cases

Epidemic curve of COVID-19 by date of report

Cases refer to the number of people who have been tested for COVID-19, and whose test has been confirmed positive according to official protocols.[339] As of 24 May, countries that publicised their testing data have typically performed many tests equal to 2.6 percent of their population, while no country has tested samples equal to more than 17.3 percent of its population.[340] Many countries, early on, had official policies to not test those with only mild symptoms.[341][342] 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.[343] 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.[344][345]

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.[346] 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.[347][348] However, such antibody surveys can be unreliable due to a selection bias in who volunteers to take the tests, and due to false positives. Some results (such as the Gangelt study) have received substantial press coverage without first passing through peer review.[349]

Analysis by age in China indicates that a relatively low proportion of cases occur in individuals under 20.[350] It is not clear whether this is because young people are less likely to be infected, or less likely to develop serious symptoms and seek medical attention and be tested.[351] A retrospective cohort study in China found that children were as likely to be infected as adults.[352] Countries that test more, relative to the number of deaths, have a younger age distribution of cases, relative to the wider population.[353]

Initial estimates of the basic reproduction number (R0) for COVID-19 in January were between 1.4 and 2.5,[354] but a subsequent analysis has concluded that it may be about 5.7 (with a 95 percent confidence interval of 3.8 to 8.9).[355] 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. As of mid-May 2020, the effective R is close to or below 1.0 in many countries, meaning the spread of the disease in these areas is stable or decreasing.[356]

Deaths

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

Most people who contract COVID-19 recover. For those who do not, the time between the onset of symptoms and death usually ranges from 6 to 41 days, typically about 14 days.[361] As of 3 June 2020, approximately 380,000[5] deaths had been attributed to COVID-19. In China, as of 5 February, about 80 percent of deaths were recorded in those aged over 60, and 75 percent had pre-existing health conditions including cardiovascular diseases and diabetes.[362]

The first confirmed death was in Wuhan on 9 January 2020.[363] The first death outside of China occurred on 1 February in the Philippines,[364] and the first death outside Asia was in France on 14 February.[365]

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 testing, e.g. at home or in nursing homes.[366] Conversely, deaths of people who had underlying conditions may lead to overcounting.[367] Comparison of statistics for deaths for all causes versus the seasonal average indicates excess mortality in many countries.[368][369] In the worst affected areas, mortality has been several times higher than average. In New York City, deaths have been four times higher than average, in Paris twice as high, and in many European countries, deaths have been on average 20 to 30 percent higher than normal.[368] This excess mortality may include deaths due to strained healthcare systems and bans on elective surgery.[370]

Several measures are used to quantify mortality.[371] These numbers vary by region and over time, influenced by testing volume, healthcare system quality, treatment options, effectiveness and rapidity of government response,[372][373][374] time since the initial outbreak, and population characteristics, such as age, sex, and overall health.[375] Some 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.[376]

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 6.0 percent (380,580 deaths for 6,395,328 cases) as of 3 June 2020.[5] The number varies by region.[377]

Other measures include the case fatality rate (CFR), which reflects the percentage of diagnosed people who die from a disease, and the infection fatality rate (IFR), which reflects the percentage of infected (diagnosed and undiagnosed) who die from a disease. These statistics are not timebound and follow a specific population from infection through case resolution. Our World in Data states that as of 25 March 2020 the IFR cannot be accurately calculated as neither the total number of cases nor the total deaths, is known.[378] In February the Institute for Disease Modeling estimated the IFR as 0.94% (95% confidence interval 0.37–2.9), based on data from China.[379][380] The University of Oxford's Centre for Evidence-Based Medicine (CEBM) estimated a global CFR of 0.8 to 9.6 percent (last revised 30 April) and IFR of 0.10 percent to 0.41 percent (last revised 2 May), acknowledging that this will vary between populations due to differences in demographics.[381] The CDC estimates for planning purposes that the fatality rate among those who are symptomatic is 0.4% (0.2% to 1%) and that 35% of infected individuals are asymptomatic, for an overall infection fatality rate of 0.26% (as of 20 May).[382][383]

Duration

The WHO said on 11 March 2020 the pandemic could be controlled.[8] The peak and ultimate duration of the outbreak are uncertain and may differ by location. Maciej Boni of Penn State University said, "Left unchecked, infectious outbreaks typically plateau and then start to decline when the disease runs out of available hosts. But it's almost impossible to make any sensible projection right now about when that will be."[386] The Imperial College study led by Neil Ferguson stated that physical distancing and other measures will be required "until a vaccine becomes available (potentially 18 months or more)".[387] William Schaffner of Vanderbilt University said because the coronavirus is "so readily transmissible", it "might turn into a seasonal disease, making a comeback every year". The virulence of the comeback would depend on herd immunity and the extent of mutation.[388]

Signs and symptoms

Symptoms of COVID-19 [389]

The usual incubation period (the time between infection and symptom onset) ranges from one to 14 days, and is most commonly five days.[9][390] Some infected people have no symptoms, known as asymptomatic or presymptomatic carriers; transmission from such a carrier is considered possible.[391] As at 6 April, estimates of the asymptomatic ratio range widely from 5% to 80%.[392]

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.[393][394][395]

Among those who develop symptoms, approximately one in five may become more seriously ill and have difficulty breathing.[9] 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.[14] Further development of the disease can lead to complications including pneumonia, acute respiratory distress syndrome, sepsis, septic shock, and kidney failure.[394]

Cause

Transmission

The virus may occur in breastmilk.[406]

Virology

Illustration of SARSr‑CoV virion

Severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) is a novel virus, first isolated from three people with pneumonia connected to the cluster of acute respiratory illness cases in Wuhan.[326] All features of the novel SARS‑CoV‑2 virus occur in related coronaviruses in nature.[407]

SARS‑CoV‑2 is closely related to SARS‑CoV, and is thought to have a zoonotic origin.[323] SARS‑CoV‑2 genetically clusters with the genus Betacoronavirus, and is 96 percent identical at the whole genome level to other bat coronavirus samples[408] and 92 percent identical to pangolin coronavirus.[409]

Diagnosis

Demonstration of a swab for COVID-19 testing

COVID-19 can be provisionally 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.[410][411]

Viral testing

The standard test for current infection with 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.[412]

A number of laboratories and companies have developed serological tests, which detect antibodies produced by the body in response to infection.[413] Several have been evaluated by Public Health England and approved for use in the UK.[414]

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.[415] The Italian Radiological Society is compiling an international online database of imaging findings for confirmed cases.[416] Due to overlap with other infections such as adenovirus, imaging without confirmation by rRT-PCR is of limited specificity in identifying COVID-19.[415] 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.[411]

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 maintaining overall good personal hygiene, 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. Those who may already have the infection have been advised to wear a surgical mask in public.[417][418] Physical distancing measures are also recommended to prevent transmission.[419][420] Health care providers taking care of someone who may be infected are recommended to use standard precautions, contact precautions, and eye protection.[421]

Many governments have restricted or advised against all non-essential travel to and from countries and areas affected by the outbreak.[422] The virus has already spread within communities in large parts of the world, with many not knowing where or how they were infected.[423]

Misconceptions are circulating about how to prevent infection; for example, rinsing the nose and gargling with mouthwash are not effective.[424] There is no COVID-19 vaccine, though many organisations are working to develop one.[425]

Hand washing

Hand washing is recommended to prevent the spread of the disease. 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.[19] CDC further recommended using an alcohol-based hand sanitiser with at least 60 percent alcohol by volume when soap and water are not readily available.[417] The WHO advises people to avoid touching the eyes, nose, or mouth with unwashed hands.[418][426] It is not clear if washing hands with ash, if soap is not available, is effective at reducing the spread of viral infections.[427]

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.[428] 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.[429]

Face masks and respiratory hygiene

Slovakia was among the first countries in the world (and the second in Europe, after the Czech Republic) to make the wearing of masks mandatory in public. [430]

Recommendations for wearing masks have been a subject of debate.[431] The WHO has recommended healthy people wear masks only if they are at high risk, such as those who are caring for a person with COVID-19.[432] China and the United States, among other countries, have encouraged the use of face masks or cloth face coverings more generally by members of the public to limit the spread of the virus by asymptomatic individuals as a precautionary principle.[433][434] Several national and local governments have made wearing masks mandatory.[435]

Surgical masks are recommended for those who may be infected, as wearing this type of mask can limit the volume and travel distance of expiratory droplets dispersed when talking, sneezing, and coughing.[432]

Social distancing

Physical distancing in Toronto, with a limited number of customers allowed inside a store

Social distancing (also known as physical distancing) includes infection control actions intended to slow the spread of 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.[418][436][437] Many governments are now mandating or recommending social distancing in regions affected by the outbreak.[438][439] Non-cooperation with distancing measures in some areas has contributed to the further spread of the pandemic.[440]

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.[441] On 22 March 2020, Germany banned public gatherings of more than two people.[442] 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.[437]

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.[443][444]

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.[445][446]

Some authorities have issued sexual health guidelines for use during the pandemic. These include recommendations to have sex only with someone you live with, and who does not have the virus or symptoms of the virus.[447][448]

Self-isolation

Transmission of COVID-19 depends on physical proximity.

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.[449][450]

Many governments have mandated or recommended self-quarantine for entire populations living in affected areas.[451][452] The strongest self-quarantine instructions have been issued to those in high risk groups.[453] 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.[9][16][454]

Management

Containment and mitigation

Goals of mitigation include delaying and reducing peak burden on healthcare ( flattening the curve) and lessening overall cases and health impact. [455] [456] Moreover, progressively greater increases in healthcare capacity ( raising the line) such as by increasing bed count, personnel, and equipment, helps to meet increased demand. [457]
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. [455] [458]

Strategies in the control of an outbreak are containment or suppression, and mitigation. Containment is undertaken in the early stages of the outbreak and aims to trace and isolate those infected as well as introduce other measures of infection control and vaccinations to stop the disease from spreading to the rest of the population. When it is no longer possible to contain the spread of 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 society. A combination of both containment and mitigation measures may be undertaken at the same time.[459] Suppression requires more extreme measures so as to reverse the pandemic by reducing the basic reproduction number to less than 1.[387]

Part of managing an infectious disease outbreak is trying to delay and decrease the epidemic peak, known as flattening the epidemic curve.[455] This decreases the risk of health services being overwhelmed and provides more time for vaccines and treatments to be developed.[455] 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.[460]

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.[461] Other countries also adopted a variety of measures aimed at limiting the spread of the virus. South Korea introduced the 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.[462]

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.[387]

Contact tracing is an important method for health authorities to determine the source of infection and to prevent further transmission.[463] 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.[464]

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.[464] Users could then receive a message if they've been in close contact with someone who has subsequently tested positive for COVID-19.[464]

On 10 April 2020, Google and Apple jointly announced an initiative for privacy-preserving contact tracing based on Bluetooth technology and cryptography.[465][466] 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.[467] In Europe and in the U.S., Palantir Technologies is also providing COVID-19 tracking services.[468]

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.[469] 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.[469][470] 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.[471][472][473]

Due to capacity limitations in the standard supply chains, some manufacturers are 3D printing healthcare material such as nasal swabs and ventilator parts.[474][475] 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.[476][477][478] On 23 April 2020, NASA reported building, in 37 days, a ventilator which is currently undergoing further testing. NASA is seeking fast-track approval.[479][480]

Treatment

Antiviral medications are under investigation for COVID-19, as well as medications targeting the immune response.[481] None has yet been shown to be clearly effective on mortality in published randomised controlled trials.[481] However, remdesivir may have an effect on the time it takes to recover from the virus.[482] Emergency use authorisation for remdesivir was granted in the U.S. on 1 May, for people hospitalised with severe COVID-19. The interim authorisation was granted considering the lack of other specific treatments, and that its potential benefits appear to outweigh the potential risks.[483] Taking over-the-counter cold medications,[484] drinking fluids, and resting may help alleviate symptoms.[417] Depending on the severity, oxygen therapy, intravenous fluids, and breathing support may be required.[485] The use of steroids may worsen outcomes.[486] Several compounds which were previously approved for treatment of other viral diseases are being investigated for use in treating COVID-19.[487]

History

Cases by country, plotted on a logarithmic scale [488]

There are several theories about where the very first case (the so-called patient zero) originated.[489] According to an unpublicized report from the Chinese government, the first case can be traced back to 17 November 2019; the person was a 55-year old citizen in Hubei province.[490] There were four men and five women reported to be infected on November, but none of them were "patient zero".[490] Starting from December, the number of coronavirus cases in Hubei gradually increased, reaching 60 by 20 December[491] and at least 266 by 31 December.[492] According to official Chinese sources, these were mostly linked to the Huanan Seafood Wholesale Market, which also sold live animals.[322] 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 that the market was the site of an early superspreading event, but it was not the site of the initial outbreak.[493]

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.[494] 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.[495]On 30 December, a test report addressed to Wuhan Central Hospital, from company CapitalBio Medlab, stated 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. That evening, the Wuhan Municipal Health Commission issued a notice to various medical institutions on "the treatment of pneumonia of unknown cause".[496] Eight of these doctors, including Li Wenliang (punished on 3 January),[497] were later admonished by the police for spreading false rumours, and another, Ai Fen, was reprimanded by her superiors for raising the alarm.[498]

The Wuhan Municipal Health Commission made the first public announcement of a pneumonia outbreak of unknown cause on 31 December, confirming 27 cases[316][499][500]—enough to trigger an investigation.[318]

During the early stages of the outbreak, the number of cases doubled approximately every seven and a half days.[501] 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.[408] On 20 January, China reported nearly 140 new cases in one day, including two people in Beijing and one in Shenzhen.[502] Later official data shows 6,174 people had already developed symptoms by then,[503] and more may have been infected.[504] 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".[332][505] On 30 January, the WHO declared the coronavirus a public health emergency of international concern.[504]

On 31 January 2020, Italy had its first confirmed cases, two tourists from China.[506] As of 13 March 2020, the WHO considered Europe the active centre of the pandemic.[507] On 19 March 2020, Italy overtook China as the country with the most deaths.[508] By 26 March, the United States had overtaken China and Italy with the highest number of confirmed cases in the world.[509] 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.[510] Retesting of prior samples found a person in France who had the virus on 27 December 2019[511][512] and a person in the United States who died from the disease on 6 February 2020.[513]

As of 3 June 2020, more than 6.39 million cases have been reported worldwide; more than 380,000 people have died and more than 2.74 million have recovered.[514][515]

National responses

Map of national and subnational lockdowns as of 27 May 2020 ( table; more details)
  National lockdown
  Subnational lockdown
  No lockdown

A total of 188[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.[516] National reactions have included containment measures such as quarantines and curfews (known as stay-at-home orders, shelter-in-place orders, or lockdowns).[517]

By 26 March, 1.7 billion people worldwide were under some form of lockdown,[518] which increased to 3.9 billion people by the first week of April—more than half the world's population.[519][520]

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.[521] Nearly 300 million people, or about 90 percent of the population, were under some form of lockdown in the United States,[522] around 100 million people in the Philippines,[521] about 59 million people in South Africa,[523] and 1.3 billion people have been under lockdown in India.[524][525] On 21 May 100,000 new infections occurred worldwide, the most since the start of the pandemic, while overall 5 million cases were surpassed.[526]

Asia

As of 19 May 2020, cases have been reported in all Asian countries except for Turkmenistan[527] and North Korea,[528] although these countries likely also have cases.[529] Despite being the first area of the world hit by the outbreak, the early wide-scale response of some Asian states, particularly South Korea,[530] Taiwan,[531] and Vietnam,[532] has allowed them to fare comparatively well.

Confirmed cases of COVID-19 per 100,000 inhabitants by province, as of 13 April, showing Hubei with around 40 times more cases than any other province
  Hubei Province: 114.40 cases per 100,000
  1.5–2.5 cases per 100,000
  1–1.5 cases per 100,000
  0.5–1 cases per 100,000
  >0–0.5 cases per 100,000
Semi-log graph of new cases and deaths in China during the COVID-19 epidemic showing the lockdown and lifting

The first confirmed case of COVID-19 has been traced back to 1 December 2019 in Wuhan;[330] one unconfirmed report suggests the earliest case was on 17 November.[335] Doctor Zhang Jixian observed a cluster of pneumonia cases of unknown cause on 26 December, upon which her hospital informed Wuhan Jianghan CDC on 27 December.[533][534] Initial genetic testing of patient samples on 27 December 2019 indicated the presence of a SARS-like coronavirus.[533] A public notice was released by Wuhan Municipal Health Commission on 31 December, confirming 27 cases and suggesting wearing face masks.[500] The WHO was informed on the same day.[316] As these notifications occurred, doctors in Wuhan were warned by police for "spreading rumours" about the outbreak.[535] The Chinese National Health Commission initially said there was no "clear evidence" of human-to-human transmission.[536] In a 14 January conference call, Chinese officials said privately that human-to-human transmission was a possibility, and pandemic preparations were needed.[537] In a briefing posted during the night of 14–15 January, the Wuhan Municipal Health Commission said the possibility of limited human-to-human transmission could not be ruled out.[538]

On 20 January, the Chinese National Health Commission confirmed human-to-human transmission of the virus.[539] That same day, Chinese Communist Party general secretary Xi Jinping and State Council premier Li Keqiang issued their first public comments about the virus, telling people in infected areas to practice social distancing and avoid travel.[540][541] During the Chinese New Year travel period, authorities instigated a City of Wuhan lockdown.[542] On 10 February the Chinese government launched a radical campaign described by paramount leader and Chinese Communist Party general secretary Xi as a "people's war" to contain the viral spread.[543] In "the largest quarantine in human history",[544] a cordon sanitaire on 23 January stopped travel in and out of Wuhan,[545][546] then extended to fifteen Hubei cities affecting about 57 million people.[547] Private vehicle use was banned in the city.[548] Several Chinese New Year (25 January) celebrations were also cancelled.[549] Authorities announced the construction of a temporary hospital, Huoshenshan Hospital, completed in ten days.[550] Leishenshan Hospital, was later built to handle additional patients.[551] China also converted other facilities in Wuhan, such as convention centres and stadiums, into temporary hospitals.[552]

Wuhan Leishenshan Hospital, an emergency speciality field hospital built in response to the pandemic
A temporary hospital for treating mild cases of COVID-19 in Wuhan, one of more than ten such hospitals in the city [553]

On 26 January, the government instituted further measures to contain the COVID-19 outbreak, including issuing health declarations for travellers and extending the Spring Festival holiday.[554] Universities and schools around the country were also closed.[555][556][557] The regions of Hong Kong and Macau instituted several measures, particularly in regard to schools and universities.[558] Remote working measures were instituted in several Chinese regions.[559] Travel restrictions were enacted in and outside of Hubei.[559][560] Public transport was modified,[561] and museums throughout China were temporarily closed.[559][562][563] Control of public movement was applied in many cities, and an estimated 760 million people (more than half the population) faced some form of outdoor restriction.[564] In January and February 2020, during the height of the epidemic in Wuhan, about 5 million people lost their jobs.[565] Many of China's nearly 300 million rural migrant workers have been stranded at home in inland provinces or trapped in Hubei province.[566][567]

After the outbreak entered its global phase in March, Chinese authorities took strict measures to prevent the virus re-entering China from other countries. For example, Beijing imposed a 14-day mandatory quarantine for all international travellers entering the city.[568] At the same time, a strong anti-foreigner sentiment quickly took hold,[569] and foreigners experienced harassment by the general public[570] and forced evictions from apartments and hotels.[32][571]

On 24 March, Chinese Premier Li Keqiang reported that the spread of domestically transmitted cases has been basically blocked and the outbreak has been controlled in China.[572] The same day travel restrictions were eased in Hubei, apart from Wuhan, two months after the lockdown was imposed.[573] The Chinese Ministry of Foreign Affairs announced on 26 March that entry for visa or residence permit holders would be suspended from 28 March onwards, with no specific details on when this policy would end. Those wishing to enter China must to apply for visas in Chinese embassies or consulates.[574][575] The Chinese government encouraged businesses and factories to re-open on 30 March, and provided monetary stimulus packages for firms.[576]

The State Council declared a day of mourning to begin with a national three-minute moment of silence on 4 April, coinciding with Qingming Festival, although the central government asked families to pay their respects online in observance of physical distancing to avoid a renewed COVID-19 outbreak.[577] On 25 April the last patients were discharged in Wuhan.[578] On 13 May the city of Jilin was put on lockdown, sparking fear of a second wave of infection.[579]

Disinfection of Tehran Metro trains against coronavirus. Similar measures have also been taken in other countries. [580]

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.[581][582] Early measures announced by the government included the cancellation of concerts and other cultural events,[583] sporting events,[584] Friday prayers,[585] and closures of universities, higher education institutions, and schools.[586] Iran allocated 5 trillion rials (equivalent to US$120,000,000) to combat the virus.[587] President Hassan Rouhani said on 26 February there were no plans to quarantine areas affected by the outbreak, and only individuals would be quarantined.[588] Plans to limit travel between cities were announced in March,[589] although heavy traffic between cities ahead of the Persian New Year Nowruz continued.[590] Shia shrines in Qom remained open to pilgrims until 16 March.[591][592]

Iran became a centre of the spread of the virus after China during February.[593][594] 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.[594][595] The Iranian Parliament was shut down, with 23 of its 290 members reported to have had tested positive for the virus on 3 March.[596] On 15 March, the Iranian government reported a hundred deaths in a single day, the most recorded in the country since the outbreak began.[597] At least twelve sitting or former Iranian politicians and government officials had died from the disease by 17 March.[598] By 23 March, Iran was experiencing fifty new cases every hour and one new death every ten minutes due to coronavirus.[599] 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.[600] The UN High Commissioner for Human Rights has demanded economic sanctions to be eased for nations most affected by the pandemic, including Iran.[601] On 20 April it was reported that Iran had reopened shopping malls and other shopping areas across the country, though there is a fear of the second wave of infection due to this move.[602] In March, and again in April, there were reports that Iran was under-reporting COVID-19 cases and deaths.[603][604]

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,[605] largely attributed to a gathering in Daegu of the Shincheonji Church of Jesus.[605][606] Shincheonji devotees visiting Daegu from Wuhan were suspected to be the origin of the outbreak.[607][608] By 22 February, among 9,336 followers of the church, 1,261 or about 13 percent reported symptoms.[609]

South Korea declared the highest level of alert on 23 February 2020.[610] On 28 February, more than 2,000 confirmed cases were reported,[611] rising to 3,150 on 29 February.[612] All South Korean military bases were quarantined after tests showed three soldiers had the virus.[607] Airline schedules were also changed.[613][614]

A banner in Seoul displays coronavirus infection prevention tips.

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.[530][615] Screening methods included mandatory self-reporting of symptoms by new international arrivals through mobile application,[616] drive-through testing for the virus with the results available the next day,[617] and increasing testing capability to allow up to 20,000 people to be tested every day.[618] South Korea's programme is considered a success in controlling the outbreak without quarantining entire cities.[530][619][620]

South Korean society was initially polarised on President Moon Jae-in's response to the crisis, many signing petitions either praising it or calling for impeachment.[621] On 23 March, it was reported that South Korea had the lowest one-day case total in four weeks.[618] On 29 March it was reported that beginning 1 April all new overseas arrivals will be quarantined for two weeks.[622] Per media reports on 1 April, South Korea has received requests for virus testing assistance from 121 different countries.[623] On 15 May it was reported that about two thousand businesses were told to close again when a cluster of a hundred infected individuals was discovered; contact tracing is being done on 11,000 people.[624]

Europe

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

The outbreak was confirmed to have spread to Italy on 31 January, when two Chinese tourists tested positive for SARS‑CoV‑2 in Rome.[506] Cases began to rise sharply, which prompted the Italian government to suspend all flights to and from China and declare a state of emergency.[632] An unassociated cluster of COVID-19 cases was later detected, starting with 16 confirmed cases in Lombardy on 21 February.[633]

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.[634] 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."[635][636]

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,[637] but on 9 March all sport was suspended completely for at least one month.[638] On 11 March, Prime Minister Conte ordered stoppage of nearly all commercial activity except supermarkets and pharmacies.[639][640]

On 6 March, the Italian College of Anaesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) published medical ethics recommendations regarding triage protocols.[641][642][643] 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.[644][645] On 22 March, it was reported that Russia had sent nine military planes with medical equipment to Italy.[646] As of 9 May, there were 217,185 confirmed cases, 30,201 deaths, and 99,023 recoveries in Italy, with the majority of those cases occurring in the Lombardy region.[647] 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.[648] 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.[649]

Residents of Valencia, Spain, maintaining social distancing while queueing
The "Wee Annie" statue in Gourock, Scotland, was given a face mask during the pandemic.

Prior to 18 March 2020, the British government did not impose any form of social distancing or mass quarantine measures on its citizens.[665][666] As a result, the government received criticism for the perceived lack of pace and intensity in its response to concerns faced by the public.[667][668]

On 16 March, Prime Minister Boris Johnson made an announcement advising against all non-essential travel and social contact, suggesting people work from home where possible and avoid venues such as pubs, restaurants, and theatres.[669][670] On 20 March, the government announced that all leisure establishments such as pubs and gyms were to close as soon as possible,[671] and promised to pay up to 80 percent of workers' wages to a limit of £2,500 per month to prevent unemployment during the crisis.[672]

On 23 March, the prime minister announced tougher social distancing measures, banning gatherings of more than two people and restricting travel and outdoor activity to that deemed strictly necessary. Unlike previous measures, these restrictions were enforceable by police through the issuing of fines and the dispersal of gatherings. Most businesses were ordered to close, with exceptions for businesses deemed "essential", including supermarkets, pharmacies, banks, hardware shops, petrol stations, and garages.[673]

On 24 April it was reported that one of the more promising vaccine trials had begun in England; the government has pledged, in total, more than 50 million pounds towards research.[674]

VE Day celebrations took place under lockdown in the United Kingdom as in this socially-distanced street party in Wetherby, West Yorkshire.

To ensure the UK health services had sufficient capacity to treat people with COVID-19, a number of temporary critical care hospitals were built.[675] The first to be operational was the 4000-bed capacity NHS Nightingale Hospital London, constructed within the ExCeL convention centre over nine days.[676] On 4 May, it was announced that the Nightingale Hospital in London would be placed on standby and remaining patients transferred to other facilities.[677] This followed reports that NHS Nightingale in London "treated 51 patients" within the first three weeks of opening.[678] On 5 May, official figures revealed that Britain had the worst COVID-19 death toll in Europe, prompting calls for an inquiry into the handling of the pandemic. The death toll in the United Kingdom was nearly 29,427 for those tested positive for the virus. Later, it was calculated at 32,313, after taking the official death count for Scotland and Northern Ireland into account.[679] 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.[680]

France has been transferring COVID-19 patients from overloaded hospitals to hospitals in other regions via military helicopters, as seen here at Strasbourg Airport.

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.[511][512] 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.[681][682]

On 13 March, Prime Minister Édouard Philippe ordered the closure of all non-essential public places,[683] and on 16 March, French President Emmanuel Macron announced mandatory home confinement, a policy which was extended at least until 11 May.[684][685][686] As of 23 April, France has reported more than 120,804 confirmed cases, 21,856 deaths, and 42,088 recoveries,[687] ranking fourth in number of confirmed cases.[688] In April, there were riots in some Paris suburbs.[689] On 18 April it was reported that schools in France had to close again after reopening, due to COVID-19 case flare-ups.[690]

Sweden differed from most other European countries in that it mostly remained open.[691] Per the Swedish Constitution, the Public Health Agency of Sweden has autonomy which prevents political interference and the agency's policy favored forgoing a lockdown in an attempt to reach herd immunity.[692] 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.[691][693] 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.[694]

North America

Cases of COVID-19 per 10,000 residents by county

On 20 January 2020, the first known case of COVID-19 was confirmed in the Pacific Northwest state of Washington in a man who had returned from Wuhan on 15 January.[702] On 31 January, the Trump administration declared a public health emergency,[703] and restricted entry for travellers from China who were not U.S. citizens.[704]

On 28 January, the Centers for Disease Control and Prevention (CDC) announced they had developed their own testing kit.[705] Despite this, the United States had a slow start in testing, which obscured the extent of the outbreak.[706][707] Testing was marred by defective test kits produced by the government in February, a lack of federal approval for non-government test kits, and restrictive criteria for people to qualify for a test.[706][707]

By 2 March there were 80 confirmed cases, with half of the cases in California. Florida and New York had declared their first two cases and the state of Washington reported many suspected cases and the first death. Vice President Pence maintained that the threat of the virus spreading throughout the U.S. was small.[708][709][710]

On 6 March, President Trump signed the Coronavirus Preparedness and Response Supplemental Appropriations Act, which provided $8.3 billion in emergency funding for federal agencies to respond to the outbreak.[711][712] Corporations encouraged employees to work from home.[713] Sports events and seasons were cancelled.[22]

On 13 March, Trump declared a national emergency, which made federal funds available to respond to the crisis.[714] Beginning on 15 March, many businesses closed or reduced hours[715] and schools across the country were shutting down.[716][717] By 17 March, the epidemic had been confirmed in all fifty states and in the District of Columbia.[718] On 26 March, the United States had more confirmed cases than any other country.[509] U.S. federal health inspectors surveyed 323 hospitals in late March; reporting "severe shortages" of test supplies, "widespread shortages" of personal protective equipment (PPE), and other strained resources due to extended patient stays while awaiting test results.[719]

The hospital ship USNS Comfort arrives in Manhattan.

On 22 April it was reported that two Californians had died from the virus (not, as previously thought, influenza) on 6 and 17 February, three weeks before the first official COVID-19 death in the U.S. had been acknowledged.[513] By 24 April, 889,309 cases had been confirmed and 50,256 people had died.[720] As of 17 May, according to a New York Times database, more than 1,474,600 people had been infected and at least 88,600 had died in the United States. The Times stated that, prior to 29 April, only deaths confirmed through testing were reported, but new criteria include probable cases and deaths. As of 17 May, the U.S., which accounts for about 4.25% of the world's population, had about 29% of the confirmed coronavirus deaths.[721]

The White House has been criticised for downplaying the threat and controlling the messaging by directing health officials and scientists to coordinate public statements and publications related to the virus with the office of Vice-President Mike Pence.[722] On 14 April, President Trump halted funding to the World Health Organization (WHO), saying they had mismanaged the pandemic. He also said the U.S. would not participate in a global effort with the WHO to develop a vaccine and drugs to combat the virus.[723] On 1 May the CDC presented a 17-page report titled "Guidance for Implementing the Opening Up America Again Framework" to the administration. It had been written to provide advice for faith leaders, places of business, and other public places, educators, and state and local officials as they began to reopen. The White House refused to use the report. Trump said he felt the guidelines were too restrictive, commenting "I see the new normal being what it was three months ago. I think we want to go back to where it was."[724][725]

By mid-May reports of new cases began to level off and most states began to open restaurants and other places of business, placing limits to the numbers of people allowed in the establishment at the same time. The head of the NIAID, Anthony Fauci, warned that if caution was not used the rate of infections could rebound and he was particularly concerned about opening the schools in the fall. President Trump expressed surprise and disapproval at Fauci's statements saying, "To me it's not an acceptable answer, especially when it comes to schools."[726] Starting in late May, large-scale protests against police brutality in at least 200 U.S. cities in response to the death of George Floyd raised concerns of a resurgence of the virus due to the close proximity of protesters.[727]

South America

Workers being trained to disinfect buses in Olinda, Pernambuco, Brazil, 16 March 2020

On 20 April 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.[735] 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".[736]

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.[745][746]

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,[747] or for all travellers.[748] 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.[749] A study in Science found that travel restrictions had only modest effects delaying the initial spread of COVID-19, unless combined with infection prevention and control measures to considerably reduce transmissions.[750] 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".[751]

The European Union rejected the idea of suspending the Schengen free travel zone and introducing border controls with Italy,[752][753] a decision which has been criticised by some European politicians.[754][755]

Evacuation of foreign citizens

Ukraine evacuates Ukrainian and foreign citizens from Wuhan, China.

Owing to the effective quarantine of public transport in 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, Sri Lanka, Australia, France, Argentina, Germany, and Thailand were among the first to plan the evacuation of their citizens.[756] Brazil and New Zealand also evacuated their own nationals and some other people.[757][758] 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.[759] Pakistan said it would not evacuate citizens from China.[760]

On 15 February, the U.S. announced it would evacuate Americans aboard the cruise ship Diamond Princess,[761] and on 21 February, Canada evacuated 129 Canadian passengers from the ship.[762] In early March, the Indian government began evacuating its citizens from Iran.[763][764] On 20 March, the United States began to partially withdraw its troops from Iraq due to the pandemic.[765]

International aid

Some Chinese students at American universities sent aid, including 50,000 N95 masks on 30 January.[766] The humanitarian aid organisation Direct Relief sent 200,000 face masks and other personal protective equipment to the Wuhan Union Hospital the same day.[767] On 5 February, the Chinese foreign ministry said 21 countries (including Belarus, Pakistan, Trinidad and Tobago, Egypt, and Iran) had sent aid to China,[768] and Bill and Melinda Gates announced a $100 million donation to the WHO to fund vaccine research and treatment efforts and protect "at-risk populations in Africa and South Asia".[769] Interaksyon said the Chinese government had donated 200,000 masks to the Philippines on 6 February after Philippine senator Richard Gordon shipped 3.16 million masks to Wuhan.[770] On 19 February, the Singapore Red Cross announced it would send $2.26 million worth of aid to China.[771]

Several countries donated masks, medical equipment or money to China, including Japan,[772] Turkey, Russia,[773] Malaysia,[774] Germany,[775] and Canada.[776][777] The U.S. State Department said on 7 February it had facilitated the transportation of nearly 17.8 tons of medical supplies to China.[778] The same day, U.S. Secretary of State Pompeo announced a $100 million pledge to China and other countries to aid their fights against the virus,[779] though on 21 March China said it had not received epidemic funding from the U.S. government and reiterated that on 3 April.[citation needed] Several corporations have also donated money or medical equipment to China.[780]

Medical supplies donated by China being received at Villamor Air Base in the Philippines

After cases in China stabilised, the country began sending aid to other nations.[781] In March, China, Cuba and Russia sent medical supplies and experts to help Italy deal with its coronavirus outbreak;[782][783] China sent three medical teams and donated more than forty tons of medical supplies to Italy.[784] Businessman Jack Ma sent 1.1 million testing kits, 6 million face masks, and 60,000 protective suits to Ethiopia for distribution by the African Union.[785][786] He later sent 5,000 testing kits, 100,000 face masks and 5 ventilators to Panama.[787]

The Netherlands, Spain, Turkey, Georgia, and the Czech Republic expressed concerns over Chinese-made masks and test kits.[788] For instance, Spain withdrew 58,000 Chinese-made coronavirus testing kits with an accuracy rate of 30 percent, while the Netherlands recalled 600,000 Chinese face masks which were said to be defective,[789] but China said this was due to misuse.[790] Belgium recalled 100,000 unusable masks, which were thought to be from China but were in fact from Colombia.[791] The Philippines stopped using test kits donated by China due to their 40 percent accuracy.[792] The Chinese government said product instructions might not have been followed, and that some products were not purchased directly from certified companies.[793] Chinese aid was well-received in parts of Latin America and Africa.[794][795] On 2 April, the World Bank launched emergency support operations for developing countries.[796] According to a statement from its Ministry of Foreign Affairs, Turkey provides the largest amount of humanitarian aid in the world while ranking third worldwide in supplying medical aid.[797][798]

WHO response measures

WHO Director-General Tedros Adhanom

Taiwan notified the WHO of a new virus on 31 December 2019.[799] The WHO has commended the Chinese authorities for providing "regular updates", contrasting it to the 2002–2004 SARS outbreak when they were accused of secrecy.[800] The WHO stated on 5 January that cases of pneumonia of unknown cause had been reported,[801] and issued technical briefings on 10 and 11 January warning of risks of human-to-human transmission and urging precautions due to the similarity to earlier SARS and MERS outbreaks.[802] though in public announcements it said there was "no clear evidence of human-to-human transmission" as late as 14 January.[803] On 20 January, the WHO said it was "now very clear" human-to-human transmission of the coronavirus had occurred, given that healthcare workers had been infected.[804] On 27 January, the WHO assessed the risk of the outbreak to be "high at the global level".[805]

On 30 January, the WHO declared the outbreak a Public Health Emergency of International Concern (PHEIC), warning that "all countries should be prepared for containment, including active surveillance, early detection, isolation and case management, contact tracing and prevention of onward spread" of the virus,[7][806] following an increase in cases outside China. This was the sixth-ever PHEIC since the measure was first invoked during the 2009 swine flu pandemic. WHO Director-General Tedros Adhanom said the PHEIC was due to "the risk of global spread, especially to low- and middle-income countries without robust health systems" but that the WHO did not "recommend limiting trade and movement".[7][807][808]

WHO representatives with Tehran city managers

On 11 February, the WHO established COVID-19 as the name of the disease, and UN Secretary-General António Guterres agreed to provide the "power of the entire UN system in the response". A UN Crisis Management Team was activated, allowing coordination of the entire United Nations, which the WHO stated will allow them to "focus on the health response while the other agencies can bring their expertise to bear on the wider social, economic and developmental implications of the outbreak".[809] On 25 February, the WHO declared "the world should do more to prepare for a possible coronavirus pandemic," stating that while it was too early to call it a pandemic, countries should be "in a phase of preparedness".[810] On 28 February, WHO officials said the coronavirus threat assessment at the global level would be raised from "high" to "very high", its highest level of alert and risk assessment.[811] On 11 March, the WHO declared the coronavirus outbreak a pandemic.[812] The Director-General said the WHO was "deeply concerned both by the alarming levels of spread and severity, and by the alarming levels of inaction".[8] Critics have said the WHO handled the pandemic inadequately and that the public health emergency declaration and pandemic classification came too late.[813]

Impact

Economics

"Those who can, put something in; those who can't, help yourself." Bologna, April 2020.
A highway sign on the Gardiner Expressway in Toronto discouraging non-essential travel

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.[814] Global stock markets fell on 24 February due to a significant rise in the number of COVID-19 cases outside China.[815][816] 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)[817] and all three major indexes ending the week down more than 10 percent.[818] On 28 February, Scope Ratings GmbH affirmed China's sovereign credit rating but maintained a Negative Outlook.[819] Stocks plunged again due to coronavirus fears, the largest fall being on 16 March.[820] Many consider an economic recession likely.[821][822]

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 that the COVID-19 pandemic will likely go down in history as the costliest disaster ever in human history.[823]

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.[824] The cruise line industry was hard hit,[825] and several train stations and ferry ports have also been closed.[826] International mail between some countries stopped or was delayed due to reduced transportation between them or suspension of domestic service.[827]

The retail sector has been impacted globally, with reductions in store hours or temporary closures.[828] Visits to retailers in Europe and Latin America declined by 40 percent. North America and Middle East retailers saw a 50–60 percent drop.[829] 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.[830]

Hundreds of millions of jobs could be lost globally.[831][832] More than 40 million Americans lost their jobs and filed unemployment insurance claims.[833]

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.[834]

Coronavirus fears have led to panic buying of essentials across the world, including toilet paper, dried and/or 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 factory and logistic operations.[835] 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). [836] The technology industry, in particular, has warned of delays to shipments of electronic goods.[837] 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.[838][839] It has also caused a shortage of personal protective equipment worldwide, with the WHO warning that this will endanger health workers.[840]

The impact of the coronavirus outbreak was worldwide. The virus created a shortage of precursors used in the manufacturing of fentanyl and methamphetamine. The Yuancheng Group, located in Wuhan, China, is one of the leading suppliers of these chemical raw materials.[841] Price increases and shortages in these illegal drugs have been noticed on the street of the UK.[842] U.S. law enforcement also told the New York Post Mexican drug cartels were having difficulty in obtaining precursors.[843]

The pandemic has disrupted global food supplies and threatens to trigger a new food crisis.[844][845] David Beasley, head of the World Food Programme (WFP), said "we could be facing multiple famines of biblical proportions within a short few months."[846]

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.[847][846][848]

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.[849] 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.[850] June prices were down but in the positive range, with a barrel of West Texas trading above $20.[850]

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.[851] In response there were intensive efforts to provide alternative services through digital platforms.[852][853][854]

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.[853] 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.[855][856][853] With the Roman Catholic Diocese of Rome closing its churches and chapels and St. Peter's Square emptied of Christian pilgrims,[853] other religious bodies also cancelled in-person services and limited public gatherings in churches, mosques, synagogues, temples and gurdwaras.[853] Iran's Health Ministry announced the cancellation of Friday prayers in areas affected by the outbreak and shrines were later closed,[585][592] while Saudi Arabia banned the entry of foreign pilgrims as well as its residents to holy sites in Mecca and Medina.[857][858]

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,[859] 2019–20 Premier League,[860] UEFA Euro 2020, 2019–20 NBA season,[861] and 2019–20 NHL season.[862] The outbreak disrupted plans for the 2020 Summer Olympics, which were originally scheduled to start at the end of July; the International Olympic Committee announced on 24 March that they will be "rescheduled to a date beyond 2020 but not later than summer 2021".[863][864]

The entertainment industry has also been affected, with many music groups suspending or cancelling concert tours.[865][866] The Eurovision Song Contest, which was due to be held in the Netherlands in May, was postponed until 2021.[867] Many large theatres such as those on Broadway also suspended all performances.[868] 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[869] or creating web-based "festivals" for artists to perform, distribute, and publicise their work.[870] Online, numerous COVID-19-themed Internet memes have spread as many turn to humour and distraction amid uncertainty.[871]

Politics

The pandemic has affected the political systems of multiple countries, causing suspensions of legislative activities,[872] isolations or deaths of multiple politicians,[873] and rescheduling of elections due to fears of spreading the virus.[874]

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,[875] UK Minister for the Cabinet Office Michael Gove,[876] and others[877] 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 efforts in central 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.[878] The U.S. intelligence community says China intentionally under-reported its number of coronavirus cases.[879]

In early March, the Italian government criticised the European Union's lack of solidarity with coronavirus-affected Italy[880][881]—Maurizio Massari, Italy's ambassador to the EU, said "only China responded bilaterally", not the EU.[882] 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.[883] President of Lombardy Attilio Fontana and Italian Foreign Minister Luigi Di Maio expressed their gratitude for the aid.[884] Russia also sent a cargo plane with medical aid to the United States.[885] 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."[886]

Several hundred anti-lockdown protesters rallied at the Ohio Statehouse 20 April. [887]

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.[888][889][890] Political analysts anticipated it may negatively affect Donald Trump's chances of re-election in the 2020 presidential election.[891][892] Beginning in mid-April 2020, there were protests in several U.S. states against government-imposed business closures and restricted personal movement and association.[893]

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.[894][895] 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."[896]

UK Prime Minister Boris Johnson (left, back row) tested positive for COVID-19 in March 2020. Russian President Vladimir Putin (right, back row) began working remotely from his office at Novo-Ogaryovo after meeting with an infected doctor.

The Iranian government has been heavily affected by the virus, with about two dozen parliament members and fifteen current or former political figures infected.[595][897] 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.[898] Saudi Arabia, which launched a military intervention in Yemen in March 2015, declared a ceasefire.[899]

Diplomatic relations between Japan and South Korea worsened due to the pandemic.[900] 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.[901] 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.[621]

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.[902][903] In the Philippines, lawmakers granted president Rodrigo Duterte temporary emergency powers during the pandemic.[904] 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.[905] In some countries, including Egypt,[906] Turkey,[907] and Thailand,[904] opposition activists and government critics have been arrested for allegedly spreading fake news about the COVID-19 pandemic.[908]

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,[950][951][952] Reports from February (when most cases were confined to China) documented racist sentiments expressed in groups worldwide about Chinese people deserving the virus.[953][954][955] Citizens in countries including Malaysia,[956] New Zealand,[957] Singapore,[958] Japan,[959] Vietnam,[960] and South Korea lobbied to ban Chinese people from entering their countries.[961] Chinese people and other Asians in the United Kingdom and United States have reported increasing levels of racist abuse and assaults.[31][962][963] U.S. president Donald Trump has been criticised for referring to the coronavirus as the "Chinese Virus", which critics say is racist and anti-Chinese.[964][965][966]

Houston's Chinatown experienced a reduction in business early during the outbreak when there were still only a few cases. [967]

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,[968][969] as were people from hotspots in other countries. Discrimination against Muslims in India escalated after public health authorities identified an Islamic missionary group's gathering in New Delhi in early March 2020 as a source of spread.[970] Paris has seen riots break out over police treatment of ethnic minorities during the coronavirus lockdown.[971] Racism and xenophobia towards South Asians and Southeast Asians increased in the Arab states of the Persian Gulf.[972][973][974] South Korea's LGBTQ community was blamed by some for the spread of COVID-19 in Seoul.[975][976]

In China, xenophobia and racism against non-Chinese residents has been inflamed by the pandemic, with foreigners described as "foreign garbage" and targeted for "disposal".[977] Some black people were evicted from their homes by police and told to leave China within 24 hours, due to disinformation that they and other foreigners were spreading the virus.[978] Chinese racism and xenophobia was criticised by foreign governments and diplomatic corps,[979] and China apologised for discriminatory practices such as restaurants excluding black customers,[980] although these and other accusations of harassment, discrimination and eviction of black people in China continued.[981]

Information dissemination

Many newspaper agencies removed their online paywalls for some or all of their coronavirus-related articles and posts,[982] while scientific publishers made scientific papers related to the outbreak available with open access.[983] Some scientists chose to share their results quickly on preprint servers such as bioRxiv.[984]

Misinformation

See also

Other Languages

Copyright