COVID-19 pandemic

COVID-19 pandemic
Covid-19 SP - UTI V. Nova Cachoeirinha.jpg
Treating a patient with COVID-19 in critical condition in an ICU
COVID-19 Outbreak World Map Total Deaths per Capita.svg
Confirmed deaths per 100,000 population
as of 15 November 2021
COVID-19 Outbreak World Map per Capita.svg
Cumulative percentage of population infected
as of 28 November 2021
  •   >10%
  •   3–10%
  •   1–3%
  •   0.3–1%
  •   0.1–0.3%
  •   0.03–0.1%
  •   0–0.03%
  •   None or no data
DiseaseCoronavirus disease 2019 (COVID-19)
Virus strainSevere acute respiratory syndrome
coronavirus 2
(SARS‑CoV‑2)
SourceBats,[1] likely indirectly[2]
LocationWorldwide
Index caseWuhan, Hubei, China
30°37′11″N 114°15′28″E / 30.61972°N 114.25778°E / 30.61972; 114.25778
DateNovember 2019 (2019-11) – present
(2 years)
Confirmed cases267,692,393[3]
Deaths
5,277,841[3] (reported)
8.7–20.8 million (estimated)[4][5]

The COVID-19 pandemic, also known as the coronavirus pandemic, is an ongoing global pandemic of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The novel virus was first identified in the Chinese city of Wuhan in December 2019; a lockdown there and in other cities in surrounding Hubei failed to contain the outbreak. The World Health Organization (WHO) declared a Public Health Emergency of International Concern on 30 January 2020, and a pandemic on 11 March 2020. Multiple variants of the virus emerged, led by the Alpha, Beta, Gamma, Delta and Omicron variants. As of 8 December 2021, more than 267 million cases and 5.27 million deaths have been confirmed, making the pandemic one of the deadliest in history.

COVID-19 symptoms range from none to life-threatening. Severe illness is more likely in elderly patients and those with certain underlying medical conditions. COVID-19 is airborne, spread via air contaminated by microscopic particles. The risk of infection is highest among people in close proximity, but can occur over longer distances, particularly indoors in poorly ventilated areas. Transmission can also occur, albeit rarely, via contaminated surfaces or fluids. Infected persons can remain contagious for up to 20 days, and can spread the virus even absent symptoms.

Vaccines have been approved and distributed in various countries. Mass vaccination campaigns began in December 2020. Other recommended preventive measures include social distancing, wearing face masks in public, ventilation/air-filtering, covering one's mouth when sneezing or coughing, hand washing, disinfecting surfaces, and quarantining those who have been exposed or are symptomatic. Treatments focus on addressing symptoms, but work is underway to develop antiviral medications. Governmental interventions include travel restrictions, lockdowns, business closures, workplace hazard controls, testing protocols, and tracing contacts of the infected.

The pandemic triggered severe social and economic disruption around the world, including the largest global recession since the Great Depression.[6] Widespread supply shortages were caused by panic buying, supply chain disruption, and food shortages. The resultant near-global lockdowns saw an unprecedented decrease in the emission of pollutants. Numerous educational institutions and public areas partially or fully closed, and many events were cancelled or postponed. Misinformation circulated through social media and mass media, and political tensions intensified. The pandemic raised issues of racial and geographic discrimination, health equity, and the balance between public health imperatives and individual rights.

Etymology

The pandemic is known by several names. It is often referred to as its colloquial name, "the coronavirus pandemic",[7] despite the existence of other human coronaviruses that have caused epidemics and outbreaks (e.g. SARS).[8]

During the initial outbreak in Wuhan, the virus and disease were commonly referred to as "coronavirus", "Wuhan coronavirus",[9] "the coronavirus outbreak" and the "Wuhan coronavirus outbreak"[10] with the disease sometimes called "Wuhan pneumonia".[11][12] In January 2020, the WHO recommended 2019-nCoV[13] and 2019-nCoV acute respiratory disease[14] as interim names for the virus and disease per 2015 guidance and international guidelines against using geographical locations (e.g. Wuhan, China), animal species, or groups of people in disease and virus names in part to prevent social stigma.[15] The official names COVID-19 and SARS-CoV-2 were issued by the WHO on 11 February 2020.[16] Tedros Adhanom explained: CO for corona, VI for virus, D for disease and 19 for when the outbreak was first identified (31 December 2019).[17] The WHO additionally uses "the COVID-19 virus" and "the virus responsible for COVID-19" in public communications.[16]

Virus variants are also known by multiple names. Initially, they were commonly named after where the variants were identified (e.g. Delta variant was known as the Indian variant).[18] A more systematic naming scheme reflected the variant's PANGO lineage (e.g., Omicron's lineage is B.1.1.529). At the end of May 2021, the WHO introduced a policy of using Greek letters for variants of concern and variants of interest.[19][20][21]

Epidemiology

For country-level data, see:
732-bar-chart
Cases
267,692,393
Deaths
5,277,841
As of 8 December 2021[3]

Background

Although the exact origin of the virus is still unknown,[22] the first known outbreak started in Wuhan, Hubei, China, in November 2019. Many early cases of COVID-19 were linked to people who had visited the Huanan Seafood Wholesale Market in Wuhan,[23][24][25] but it is possible that human-to-human transmission was happening before this.[26][27] SARS-CoV-2 is a newly discovered virus that is closely related to bat coronaviruses,[28] pangolin coronaviruses,[29][30] and SARS-CoV.[31]

The scientific consensus is that the virus is most likely of zoonotic origin, from bats or another closely-related mammal.[26][32] Despite this, the subject has generated extensive speculation.[33][27][34] The origin controversy heightened geopolitical divisions, notably between the United States and China.[35]

The earliest known infected person fell ill on 1 December 2019. That person did not have visible connections with the later wet market cluster.[36][37] However, an earlier case may have occurred on 17 November.[38] Two-thirds of the initial case cluster were linked with the market.[39][40][41] Molecular clock analysis suggests that the index case is likely to have been infected between mid-October and mid-November 2019.[42][43]

Cases

Cumulative confirmed cases by country, as of 1 December 2021
  •   10,000,000+
  •   1,000,000–9,999,999
  •   100,000–999,999
  •   10,000–99,999
  •   1,000–9,999
  •   100–999
  •   1–99
  •   0

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.[44][45] Many countries, early on, had official policies to not test those with only mild symptoms.[46][47] An analysis of the outbreak up to 23 January estimated that 86 percent of COVID-19 infections had not been detected, and that these undocumented infections were the source for 79 percent of documented cases.[48] Several other studies claimed that total infections are considerably greater than reported cases.[49][50]

On 9 April 2020, preliminary results found that in Gangelt, the centre of a major infection cluster in Germany, 15 percent of a population sample tested positive for antibodies.[51] Screening for COVID-19 in pregnant women in New York City, and blood donors in the Netherlands, found rates of positive antibody tests that indicated more infections than reported.[52][53] Seroprevalence-based estimates are conservative as some studies show that persons with mild symptoms do not have detectable antibodies.[54]

An analysis in early 2020 of cases by age in China indicated that a relatively low proportion of cases occurred in individuals under 20.[55] It was not clear whether this was because young people were less likely to be infected, or less likely to develop symptoms and be tested.[56] A retrospective cohort study in China found that children and adults were just as likely to be infected.[57]

Initial estimates of the basic reproduction number (R0) for COVID-19 in January were between 1.4 and 2.5,[58] but a subsequent analysis claimed that it may be about 5.7 (with a 95 percent confidence interval of 3.8 to 8.9).[59] R0 can vary across populations/circumstances and is not to be confused with the effective reproduction number (commonly just called R), which takes into account mitigation efforts and herd immunity.

Deaths

Deceased in a refrigerated "mobile morgue" outside a hospital in Hackensack, New Jersey, U.S.

As of 8 December 2021, more than 5.27 million[3] deaths had been attributed to COVID-19. Official deaths from COVID-19 generally refer to people who died after testing positive. Such counts may ignore deaths of people who die without a test.[61] Conversely, deaths of people who had underlying conditions may lead to over-counting.[62] Comparisons of statistics for deaths for all causes versus multi-year averages reflect excess mortality in many countries.[63][64] These include deaths due to healthcare capacity constraints and priorities.[65]

The first confirmed death was in Wuhan on 9 January 2020.[66] The first reported death outside of China occurred on 1 February 2020 in the Philippines,[67] and the first reported death outside Asia was in the United States on 6 February 2020.[68]

The time between symptom onset and death usually ranges from 6 to 41 days, typically about 14 days.[69] People at the greatest risk of mortality from COVID-19 are the elderly (age 65 years or older) and those with underlying conditions.[70][71] The strongest risk factors for severe illness are obesity, complications of diabetes, anxiety disorders, and the total number of conditions.[72]

Multiple measures are used to quantify mortality.[73] These numbers vary by region and over time, influenced by testing volume, healthcare system quality, treatment options, government response,[74] time since the initial outbreak, and population characteristics, such as age, sex, and overall health.[75] Countries such as Belgium include deaths from suspected cases, including those without a test, thereby increasing counts.[76]

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 1.97 percent (5,277,841 deaths for 267,692,393 cases) as of 8 December 2021.[3] The number varies by region.[77]

Official death counts have been criticised for underreporting the actual death toll, because comparisons of death rates before and during the pandemic show an increase in deaths that is not explained by COVID-19 deaths alone.[4] Using such data, estimates of the true number of deaths from COVID-19 worldwide have included a range from 9.5 to 18.6 million by The Economist, as well as over 10.3 million by the Institute for Health Metrics and Evaluation.[4][5]

Reporting

On 24 March 2020, the United States Centers for Disease Control and Prevention (CDC) indicated the WHO had provided two codes for COVID-19: U07.1 when confirmed by laboratory testing and U07.2 for clinically or epidemiological diagnosis where laboratory confirmation is inconclusive or not available.[78][79] The CDC noted that "Because laboratory test results are not typically reported on death certificates in the US, [the National Center for Health Statistics (NCHS)] is not planning to implement U07.2 for mortality statistics" and that U07.1 would be used "If the death certificate reports terms such as 'probable COVID-19' or 'likely COVID-19'." The CDC also noted "It Is not likely that NCHS will follow up on these cases" and 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."[78]

On 16 April 2020, the WHO, in its formal publication of the two codes, U07.1 and U07.2, "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'."[80][81] It was also noted that the WHO "does not distinguish" between infection by SARS-CoV-2 and COVID-19.[82]

Infection fatality ratio (IFR)

IFR estimate per age group[83]
Age group IFR
0–34 0.004%
35–44 0.068%
45–54 0.23%
55–64 0.75%
65–74 2.5%
75–84 8.5%
85 + 28.3%

A crucial metric in assessing a disease is the infection fatality ratio (IFR), which is the cumulative number of deaths attributed to the disease divided by the cumulative number of infected individuals (including asymptomatic and undiagnosed infections).[84][85][86] Epidemiologists frequently refer to this metric as the 'infection fatality rate' to clarify that it is expressed in percentage points (not as a decimal).[87] Other published studies refer to this metric as the 'infection fatality risk'.[88][89]

In November 2020, a review article in Nature reported estimates of population-weighted IFRs for various countries, excluding deaths in elderly care facilities, and found a median range of 0.24% to 1.49%.[90]

Children and younger adults faced much lower IFRs (e.g., 0.002% at age 10 and 0.01% at age 25) compared with higher IFRs for older adults (0.4% at age 55, 1.4% at age 65, 4.6% at age 75, and 15% at age 85). These rates vary by a factor of ~10,000 across the age groups.[83] For comparison the risk for middle-aged adults of a fatal COVID-19 infection is two orders of magnitude more likely than the annualised risk of a fatal automobile accident and far more dangerous than seasonal influenza.[83]

In December 2020, a systematic review and meta-analysis estimated that population-weighted IFR was 0.5% to 1% in some countries (France, Netherlands, New Zealand, and Portugal), 1% to 2% in other countries (Australia, England, Lithuania, and Spain), and about 2.5% in Italy; these estimates included fatalities in elderly care facilities.[83] This study reported that most of the differences reflected corresponding differences in the population's age structure and the age-specific pattern of infections.

Case fatality ratio (CFR)

Another metric in assessing death rate is the case fatality ratio (CFR),[a] which is the ratio of deaths to diagnoses. This metric can be misleading because of the delay between symptom onset and death and because testing focuses on symptomatic individuals (and particularly on those manifesting more severe symptoms).[82] On 4 August 2020, 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%."[85]

Disease

{{Main|COVID-19}

Signs and symptoms

Symptoms of COVID-19

Symptoms of COVID-19 are variable, ranging from mild symptoms to severe illness.[91][92] Common symptoms include headache, loss of smell and taste, nasal congestion and runny nose, cough, muscle pain, sore throat, fever, diarrhea, and breathing difficulties.[93] People with the same infection may have different symptoms, and their symptoms may change over time. Three common clusters of symptoms have been identified: one respiratory symptom cluster with cough, sputum, shortness of breath, and fever; a musculoskeletal symptom cluster with muscle and joint pain, headache, and fatigue; a cluster of digestive symptoms with abdominal pain, vomiting, and diarrhea.[93] In people without prior ear, nose, and throat disorders, loss of taste combined with loss of smell is associated with COVID-19 and is reported in as many as 88% of cases.[94][95][96]

Of people who show symptoms, 81% develop only mild to moderate symptoms (up to mild pneumonia), while 14% develop severe symptoms (dyspnea, hypoxia, or more than 50% lung involvement on imaging) and 5% of patients suffer critical symptoms (respiratory failure, shock, or multiorgan dysfunction).[97] At least a third of the people who are infected with the virus do not develop noticeable symptoms at any point in time.[98][99] These asymptomatic carriers tend not to get tested and can spread the disease.[99][100][101][102] Other infected people will develop symptoms later, called "pre-symptomatic", or have very mild symptoms and can also spread the virus.[102]

As is common with infections, there is a delay between the moment a person first becomes infected and the appearance of the first symptoms. The median delay for COVID-19 is four to five days.[103] Most symptomatic people experience symptoms within two to seven days after exposure, and almost all will experience at least one symptom within 12 days.[103][104]

Most people recover from the acute phase of the disease. However, some people – over half of a cohort of home-isolated young adults[105][106] – continue to experience a range of effects, such as fatigue, for months after recovery, a condition called long COVID; long-term damage to organs has been observed. Multi-year studies are underway to further investigate the long-term effects of the disease.[107]

Transmission

The respiratory route of spread of COVID-19, encompassing larger droplets and aerosols.

The disease is mainly transmitted via the respiratory route when people inhale droplets and small airborne particles (that form an aerosol) that infected people exhale as they breathe, talk, cough, sneeze, or sing.[108][109][110][111] Infected people are more likely to transmit COVID-19 when they are physically close. However, infection can occur over longer distances, particularly indoors.[108][112]

Infectivity can occur 1-3 days before the onset of symptoms.[113] Infected persons can spread the disease even if they are pre-symptomatic or asymptomatic.[113] Most commonly, the peak viral load in upper respiratory tract samples occurs close to the time of symptom onset and declines after the first week after symptoms begin.[113] Current evidence suggests a duration of viral shedding and the period of infectiousness of up to 10 days following symptom onset for persons with mild to moderate COVID-19, and a up to 20 days for persons with severe COVID-19, including immunocompromised persons.[114][113]

Infectious particles range in size from aerosols that remain suspended in the air for long periods of time to larger droplets that remain airborne or fall to the ground.[115][116][117][118] Additionally, COVID-19 research has redefined the traditional understanding of how respiratory viruses are transmitted.[118][119] The largest droplets of respiratory fluid do not travel far, and can be inhaled or land on mucous membranes on the eyes, nose, or mouth to infect.[117] Aerosols are highest in concentration when people are in close proximity, which leads to easier viral transmission when people are physically close,[117][118][119] but airborne transmission can occur at longer distances, mainly in locations that are poorly ventilated;[117] in those conditions small particles can remain suspended in the air for minutes to hours.[117]

The number of people generally infected by one infected person varies;[120] as only 10 to 20% of people are responsible for the disease's spread.[121] It often spreads in clusters, where infections can be traced back to an index case or geographical location.[122] Often in these instances, superspreading events occur, where many people are infected by one person.[120]

Cause

SARS‑CoV‑2 belongs to the broad family of viruses known as coronaviruses.[123] It is a positive-sense single-stranded RNA (+ssRNA) virus, with a single linear RNA segment. Coronaviruses infect humans, other mammals, including livestock and companion animals, and avian species.[124] Human coronaviruses are capable of causing illnesses ranging from the common cold to more severe diseases such as Middle East respiratory syndrome (MERS, fatality rate ~34%). SARS-CoV-2 is the seventh known coronavirus to infect people, after 229E, NL63, OC43, HKU1, MERS-CoV, and the original SARS-CoV.[125]
Illustration of SARS-CoV-2 virion
Viral genetic sequence data can provide critical information about whether viruses separated by time and space are likely to be epidemiologically linked.[126] With a sufficient number of sequenced genomes, it is possible to reconstruct a phylogenetic tree of the mutation history of a family of viruses. By 12 January 2020, five genomes of SARS‑CoV‑2 had been isolated from Wuhan and reported by the Chinese Center for Disease Control and Prevention (CCDC) and other institutions;[127][128] the number of genomes increased to 42 by 30 January 2020.[129] A phylogenetic analysis of those samples showed they were "highly related with at most seven mutations relative to a common ancestor", implying that the first human infection occurred in November or December 2019.[129] Examination of the topology of the phylogenetic tree at the start of the pandemic also found high similarities between human isolates.[130] As of 21 August 2021, 3,422 SARS‑CoV‑2 genomes, belonging to 19 strains, sampled on all continents except Antarctica were publicly available.[131]

Diagnosis

Demonstration of a nasopharyngeal swab for COVID-19 testing
The standard methods of testing for presence of SARS-CoV-2 are nucleic acid tests,[132][133] which detects the presence of viral RNA fragments.[134] As these tests detect RNA but not infectious virus, its "ability to determine duration of infectivity of patients is limited."[135] The test is typically done on respiratory samples obtained by a nasopharyngeal swab; however, a nasal swab or sputum sample may also be used.[136][137] Results are generally available within hours.[132] The WHO has published several testing protocols for the disease.[138]
Chest CT scans may be helpful to diagnose COVID-19 in individuals with a high clinical suspicion of infection but are not recommended for routine screening.[139][140] Bilateral multilobar ground-glass opacities with a peripheral, asymmetric, and posterior distribution are common in early infection.[139][141] Subpleural dominance, crazy paving (lobular septal thickening with variable alveolar filling), and consolidation may appear as the disease progresses.[139][142] Characteristic imaging features on chest radiographs and computed tomography (CT) of people who are symptomatic include asymmetric peripheral ground-glass opacities without pleural effusions.[143]

Prevention

Without pandemic containment measures – such as social distancing, vaccination, and face masks – pathogens can spread exponentially.[144] This graphic shows how early adoption of containment measures tends to protect wider swaths of the population.

Preventive measures to reduce the chances of infection include getting vaccinated, staying at home, wearing a mask in public, avoiding crowded places, keeping distance from others, ventilating indoor spaces, managing potential exposure durations,[145] washing hands with soap and water often and for at least twenty seconds, practising good respiratory hygiene, and avoiding touching the eyes, nose, or mouth with unwashed hands.[146][147]

Those diagnosed with COVID-19 or who believe they may be infected are advised by the CDC to stay home except to get medical care, call ahead before visiting a healthcare provider, wear a face mask before entering the healthcare provider's office and when in any room or vehicle with another person, cover coughs and sneezes with a tissue, regularly wash hands with soap and water and avoid sharing personal household items.[148][149]

Vaccines

A doctor at Walter Reed National Military Medical Center receiving a COVID-19 vaccination

A COVID‑19 vaccine is a vaccine intended to provide acquired immunity against severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2), the virus that causes coronavirus disease 2019 (COVID‑19). Prior to the COVID‑19 pandemic, an established body of knowledge existed about the structure and function of coronaviruses causing diseases like severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). This knowledge accelerated the development of various vaccine platforms during early 2020.[150] The initial focus of SARS-CoV-2 vaccines was on preventing symptomatic, often severe illness.[151] On 10 January 2020, the SARS-CoV-2 genetic sequence data was shared through GISAID, and by 19 March, the global pharmaceutical industry announced a major commitment to address COVID‑19.[152] The COVID‑19 vaccines are widely credited for their role in reducing the severity and death caused by COVID‑19.[153]

Many countries have implemented phased distribution plans that prioritize those at highest risk of complications, such as the elderly, and those at high risk of exposure and transmission, such as healthcare workers.[154]

On 21 December 2020, the European Union approved the Pfizer BioNTech vaccine. Vaccinations began to be administered on 27 December 2020. The Moderna vaccine was authorised on 6 January 2021 and the AstraZeneca vaccine was authorised on 29 January 2021.[155]

Elderly woman roles up sleeve as two nurses administer a vaccine
Vaccinations at a Retirement home in Gijón, Spain

On 4 February 2020, US Secretary of Health and Human Services Alex Azar published a notice of declaration under the Public Readiness and Emergency Preparedness Act for medical countermeasures against COVID-19, covering "any vaccine, used to treat, diagnose, cure, prevent, or mitigate COVID-19, or the transmission of SARS-CoV-2 or a virus mutating therefrom", and stating that the declaration precludes "liability claims alleging negligence by a manufacturer in creating a vaccine, or negligence by a health care provider in prescribing the wrong dose, absent willful misconduct".[156] On 8 December, it was reported that the AstraZeneca vaccine is about 70% effective, according to a study.[157]

As of mid-August 2021, more than 4.6 billion doses of COVID-19 vaccines had been administered in over 190 countries. The Oxford-AstraZeneca vaccine was the most widely used.[158]

Treatment

No specific, effective treatment or cure is available for COVID-19.[159][160] Thus, the cornerstone of management of COVID-19 is supportive care, which includes treatment to relieve symptoms, fluid therapy, oxygen support and prone positioning as needed, and medications or devices to support other affected vital organs.[161]

A critically ill patient receiving invasive ventilation in the intensive care unit of the Heart Institute, University of São Paulo. Due to a shortage of mechanical ventilators, a bridge ventilator is being used to automatically actuate a bag valve mask.

Most cases of COVID-19 are mild. In these, supportive care includes medication such as paracetamol or NSAIDs to relieve symptoms (fever,[162] body aches, cough), adequate intake of oral fluids and rest.[160][163] Good personal hygiene and a healthy diet are also recommended.[164] The CDC recommends that those who are sick stay home.[165]

More severe cases may need treatment in hospital. In those with low oxygen levels, use of the glucocorticoid dexamethasone is recommended, as it can reduce the risk of death.[166] Noninvasive ventilation and, ultimately, admission to an intensive care unit for mechanical ventilation may be required to support breathing.[167] Extracorporeal membrane oxygenation (ECMO) has been used to address the issue of respiratory failure.[168][169]

Several experimental treatments are undergoing clinical trials.[159] Others thought to be effective, such as hydroxychloroquine and lopinavir/ritonavir, and so-called early treatment are not recommended by US or European health authorities.[159][170][171] Two monoclonal antibody-based therapies are available for early use in high-risk cases.[171] The antiviral remdesivir is available in the US, Canada, Australia, and several other countries, with varying restrictions; however, it is not recommended for use with mechanical ventilation, and is discouraged altogether by the World Health Organization (WHO),[172] due to limited evidence of its efficacy.[159]

Variants

Several variants have been named by WHO and label as a variant of concern (VoC) or a variant of interest (VoI). They share the more infectious D614G mutation:[173][174][175]

Variants
Name Lineage Detected Countries Priority
Alpha B.1.1.7 UK 190 VoC
Beta B.1.351 South Africa 140 VoC
Delta B.1.617.2 India 170 Voc
Gamma P.1 Brazil 90 VoC
Lambda C.37 Peru 30 VoI
Mu B.1.621 Columbia 57 VoI
Omicron B.1.1.529 Botswana 25 VoC[176]

Prognosis

Burial of a deceased COVID-19 patient in Hamadan, Iran, March 2020
The severity of COVID-19 varies. The disease may take a mild course with few or no symptoms, resembling other common upper respiratory diseases such as the common cold. In 3–4% of cases (7.4% for those over age 65) symptoms are severe enough to cause hospitalization.[177] Mild cases typically recover within two weeks, while those with severe or critical diseases may take three to six weeks to recover. Among those who have died, the time from symptom onset to death has ranged from two to eight weeks.[178] The Italian Istituto Superiore di Sanità reported that the median time between the onset of symptoms and death was twelve days, with seven being hospitalised. However, people transferred to an ICU had a median time of ten days between hospitalisation and death.[179] Prolonged prothrombin time and elevated C-reactive protein levels on admission to the hospital are associated with severe course of COVID-19 and with a transfer to ICU.[180][181]

Strategies

Many countries attempted to slow or stop the spread of COVID-19 by recommending, mandating or prohibiting behavior changes, while others relied primarily on providing information. Measures ranged from public advisories to stringent lockdowns. Strategies in the control of an outbreak are containment and mitigation. They can be pursued sequentially or simultaneously.[182]

Goals of mitigation include delaying and reducing peak burden on healthcare (flattening the curve) and lessening overall cases and health impact.[183][184] Moreover, progressively greater increases in healthcare capacity (raising the line) such as by increasing bed count, personnel, and equipment, help to meet increased demand.[185]
The CDC and WHO advise that masks (such as worn here by Taiwanese president Tsai Ing-wen) reduce the spread of SARS-CoV-2.

Containment

Containment is undertaken to stop an outbreak from spreading into the general population. Infected individuals are isolated while they are infectious. The people they have interacted with are contacted and isolated for long enough to ensure that they are either not infected or no longer contagious. Successful containment or suppression reduces Rt to less than 1.[186]

Screening is the starting point for containment. Screening is done by checking for symptoms to identify infected individuals, who can then be isolated and/or offered treatment.[187]

Mitigation

Should containment fail, efforts focus on mitigation: measures taken to slow the spread and limit its effects on the healthcare system and society.

Successful mitigation delays and decreases the epidemic peak, known as "flattening the epidemic curve".[183] This decreases the risk of overwhelming health services and provides more time for developing vaccines and treatments.[183]

Non-pharmaceutical interventions

Non-pharmaceutical interventions that may manage the outbreak include personal actions such as hand hygiene, wearing face masks, and self-quarantine; community measures aimed at reducing interpersonal contacts such as closing workplaces and schools and cancelling mass gathering events; community engagement to encourage acceptance and participation in such interventions; as well as environmental measures such as surface cleaning.[188] Many such measures, such as cleaning surfaces, have been criticised as hygiene theatre.[189]

Other measures

More drastic actions, such as quarantining entire populations and strict travel bans have been attempted in various jurisdictions.[190] China and Australia's lockdowns have been the most strict. New Zealand implemented the most severe travel restrictions. South Korea introduced mass screening and localised quarantines, and issued alerts on the movements of infected individuals. Singapore provided financial support, quarantined, and imposed large fines for those who failed to do so. Taiwan increased face mask production and penalised the hoarding of medical supplies.[191]

Contact tracing

Contact tracing attempts to identify recent contacts of newly-infected individuals, attempting to screen them for infection.[192] The traditional approach is to request a list of contacts from infectees, and then telephone or visit the contacts.

Another approach is to collect location data from mobile devices to identify those who have come in significant contact with infectees, although this has prompted privacy concerns.[193] On 10 April 2020, Google and Apple announced an initiative for privacy-preserving contact tracing.[194][195] In Europe and in the US, Palantir Technologies initially provided COVID-19 tracking services.[196]

Health care

A temporary hospital for COVID-19 patients in Brazil.

Increasing capacity and adapting healthcare for the needs of COVID-19 patients is described by the WHO as a fundamental outbreak response measure.[197] The ECDC and the European regional office of the WHO 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, separating and isolating COVID-19 patients, and increasing intensive care capabilities by training personnel and increasing ventilators and beds.[197][198] The pandemic has driven an explosive increase in telehealth.[199]

Improvised manufacturing

Due to capacity limitations in existing supply chains, some manufacturers began 3D printing material such as nasal swabs and ventilator parts.[200][201] In one example, an Italian startup received legal threats due to alleged patent infringement after reverse-engineering and printing one hundred requested ventilator valves overnight.[202] On 23 April 2020, NASA reported building, in 37 days, a ventilator which is undergoing further testing.[203][204] Individuals and groups of makers created and shared open source designs, and manufacturing devices using locally sourced materials, sewing, and 3D printing. Millions of face shields, protective gowns, and masks were made. Other ad hoc medical supplies included shoe covers, surgical caps, powered air-purifying respirators, and hand sanitizer. Novel devices were created such as ear savers, non-invasive ventilation helmets, and ventilator splitters.[205]

Herd immunity

In July 2021, several experts expressed concern that achieving herd immunity may not currently be possible because the Delta variant is transmitted among those immunized with current vaccines.[206] The CDC published data showing that vaccinated people could transmit the Delta variant, something officials believed was not possible with other variants. Consequently, the WHO and the CDC encourage vaccinated people to continue with preventive measures, such as social distancing and wearing masks indoors.[207]

History

2019

An aerial view of the market, looking like a construction site.
The Huanan Seafood Wholesale Market in March 2020, after it was closed down.
Desc-i.svg
Interactive timeline map of confirmed cases per million people
(drag circle to adjust; may not work on mobile devices)

Although the exact origin of the virus is still unknown, the outbreak was discovered in Wuhan in November 2019. Many early cases of COVID-19 were linked to people who had visited the Huanan Seafood Wholesale Market in Wuhan, but it is possible that human-to-human transmission was happening before this.[26][27] Based on a retrospective analysis starting from December 2019, the number of COVID-19 cases in Hubei gradually increased, reaching 60 by 20 December and at least 266 by 31 December.[208]

On 24 December 2019, Wuhan Central Hospital sent a bronchoalveolar lavage fluid (BAL) sample from an unresolved clinical case to sequencing company Vision Medicals.[209] On 27 and 28 December, Vision Medicals informed the Wuhan Central Hospital and the China CDC (CCDC) of the results of the test, reporting a novel coronavirus.[209][210] A pneumonia cluster of unknown cause was observed on 26 December and treated by Doctor Zhang Jixian in Hubei Provincial Hospital. He informed the Wuhan Jianghan CDC on 27 December.[211]

On 30 December 2019, a test report addressed to Wuhan Central Hospital, from company CapitalBio Medlab, reported an erroneous positive result for SARS, causing doctors at Wuhan Central Hospital to alert their colleagues and hospital authorities. Eight of those doctors, including Li Wenliang (who was also punished on 3 January),[212] were later admonished by the police for spreading false rumours; and another doctor, Ai Fen, was reprimanded by her superiors.[213] That evening, Wuhan Municipal Health Commission (WMHC) issued a notice to various medical institutions about "the treatment of pneumonia of unknown cause".[214] The next day, WMHC made the first public announcement of a pneumonia outbreak of unknown cause, confirming 27 cases[215][216][217]—enough to trigger an investigation.[218]

On 31 December, the WHO office in China was informed of cases of pneumonia of unknown cause in Wuhan.[219][215] An investigation was launched at the start of January 2020.[218]

Official Chinese sources claimed that the early cases were mostly linked to the Huanan Seafood Wholesale Market, which also sold live animals.[220] However, in May 2020, CCDC director George Gao said animal samples collected from the market had tested negative, indicating the market was not the source of the initial outbreak.[221] In March 2021, WHO published their report, concluding that infection via an animal host was the most likely explanation, without ruling out bats or the food supply chain.[2][25]

2020

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

From 31 December 2019 to 3 January 2020, 44 cases of "pneumonia of unknown causes" were reported to WHO by the Chinese authorities.[222] On 11 January, WHO received further information from the Chinese National Health Commission that the outbreak was associated with exposures in the market, and that China had identified a new type of coronavirus, which it isolated on 7 January.[219]

Initially, the number of cases doubled approximately every seven and a half days.[223] In early and mid-January, the virus spread to other Chinese provinces, helped by the Chinese New Year migration. Wuhan served as a transport hub and major rail interchange.[224] On 10 January, the virus' genome was shared through GISAID.[225] A retrospective study published in March found that 6,174 people had reported symptoms by 20 January,[226] while more may have been infected.[227] A 24 January report indicated human transmission, recommended personal protective equipment for health workers, and advocated testing, given the virus' "pandemic potential".[39][228] On 31 January the first published modelling study warned of inevitable "independent self-sustaining outbreaks in major cities globally" and called for "large-scale public health interventions."[229]

On 30 January, 7,818 infections had been confirmed, leading WHO to declare the outbreak a Public Health Emergency of International Concern (PHEIC).[230][231] On 11 March, WHO declared it a pandemic.[232][233]

By 31 January, Italy had its first confirmed infections, in two tourists from China.[234] On 19 March, Italy overtook China as the country with the most reported deaths.[235] By 26 March, the United States had overtaken China and Italy as the country with the highest number of confirmed infections.[236] Genomic analysis indicates the majority of New York confirmed infections came from Europe, rather than directly from Asia.[237] Testing of prior samples revealed a person in France who had an infection on 27 December 2019[238][239] and a person in the United States who died from the disease on 6 February.[240]

A patient in Ukraine in May 2020 wears a scuba mask in the absence of artificial ventilation.

In October, the WHO reported that one in ten people around the world may have been infected, or 780 million people, while only 35 million infections had been confirmed.[241]

On 9 November, Pfizer released trial results for a candidate vaccine, showing that 90% effectiveness against severe infection.[242] That day, Novavax entered an FDA Fast Track application for their vaccine.[243]

On 14 December, Public Health England reported that a variant had been discovered in the UK's southeast, predominantly in Kent. The variant, named Variant of Concern 202012/01, showed changes to the spike protein that could be more infectious. As of 13 December, 1,108 infections had been confirmed.[244]

2021

On 2 January, VOC-202012/01, a variant of SARS-CoV-2 first discovered in the UK, had been identified in 33 countries.[245]

On 6 January, the P.1 variant was first identified in Japanese travellers returning from Brazil.[246]

On 14 January, a team of WHO-led scientists arrived in China to study the virus' origin and trace the intermediate hosts between the original reservoir and humans.[247]

On 29 January, it was reported that the Novavax vaccine was only 49% effective against the 501.V2 variant in a clinical trial in South Africa.[248][249] The China COVID-19 vaccine CoronaVac was reported to be 50.4% effective in a Brazil clinical trial.[250]

On 12 March, several countries stopped using the Oxford-AstraZeneca COVID-19 vaccine due to blood clotting problems, specifically cerebral venous sinus thrombosis (CVST).[251] On 20 March, the WHO and European Medicines Agency found no link to thrombus, leading several countries to resume the vaccine.[252]

In April and May, a severe wave of infections hit India, where the Delta variant was first identified. In mid-April, the variant was first detected in the UK and two months later it has catalysed a third wave in the country, forcing the government to delay the full reopening from lockdown which was originally scheduled on 21 June.[253]

On 11 August, the developers of Sputnik V offered the first component of that two-dose vaccine, 'Sputnik Light' (Ad26), to Pfizer for trial as a booster against the Delta variant.[254][255]

On 31 August, The National Institute for Communicable Diseases (South Africa) indicated a potential variant of interest known as C.1.2; it has been identified in the entire country and abroad.[256]

On 3 September Dr. Anthony Fauci, medical adviser to President Biden and Director of the National Institute of Allergy and Infectious Diseases, indicated that 3 doses of vaccine for COVID-19 will become the new norm.[257]

As of 8 December 2021, more than 267 million cases have been reported worldwide due to COVID-19; more than 5.27 million have died.[3]

National responses

Then-US President Donald Trump signs the Coronavirus Preparedness and Response Supplemental Appropriations Act into law with Alex Azar on 6 March 2020.

Due to the pandemic in Europe, many countries in the Schengen Area have restricted free movement and set up border controls.[258] National reactions have included containment measures such as quarantines and curfews (known as stay-at-home orders, shelter-in-place orders, or lockdowns).[259] The WHO's recommendation on curfews and lockdowns is that they should be short-term measures to reorganise, 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.[260]

By 26 March 2020, 1.7 billion people worldwide were under some form of lockdown,[261] which increased to 3.9 billion people by the first week of April—more than half the world's population.[262][263]

By late April 2020, 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.[264] Nearly 300 million people, or about 90 per cent of the population, were under some form of lockdown in the United States,[265] around 100 million people in the Philippines,[264] about 59 million people in South Africa,[266] and 1.3 billion people have been under lockdown in India.[267][268]

Asia

As of 30 April 2020,[269] cases have been reported in all Asian countries except for Turkmenistan and North Korea, although these countries likely also have cases.[270][271] Despite being the first area of the world hit by the outbreak, the early wide-scale response of some Asian states, particularly Bhutan,[272] Singapore,[273][274] Taiwan[275] and Vietnam[276] has allowed them to fare comparatively well. China is criticised for initially minimising the severity of the outbreak, but the delayed wide-scale response has largely contained the disease since March 2020.[277][278]

In Japan, the pandemic has been believed to have caused direct side effects in regards to mental health. According to the report by the country's National Police Agency, suicides had increased to 2,153 in October 2020. Experts also state that the pandemic has worsened mental health issues due to lockdowns and isolation from family members, among other issues.[279]

China

A temporary hospital constructed in Wuhan in February 2020

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; asymptomatic cases have not been reported prior to 31 March 2020—with 4,634 deaths and 78,509 recoveries,[280] meaning there are only 402 cases. Hubei has the most cases, followed by Xinjiang.[281] By March 2020, COVID-19 infections were largely put under control in China,[277] with minor outbreaks since.[282] It was reported on 25 November 2020, that some 1 million people in the country of China had been vaccinated according to China's state council; the vaccines against COVID-19 came from Sinopharm, which makes the BIBP and WIBP vaccines, and from Sinovac, which makes CoronaVac.[283]

However, throughout the pandemic, multiple sources have cast doubt upon the accuracy of China's official numbers for deaths and infections of COVID-19 during the initial outbreak, with some suggesting intentional suppression of data.[284][285][286]

India

Indian officials conducting temperature checks at the Ratha Yatra Hindu festival on 23 June 2020

The first case of COVID-19 in India was reported on 30 January 2020. India ordered a nationwide lockdown for the entire population starting 24 March 2020,[287] with a phased unlock beginning 1 June 2020. Six cities account for around half of all reported cases in the country—Mumbai, Delhi, Ahmedabad, Chennai, Pune and Kolkata.[288] On 10 June 2020, India's recoveries exceeded active cases for the first time.[289]

On 30 August 2020, India surpassed the US record for the most cases in a single day, with more than 78,000 cases,[290] and set a new record on 16 September 2020, with almost 98,000 cases reported that day.[291] As of 30 August 2020, India's case fatality rate is relatively low at 2.3%, against the global 4.7%.[292][needs update]

As of September 2020, India had the largest number of confirmed cases in Asia;[293] and the second-highest number of confirmed cases in the world,[294] behind the United States,[295] with the number of total confirmed cases breaching the 100,000 mark on 19 May 2020,[296] 1,000,000 on 16 July 2020,[297] and 5,000,000 confirmed cases on 16 September 2020.[298]

On 19 December 2020, India crossed the total number of 10,000,000 confirmed cases but with a slow pace.[299]

The Indian Ministry of Science initiated a mathematical simulation of the pandemic, the so-called "Indian Supermodel", which correctly predicted the decrease of active cases starting in September 2020.[300]

A second wave hit India in April 2021, placing healthcare services under severe strain.[301] By late April, the government was reporting over 300,000 new infections and 2,000 deaths per day, with concerns of undercounting.[302]

Iran

Disinfection of Tehran Metro trains against COVID-19 transmission. Similar measures have also been taken in other countries.[303]

Iran reported its first confirmed cases of SARS-CoV-2 infections on 19 February 2020 in Qom, where, according to the Ministry of Health and Medical Education, two people had died that day.[304][305] Early measures announced by the government included the cancellation of concerts and other cultural events,[306] sporting events,[307] Friday prayers,[308] and closures of universities, higher education institutions, and schools.[309] Iran allocated 5 trillion rials (equivalent to US$120,000,000) to combat the virus.[310] President Hassan Rouhani said on 26 February 2020 there were no plans to quarantine areas affected by the outbreak, and only individuals would be quarantined.[311] Plans to limit travel between cities were announced in March 2020,[312] although heavy traffic between cities ahead of the Persian New Year Nowruz continued.[313] Shia shrines in Qom remained open to pilgrims until 16 March.[314][315]

Iran became a centre of the spread of the virus after China in February 2020.[316][317] 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.[317][318] The Iranian Parliament was shut down, with 23 of its 290 members reported to have had tested positive for the virus on 3 March 2020.[319] On 15 March 2020, the Iranian government reported a hundred deaths in a single day, the most recorded in the country since the outbreak began.[320] At least twelve sitting or former Iranian politicians and government officials had died from the disease by 17 March 2020.[321] By 23 March 2020, Iran was experiencing fifty new cases every hour and one new death every ten minutes due to COVID-19.[322] According to a WHO official, there may be five times more cases in Iran than what is being reported. It is also suggested that US sanctions on Iran may be affecting the country's financial ability to respond to the viral outbreak.[323]

On 20 April 2020, Iran reopened shopping malls and other shopping areas across the country.[324] After reaching a low in new cases in early May, a new peak was reported on 4 June 2020, raising fear of a second wave.[325] On 18 July 2020, President Rouhani estimated that 25 million Iranians had already become infected, which is considerably higher than the official count.[326] Leaked data[who?] suggest that 42,000 people had died with COVID-19 symptoms by 20 July 2020, nearly tripling the 14,405 officially reported by that date.[327]

In August 2021, the pandemic was in its fifth wave in the country with more than 400 deaths in 1 day according to the official reported statistics.[328]

South Korea

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,[329] largely attributed to a gathering in Daegu of the Shincheonji Church of Jesus.[329][330] Shincheonji devotees visiting Daegu from Wuhan were suspected to be the origin of the outbreak.[331][332] By 22 February, among 9,336 followers of the church, 1,261 or about 13 per cent reported symptoms.[333] South Korea declared the highest level of alert on 23 February 2020.[334] On 29 February, more than 3,150 confirmed cases were reported.[335] All South Korean military bases were quarantined after tests showed three soldiers had the virus.[331] Airline schedules were also changed.[336][337]

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.[338][339] Screening methods included mandatory self-reporting of symptoms by new international arrivals through mobile application,[340] drive-through testing for the virus with the results available the next day,[341] and increasing testing capability to allow up to 20,000 people to be tested every day.[342] Despite some early criticisms of President Moon Jae-in's response to the crisis,[343] South Korea's programme is considered a success in controlling the outbreak without quarantining entire cities.[338][344][345]

On 23 March 2020, it was reported that South Korea had the lowest one-day case total in four weeks.[342] On 29 March, it was reported that beginning 1 April all new overseas arrivals will be quarantined for two weeks.[346] Per media reports on 1 April, South Korea has received requests for virus testing assistance from 121 different countries.[347] 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 the second wave of infections,[348] although a WHO official disagreed with that assessment.[349]

Europe

Deaths per 100,000 residents

The global COVID-19 pandemic arrived in Europe with its first confirmed case in Bordeaux, France, on 24 January 2020, and subsequently spread widely across the continent. By 17 March 2020, every country in Europe had confirmed a case,[350] and all have reported at least one death, with the exception of Vatican City.

Italy was the first European nation to experience a major outbreak in early 2020, becoming the first country worldwide to introduce a national lockdown.[351] By 13 March 2020, the World Health Organization (WHO) declared Europe the epicentre of the pandemic[352][353] and it remained so until the WHO announced it has been overtaken by South America on 22 May.[354] By 18 March 2020, more than 250 million people were in lockdown in Europe.[355] Despite deployment of COVID-19 vaccines, Europe became the pandemic's epicentre once again in late 2021.[356]

The European countries with the highest number of confirmed COVID-19 cases are the United Kingdom, Russia, France, Spain, and Italy.[357] The countries with the highest death toll are Russia, the United Kingdom, Italy, France, and Germany, each having reported over 100,000 deaths.

As the outbreak became a major crisis across Europe, national and European Union responses have led to debate over restrictions of civil liberties and the extent of European Union solidarity.

On 21 August, it was reported the COVID-19 cases were climbing among younger individuals across Europe.[358] On 21 November, it was reported by the Voice of America that Europe is the worst hit area by COVID-19, with numbers exceeding 15 million cases.[359]

On 22 November, the WHO indicated that a new surge of the virus in Europe had caused Austria to implement another lockdown, while other countries in the region such as Germany are contemplating a lockdown,due to rising cases, as well.[360]

France

Empty streets in Paris, 2020

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.[238][239] 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.[361][362]

On 13 March, Prime Minister Édouard Philippe ordered the closure of all non-essential public places,[363] and on 16 March, French President Emmanuel Macron announced mandatory home confinement, a policy which was extended at least until 11 May.[364] As of 14 September, France has reported more than 402,000 confirmed cases, 30,000 deaths, and 90,000 recoveries,[365] ranking fourth in number of confirmed cases.[366] In April, there were riots in some Paris suburbs.[367] On 18 May, it was reported that schools in France had to close again after reopening, due to COVID-19 case flare-ups.[368]

On 12 November, it was reported that France had become the worst-hit country by the COVID-19 pandemic, in all of Europe, in the process surpassing Russia. The new total of confirmed cases was more than 1.8 million and counting; additionally it was indicated by the French government that the national lockdown would remain in place.[369]

Italy

Civil Protection volunteers conduct health checks at the Guglielmo Marconi Airport in Bologna on 5 February 2020.

The outbreak was confirmed to have spread to Italy on 31 January 2020, when two Chinese tourists tested positive for SARS-CoV-2 in Rome.[234] Cases began to rise sharply, which prompted the Italian government to suspend all flights to and from China and declare a state of emergency.[370] An unassociated cluster of COVID-19 cases was later detected, starting with 16 confirmed cases in Lombardy on 21 February 2020.[371]

On 22 February 2020, 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.[372] 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."[373][374]

On 4 March 2020, 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,[375] but on 9 March, all sport was suspended completely for at least one month.[376] On 11 March 2020, Prime Minister Conte ordered stoppage of nearly all commercial activity except supermarkets and pharmacies.[377][378]

An exhausted anesthesiologist physician in Pesaro, Italy, March 2020

On 6 March 2020, the Italian College of Anaesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) published medical ethics recommendations regarding triage protocols.[379][380][381] On 19 March 2020, Italy overtook China as the country with the most COVID-19-related deaths in the world after reporting 3,405 fatalities from the pandemic.[382][383] On 22 March 2020, it was reported that Russia had sent nine military planes with medical equipment to Italy.[384] As of 28 March, there were 3,532,057 confirmed cases, 107,933 deaths, and 2,850,889 recoveries in Italy, with a large number of those cases occurring in the Lombardy region.[3] 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.[385] On 19 April 2020, it was reported that the country had its lowest deaths at 433 in seven days and some businesses were asking for a loosening of restrictions after six weeks of lockdown.[386] On 13 October 2020, the Italian government again issued restrictive rules to contain a rise in infections.[387]

On 11 November, it was reported that Silvestro Scotti, president of the Italian Federation of General Practitioners indicated that all of Italy should come under restrictions due to the spread of COVID-19. A couple of days prior Filippo Anelli, president of the National Federation of Doctor's Guilds (FNOMCEO) asked for a complete lockdown of the peninsular nation due to the pandemic.[388] On the 10th, a day before, Italy surpassed 1 million confirmed COVID-19 cases.[389] On 23 November, it was reported that the second wave of the virus has caused some hospitals in Italy to stop accepting patients.[390]

Spain

Residents of Valencia, Spain, maintaining social distancing while queueing (20 March 2020)

The virus was first confirmed to have spread to Spain on 31 January 2020, when a German tourist tested positive for SARS-CoV-2 in La Gomera, Canary Islands.[391] Post-hoc genetic analysis has shown that at least 15 strains of the virus had been imported, and community transmission began by mid-February.[392] By 13 March, cases had been confirmed in all 50 provinces of the country.

A partially unconstitutional lockdown was imposed on 14 March 2020.[393][394] On 29 March, it was announced that, beginning the following day, all non-essential workers were ordered to remain at home for the next 14 days.[395] By late March, the Community of Madrid has recorded the most cases and deaths in the country. Medical professionals and those who live in retirement homes have experienced especially high infection rates.[396] On 25 March, the official death toll in Spain surpassed that of mainland China.[397] On 2 April, 950 people died of the virus in a 24-hour period—at the time, the most by any country in a single day.[398] On 17 May, the daily death toll announced by the Spanish government fell below 100 for the first time,[399] and 1 June was the first day without deaths by COVID-19.[400] The state of alarm ended on 21 June.[401] However, the number of cases increased again in July in a number of cities including Barcelona, Zaragoza and Madrid, which led to reimposition of some restrictions but no national lockdown.[402][403][404][405]

Studies have suggested that the number of infections and deaths may have been underestimated due to lack of testing and reporting, and many people with only mild or no symptoms were not tested.[406][407] Reports in May suggested that, based on a sample of more than 63,000 people, the number of infections may be ten times higher than the number of confirmed cases by that date, and Madrid and several provinces of Castilla–La Mancha and Castile and León were the most affected areas with a percentage of infection greater than 10%.[408][409] There may also be as many as 15,815 more deaths according to the Spanish Ministry of Health monitoring system on daily excess mortality (Sistema de Monitorización de la Mortalidad Diaria – MoMo).[410] On 6 July 2020, the results of a Government of Spain nationwide seroprevalence study showed that about two million people, or 5.2% of the population, could have been infected during the pandemic.[411][412] Spain was the second country in Europe (behind Russia) to record half a million cases.[413] On 21 October, Spain passed 1 million COVID-19 cases, with 1,005,295 infections and 34,366 deaths reported, a third of which occurred in Madrid.[414]

As of September 2021, Spain is one of the countries with the highest percentage of its population vaccinated (76% fully vaccinated and 79% with the first dose),[415] while also being one of the countries more in favor of vaccines against COVID-19 (nearly 94% of its population is already vaccinated or wants to be).[416]

Sweden

Sweden differed from most other European countries in that it mostly remained open.[417] 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.[418][419] 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.[417][420] 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.[421] In the end of June, Sweden no longer had excess mortality.[422]

United Kingdom

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.[423] The UK government started enforcing social distancing and quarantine measures on 18 March 2020[424][425] and was criticised for a perceived lack of intensity in its response to concerns faced by the public.[426][427] 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.[428][429] On 20 March, the government ordered all leisure establishments to close as soon as possible,[430] and promised to prevent unemployment.[431] 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 non-essential businesses were ordered to close.[432]

On 24 April, it was reported that a promising vaccine trial had begun in England; the government pledged more than £50 million towards research.[433] A number of temporary critical care hospitals were built.[434] The first operating was the 4,000-bed NHS Nightingale Hospital London, constructed in just over nine days.[435] On 4 May, it was announced that it would be placed on standby and remaining patients transferred to other facilities;[436] 51 patients had been treated in the first three weeks.[437]

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.[438]

On 2 December, the UK became the first Western country to approve the Pfizer vaccine against the COVID-19 virus; 800,000 doses would be immediately available for use.[439] It was reported on 5 December, that the United Kingdom would begin vaccination against the virus on 8 December, less than a week after having been approved.[440] On 9 December, MHRA stated that any individual with a significant allergic reaction to a vaccine, such as an anaphylactoid reaction, should not take the Pfizer vaccine for COVID-19 protection.[441][442]

North America

The first cases in North America were reported in the United States on 23 January 2020. Cases were reported in all North American countries after Saint Kitts and Nevis confirmed a case on 25 March, and in all North American territories after Bonaire confirmed a case on 16 April.[443]

As of 24 May 2021, Canada has reported 1,361,564 cases and 25,265 deaths,[444] while Mexico has reported 2,396,604 cases and 221,647 deaths.[445] The most cases by state is California with 3,778,711 cases and 62,945 deaths as of 24 May 2021.[446]

United States

The hospital ship USNS Comfort arrives in Manhattan on 30 March 2020.

49,387,208[447] confirmed cases have been reported in the United States with 791,514[447] deaths, the most of any country, and the nineteenth-highest per capita worldwide.[448] As many infections have gone undetected, the Centers for Disease Control and Prevention (CDC) estimated that, as of May 2021, there could be a total 120.2 million infections in the United States, or more than a third of the total population.[449][450] COVID-19 is the deadliest pandemic in U.S. history;[451] it was the third-leading cause of death in the U.S. in 2020, behind heart disease and cancer.[452] From 2019 to 2020, U.S. life expectancy dropped by 3 years for Hispanic Americans, 2.9 years for African Americans, and 1.2 years for white Americans.[453] These effects have persisted as U.S. deaths due to COVID-19 in 2021 exceeded those in 2020.[454]

The first American case was reported on January 20, and President Donald Trump declared the U.S. outbreak a public health emergency on January 31. Restrictions were placed on flights arriving from China,[455][456] but the initial U.S. response to the pandemic was otherwise slow, in terms of preparing the healthcare system, stopping other travel, and testing.[457][458][459][b]

The first known American deaths occurred in February. On March 6, 2020, Trump allocated $8.3 billion to fight the outbreak and declared a national emergency on March 13. The government also purchased large quantities of medical equipment, invoking the Defense Production Act of 1950 to assist.[461] By mid-April, disaster declarations were made by all states and territories as they all had increasing cases. A second wave of infections began in June, following relaxed restrictions in several states, leading to daily cases surpassing 60,000. By mid-October, a third surge of cases began; there were over 200,000 new daily cases during parts of December 2020 and January 2021.[462][463]

COVID-19 vaccines became available in December 2020, under emergency use, beginning the national vaccination program, with the first vaccine officially approved by the Food and Drug Administration (FDA) on August 23, 2021.[464] Studies have shown them to be highly protective against severe illness, hospitalization, and death. In comparison with fully vaccinated people, the CDC found that those who were not vaccinated were from 5 to nearly 30 times more likely to become either infected or hospitalized. There has nonetheless been some vaccine hesitancy for various reasons, although side effects are rare.[465][466][467] There have also been numerous reports that unvaccinated COVID-19 patients have strained the capacity of hospitals throughout the country, forcing many to turn away patients with life-threatening diseases.

South America

The pandemic was confirmed to have reached South America on 26 February 2020 when Brazil confirmed a case in São Paulo.[468] By 3 April, all countries and territories in South America had recorded at least one case.[469]

On 13 May 2020, it was reported that Latin America and the Caribbean had reported over 400,000 cases of COVID-19 infection with, 23,091 deaths. On 22 May 2020, citing the rapid increase of infections in Brazil, the WHO declared South America the epicentre of the pandemic.[470][471]

As of 16 July 2021, South America had recorded 34,359,631 confirmed cases and 1,047,229 deaths from COVID-19. Due to a shortage of testing and medical facilities, it is believed that the outbreak is far larger than the official numbers show.[472]

Brazil

Disinfection of public area in Itapevi, Brazil.

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.[473] 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 controversy by 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 been likened to that of former US President Trump, with Bolsonaro being called the "Trump of the Tropics".[474] Bolsonaro later tested positive for the virus.[475]

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.[476] 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.[477] Brazil briefly paused Phase III trials for the Coronavac COVID-19 vaccine on 10 November after the suicide of a volunteer before resuming on 11 November.[478]

By early 2021, the death toll had climbed to 231,534. The total number of cases on 7 February exceeded 9.5 million. The only countries with worse outbreaks were India and the United States.[479]

Africa

US Air Force personnel unload a C-17 aircraft carrying approximately 1,800 kg (4,000 lb) of medical supplies in Niamey, Niger.

The pandemic was confirmed to have spread to Africa on 14 February 2020, with the first confirmed case announced in Egypt.[480][481] The first confirmed case in sub-Saharan Africa was announced in Nigeria at the end of February 2020.[482] Within three months, the virus had spread throughout the continent, as Lesotho, the last African sovereign state to have remained free of the virus, reported a case on 13 May 2020.[483][484] By 26 May, it appeared that most African countries were experiencing community transmission, although testing capacity was limited.[485] Most of the identified imported cases arrived from Europe and the United States rather than from China where the virus originated.[486]

In early June 2021, Africa faced a third wave of COVID infections with cases rising in 14 countries.[487] By 4 July the continent recorded more than 251,000 new Covid cases, a 20% increase from the prior week and a 12% increase from the January peak. More than sixteen African countries, including Malawi and Senegal, recorded an uptick in new cases.[488] The World Health Organization labelled it Africa's 'Worst Pandemic Week Ever'.[489]

Many preventive measures have been implemented by different countries in Africa. These include travel restrictions, flight cancellations, event cancellations,[490] school closures, and border closures.[491]

It is believed that there is widespread under-reporting in many African countries with less developed healthcare systems.[492] According to the autumn 2020 seroprevalence study in Juba in South Sudan, less than 1% of infected were actually reported.[493]

Oceania

The COVID-19 pandemic was confirmed to have reached Oceania on 25 January 2020 with the first confirmed case reported in Melbourne, Australia.[494] It has since spread elsewhere in the region,[495] although many small Pacific island nations have thus far avoided the outbreak by closing their international borders. Two Oceania sovereign states (Nauru and Tuvalu) and one dependency (Cook Islands) have yet to report an active case. Australia and New Zealand were praised for their handling of the pandemic in comparison to other Western nations, with New Zealand and each state in Australia wiping out all community transmission of the virus several times even after re-introduction in the community.[496][497][498]

As a result of the high transmissibility of the Delta variant however, by August 2021, the Australian states of New South Wales and Victoria had conceded defeat in their eradication efforts.[499] In early October 2021, New Zealand also abandoned its elimination strategy.[500][501]

Antarctica

Due to its remoteness and sparse population, Antarctica was the last continent to have confirmed cases of COVID-19 and was one of the last regions of the world affected directly by the pandemic.[502][503][504] The first cases were reported in December 2020, almost a year after the first cases of COVID-19 were detected in China. At least 36 people are confirmed to have been infected.[505]

International responses

Workers unloading boxes of medical supplies at Villamor Air Base
Donated medical supplies received in the Philippines

The COVID-19 pandemic shook the world's economy, with especially severe economic damage in the United States, Europe, and Latin America.[506] A consensus report by American intelligence agencies in April 2021 concluded, "Efforts to contain and manage the virus have reinforced nationalist trends globally, as some states turned inward to protect their citizens and sometimes cast blame on marginalized groups." Furthermore, COVID-19 has inflamed partisanship and polarisation around the world as bitter arguments explode over whom to scapegoat and whom to help first. The risks include further disruption of international trade and the formation of no-entry enclaves.[507]

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,[508] or for all travellers.[509] 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.[510] 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.[511] 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".[512]

The European Union rejected the idea of suspending the Schengen free travel zone.[513][514]

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,[515] Sri Lanka, Australia, France, Argentina, Germany, and Thailand were among the first to plan the evacuation of their citizens.[516] Brazil and New Zealand also evacuated their own nationals and some other people.[517][518] On 14 March 2020, 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.[519] Pakistan said it would not evacuate citizens from China.[520]

On 15 February 2020, the US announced it would evacuate Americans aboard the cruise ship Diamond Princess,[521] and on 21 February, Canada evacuated 129 Canadian passengers from the ship.[522] In early March, the Indian government began evacuating its citizens from Iran.[523][524] On 20 March, the United States began to partially withdraw its troops from Iraq due to the pandemic.[525]

United Nations response measures

In June 2020, the Secretary-General of the United Nations launched the "UN Comprehensive Response to COVID-19".[526] The United Nations Conference on Trade and Development (UNSC) has been criticised 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.[527]

WHO response measures

World Health Organization representatives holding joint meeting with Tehran city administrators in March 2020

The WHO is a leading organisation involved in the global coordination for mitigating the pandemic.

The WHO has spearheaded several initiatives like the COVID-19 Solidarity Response Fund to raise money for the pandemic response, the UN COVID-19 Supply Chain Task Force, and the solidarity trial for investigating potential treatment options for the disease. The WHO's COVAX vaccine-sharing program aims to distribute 2 billion doses of COVID-19 vaccine for free or at a reduced cost by the end of 2021, and has begun distributing them.

The WHO's handling of the initial outbreak of the pandemic has required a "diplomatic balancing act" between member states, in particular between the United States and China. On August 27, the WHO announced the setting up of an independent expert Review Committee to examine aspects of the international treaty that governs preparedness and response to health emergencies. A WHO-led international mission arrived in China in January 2021 to investigate the origins of the COVID-19 pandemic and released preliminary findings in February 2021.

Protests against governmental measures

In several countries, protests have risen against governmental restrictive responses to the COVID-19 pandemic, such as lockdowns. A February 2021 study found that large protest rallies against COVID-19 measures are likely to directly increase the spread of viruses, including COVID-19.[528]

Impact

Economics

The outbreak is a major destabilising threat to the global economy. 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.[529] Global stock markets fell on 24 February due to a significant rise in the number of COVID-19 cases outside China.[530][531] On 27 February, due to mounting worries about the COVID-19 outbreak, US 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)[532] and all three major indexes ending the week down more than 10 per cent.[533] On 28 February, Scope Ratings GmbH affirmed China's sovereign credit rating but maintained a Negative Outlook.[534] Stocks plunged again due to COVID-19 fears, the largest fall being on 16 March.[535]

Lloyd's of London estimated that the global insurance industry will absorb losses of US$204 billion, exceeding the losses from the 2017 Atlantic hurricane season and 11 September attacks, suggesting the COVID-19 pandemic will likely go down in history as the costliest disaster ever in human history.[536]

A highway sign in Toronto discouraging non-essential travel in March 2020

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.[537] The cruise line industry was hard hit,[538] and several train stations and ferry ports have also been closed.[539] International mail between some countries stopped or was delayed due to reduced transportation between them or suspension of domestic service.[540]

The retail sector has been impacted globally, with reductions in store hours or temporary closures.[541] Visits to retailers in Europe and Latin America declined by 40 per cent. North America and Middle East retailers saw a 50–60 per cent drop.[542] This also resulted in a 33–43 per cent 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.[543]

A socially distanced homeless encampment in San Francisco, California, in May 2020

Hundreds of millions of jobs could be lost globally.[544][545] More than 40 million Americans lost their jobs and filed unemployment insurance claims.[546] The economic impact and mass unemployment caused by the pandemic has raised fears of a mass eviction crisis,[547][548] with an analysis by the Aspen Institute indicating between 30 and 40 million Americans are at risk for eviction by the end of 2020.[549][550] According to a report by Yelp, about 60% of US businesses that have closed since the start of the pandemic will stay shut permanently.[551]

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.[552] According to the World Bank, up to 100 million more people globally could fall into extreme poverty due to the shutdowns.[553][554] The International Labour Organization (ILO) informed that the income generated in the first nine months of 2020 from work across the world dropped by 10.7 per cent, or $3.5 trillion, amidst the COVID-19 outbreak.[555]

Supply shortages

COVID-19 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 factory and logistic operations.[556] 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).[557] The technology industry, in particular, has warned of delays to shipments of electronic goods.[558] 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.[559][560] It has also caused a shortage of personal protective equipment worldwide, with the WHO warning that this will endanger health workers.[561]

The impact of the COVID-19 outbreak was worldwide. The virus created a shortage of precursors (raw material) used in the manufacturing of fentanyl and methamphetamine.[562] Price increases and shortages in these illegal drugs have been noticed on the streets of the UK.[563]

The pandemic has disrupted global food supplies and threatens to trigger a new food crisis.[564][565] In April 2020, David Beasley, head of the World Food Programme (WFP), said "we could be facing multiple famines of biblical proportions within a short few months."[566] 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.[566][567][568]

Oil and other energy markets

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.[569] 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.[570] June prices were down but in the positive range, with a barrel of West Texas trading above $20.[570]

The 2021 global energy crisis was driven by a global surge in demand as the world quit the economic recession caused by COVID-19, particularly due to strong energy demand in Asia.[571][572][573]

Culture

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

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. 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.[574] Some services continued through digital platforms,[575][576][577] such as live streaming concerts[578] or web-based arts festivals.[579]

Politics

Meeting of the Italian government task force to face the coronavirus outbreak, 23 February 2020
An Italian government task force meets to discuss COVID-19 in February 2020

The pandemic has affected the political systems of multiple countries, causing suspensions of legislative activities,[580] isolations or deaths of multiple politicians,[581] and rescheduling of elections due to fears of spreading the virus.[582]

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.[583]

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;[584][585] 172 UN Member States and Observers signed a non-binding statement in support of the appeal in June,[586] and the UN Security Council passed a resolution supporting it in July.[587][588]

China

The government of China has been criticised by the United States,[589] the UK Minister for the Cabinet Office Michael Gove,[590] and others[591] 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 CCP general secretary Xi Jinping from the controversy.[592] The US intelligence community claims China intentionally under-reported its number of COVID-19 cases.[593] The Chinese government maintains it has acted swiftly and transparently.[594][595] However, journalists and activists who have reported on the pandemic have been detained by authorities,[596][597] such as Zhang Zhan, who was arrested and tortured for reporting on the pandemic and the detainment of other independent journalists.[598][599][600]

Italy

In early March, the Italian government criticised the EU's lack of solidarity with COVID-19-affected Italy[601][602]—Maurizio Massari, Italy's ambassador to the EU, said "only China responded bilaterally", not the EU.[603] 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.[604] President of Lombardy Attilio Fontana and Italian Foreign Minister Luigi Di Maio expressed their gratitude for the aid.[605] Russia also sent a cargo plane with medical aid to the United States.[606] Kremlin spokesman Dmitry Peskov said "when offering assistance to US colleagues, [Putin] assumes that when US manufacturers of medical equipment and materials gain momentum, they will also be able to reciprocate if necessary."[607] In early April, Norway and EU states like Romania and Austria started to offer help by sending medical personnel and disinfectant,[608] and Ursula von der Leyen offered an official apology to the country.[609]

United States

Several hundred anti-lockdown protesters rallied at the Ohio Statehouse on 20 April 2020.[610]

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.[611][612][613] Political analysts believe it may have contributed to Donald Trump's loss in the 2020 presidential election.[614][615] Beginning in mid-April 2020, there were protests in several US states against government-imposed business closures and restricted personal movement and association.[616] Simultaneously, protests ensued by essential workers in the form of a general strike.[617] In early October 2020, Donald Trump, his family members, and many other government officials were diagnosed with COVID-19, further disrupting the country's politics.[618]

Other countries

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, was held on a reduced scale.[619][620] 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 US and the many European countries participating but the inhabitants of the countries in which they are operating."[621]

The Iranian government has been heavily affected by the virus, with about two dozen parliament members and political figures infected.[318][622] 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.[623] Saudi Arabia, which launched a military intervention in Yemen in March 2015, declared a ceasefire.[624]

Diplomatic relations between Japan and South Korea worsened due to the pandemic.[625] 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.[626] 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.[343]

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.[627][628] In the Philippines, lawmakers granted president Rodrigo Duterte temporary emergency powers during the pandemic.[629] 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.[630] In some countries, including Egypt,[631] Turkey,[632] and Thailand,[629] opposition activists and government critics have been arrested for allegedly spreading fake news about the COVID-19 pandemic.[633]

In India, journalists criticising the government's response were arrested or issued warnings by police and authorities.[634] Rates of imprisoned or detained journalists increased worldwide, with some being related to the pandemic.[635][636]

Agriculture and food systems

The COVID-19 pandemic has disrupted agricultural and food systems worldwide.[637] 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.[638] 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.[638][639][640][641] 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.[637][638]

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 UN called a crisis "of biblical proportions,"[642] or "hunger pandemic."[643] 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.[644][642][645] This pandemic, in conjunction with the 2019–2021 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 per cent of the global population in some way.[646] 55 countries are reported to be at risk, with three dozen succumbing to crisis-level famines or above in the worst-case scenario.[647] 265 million people are forecast to be in famine conditions, an increase of 125 million due to the pandemic.[644]

Education

Students take end-of-year exams in Tabriz, Iran, during the pandemic.
The pandemic has severely impacted educational systems globally. Most governments have temporarily closed educational institutions, with many switching to online education. As of September 2020, approximately 1.077 billion learners were affected due to school closures in response to the pandemic. According to UNICEF monitoring, as of March 2020, 53 countries had closed all schools and 27 some, impacting about 61.6 per cent of the world's student population.[648] School closures impact not only students, teachers, and families but have far-reaching economic and societal consequences. They shed light on social and economic issues, including student debt, digital learning, food insecurity, and homelessness, as well as access to childcare, health care, housing, internet, and disability services. The impact has been more severe for disadvantaged children and their families.[649]

The Higher Education Policy Institute conducted a report which discovered that around 63% of students claimed that their mental health had been worsened as a result of the COVID-19 pandemic, and alongside this 38% demonstrated satisfaction with the accessibility of mental health services. Despite this, the director for policy and advocacy at the institute has explained that it is still unclear as to how and when normality will resume for students regarding their education and living situation.[650]

Other health issues

The pandemic has had many impacts on global health beyond those caused by the COVID-19 disease itself. It has led to a reduction in hospital visits for other reasons. There have been 38 per cent fewer hospital visits for heart attack symptoms in the United States and 40 per cent fewer in Spain.[651] The head of cardiology at the University of Arizona said, "My worry is some of these people are dying at home because they're too scared to go to the hospital."[652] There is also concern that people with strokes and appendicitis are not seeking timely treatment.[652] Shortages of medical supplies have impacted people with various conditions.[653]

In several countries there has been a marked reduction of spread of sexually transmitted infections, including HIV/AIDS, attributable to COVID-19 quarantines, social distancing measures, and recommendations to not engage in casual sex.[654][655] Similarly, in some places, rates of transmission of influenza and other respiratory viruses significantly decreased during the pandemic.[656][657][658]

The pandemic has also negatively impacted mental health globally, including increased loneliness resulting from social distancing[659] and depression and domestic violence from lockdowns.[660] As of June 2020, 40% of U.S. adults were experiencing adverse mental health symptoms, with 11% having seriously considered trying to kill themselves in the past month.[661] The research data suggest that the pandemic has negative effects on both weight loss and food health monitoring but the effects were short lived results.[662]

Paying attention and taking measures to prevent mental health problems and post-traumatic stress syndrome, particularly in women, is already a need.[663]

Environment and climate

Images from the NASA Earth Observatory show a stark drop in pollution in Wuhan, when comparing NO2 levels in early 2019 (top) and early 2020 (bottom).[664]

As of November 2021, the continuing COVID-19 pandemic had killed over 5 million people.[665] As a result of the severity of the virus, most countries enacted lockdowns to protect people, mitigate the spread, and ensure space in hospitals.[666] These lockdowns disrupted everyday life worldwide, decreasing the level and frequency of human activity and production. Despite the severity of these circumstances, there were clear positive effects on the environment and climate as a result of human inactivity. As human activity slowed globally (commonly referred to as "anthropause"), a substantial decrease in fossil fuel use, resource consumption, and waste disposal was observed, generating less air and water pollution in many regions of the world.[667] Specifically, there was a sharp and lasting decline in planned air travel and vehicle transportation throughout the COVID-19 pandemic. In China, lockdowns and other measures resulted in a 25% reduction in carbon emissions, 26% decrease in coal consumption, and a 50% reduction in nitrogen oxides emissions.[667] Earth systems scientist Marshall Burke estimated that two months of pollution reduction likely saved the lives of 77,000 Chinese residents.[668]

Other positive effects on the environment included governance-system-controlled investments towards a sustainable energy transition and other goals related to environmental protection. One of these investments was the European Union's seven-year €1 trillion budget proposal and €750 billion recovery plan, "Next Generation EU," which seeks to reserve 25% of EU spending for climate-friendly expenditure.[669][670][671]

However, decreased human activity during the pandemic diverted attention from illegal activities such as deforestation of the Amazon rainforest and increased poaching in Africa.[672][673][674] The hindrance of environmental diplomacy efforts in combination with late capitalism also created economic fallout that some predict will slow investment in green energy technologies.[675][676][677]

Another negative side effect of COVID-19 included a global increase of biomedical waste due to hospitals treating a larger than normal number of patients. The extra precautionary disinfection measures required when treating COVID patients played a role in excess medical waste. This required a larger than normal number of masks, gloves, needles, syringes, and medications.[667]

Discrimination and prejudice

Heightened prejudice, xenophobia, and racism have been documented around the world toward people of Chinese and East Asian descent.[678][679][680] Reports from February 2020 (when most confirmed cases were confined to China) documented racist sentiments expressed in groups worldwide about Chinese people 'deserving' the virus.[681][682][683] Chinese people and other Asian peoples in the United Kingdom and United States have reported increasing levels of racist abuse and assaults.[684][685][686] Former US President Donald Trump was criticised for referring to the COVID-19 as the "Chinese Virus" and "Kung Flu", which has been condemned as racist and xenophobic.[687][688][689]

Age-based discrimination against older adults, while already present before the pandemic, was more prevalent during the pandemic. This has been attributed to their perceived vulnerability to the virus and subsequent physical and social isolation measures, which, coupled with their already reduced social activity, has increased dependency on others. Similarly, limited digital literacy has left the elderly more vulnerable to the effects of isolation, depression, and loneliness.[690]

Lifestyle changes

The pandemic has resulted in many people adapting to massive changes in life, from increased internet commerce activity to the job market. Social distancing has caused increased sales from large e-commerce companies such as Amazon, Alibaba, and Coupang. Online retailers in the US posted 791.70 billion dollars in sales in 2020, an increase of 32.4% from 598.02 billion dollars from the year before.[691] The trend of home delivery orders have increased due to the pandemic, with indoor dining restaurants shutting down due to lockdown orders or low sales.[692][693] Hackers and cybercriminals/scammers have started targeting people due to the massive changes, with some pretending to be part of the CDC, and others using different phishing schemes.[694] Education worldwide has increasingly shifted from physical attendance to video conferencing apps such as Zoom as lockdown measures have resulted in schools being forced to shut down.[695] Due to the pandemic, mass layoffs have occurred in the airline, travel, hospitality, and some other industries. (There were no signs of permanent recovery as of May 2021.)[696][697]

Information dissemination

Ongoing COVID-19 research is indexed and searchable in the NIH COVID-19 Portfolio.[698] Some newspaper agencies removed their online paywalls for some or all of their COVID-19-related articles and posts,[699] while scientific publishers made scientific papers related to the outbreak available with open access.[700][701] Some scientists chose to share their results quickly on preprint servers such as bioRxiv.[702]

Maps have played a key role in disseminating information concerning the spatial distribution of the disease, especially with the development of dashboards to present data in near real-time. Methods of data visualisation have drawn some criticism, however, in the over-simplification of geographical patterns indicated by choropleth maps that adopt national, rather than local, map scales.[703]

Misinformation

COVID-19 misinformation refers to misinformation and conspiracy theories about the scale of the COVID-19 pandemic and the origin, prevention, diagnosis, and treatment of the disease COVID-19, which is caused by the virus SARS-CoV-2. False information, including intentional disinformation, has been spread through social media, text messaging,[704] and mass media. False information has been propagated by celebrities, politicians, and other prominent public figures. Multiple countries have passed laws against "fake news", and thousands of people have been arrested for spreading COVID-19 misinformation. The spread of COVID-19 misinformation by governments has also been significant.

Commercial scams have claimed to offer at-home tests, supposed preventives, and "miracle" cures.[705] Several religious groups have claimed their faith will protect them from the virus.[706] Without evidence, some people have claimed the virus is a bioweapon accidentally or deliberately leaked from a laboratory, a population control scheme, the result of a spy operation, or the side effect of 5G upgrades to cellular networks.[707]

The World Health Organization (WHO) declared an "infodemic" of incorrect information about the virus that poses risks to global health.[708] While belief in conspiracy theories is not a new phenomenon, in the context of the COVID-19 pandemic, this can lead to adverse health effects. Cognitive biases, such as jumping to conclusions and confirmation bias, may be linked to the occurrence of conspiracy beliefs.[709] In addition to health effects, harms resulting from the spread of misinformation and endorsement of conspiracy theories include increasing distrust of news organizations and medical authorities as well as divisiveness and political fragmentation.[710]

See also

Notes

  1. ^ Some refer to 'fatality rate'; however 'fatality ratio' is more accurate as this is not per unit time.[85]
  2. ^ A lack of mass testing obscured the extent of the outbreak.[460]

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