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COVID-19 pandemic

Map of confirmed cases per capita as of 5 May 2020

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Total confirmed cases map

Map of total confirmed cases as of 5 May 2020

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Confirmed deaths per capita map

Map of confirmed deaths per capita as of 5 May 2020

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Confirmed cases per capita interactive timeline

Cumulative per capita confirmed COVID-19 cases

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1,000+ confirmed cases per million

100-1,000 confirmed cases per million

10-100 confirmed cases per million

>0-10 confirmed cases per million

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Disease

Coronavirus disease 2019 (COVID-19)

Virus strain

Severe acute respiratory syndrome
coronavirus 2 (SARS‑CoV‑2)[a]

Source

Likely bats, possibly via pangolins[2][3]

Location

Worldwide ( list of locations)

First outbreak

China[4]

Index case

Wuhan, Hubei, China
30°37′11″N 114°15′28″E ﻿ / ﻿ 30.61972°N 114.25778°E

Date

December 2019[4] - present
(5 months and 1 week)

Confirmed cases

3,659,271[5][b]

Active cases

2,205,195[5]

Recovered

1,197,340[5]

256,736[5]

187[5]

The COVID-19 pandemic, also known as the coronavirus pandemic, is an ongoing pandemic of coronavirus disease 2019 (COVID‑19) caused by severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2). The outbreak was identified in Wuhan, China, in December 2019. The World Health Organization declared the outbreak a Public Health Emergency of International Concern on 30 January, and a pandemic on 11 March. As of 5 May 2020, more than 3.65 million cases of COVID-19 have been reported in over 187 countries and territories, resulting in more than 256,000 deaths. More than 1.19 million people have recovered.

The virus is primarily spread between people during close contact, often via small droplets produced by coughing, sneezing, and talking. The droplets, although produced when breathing out, usually fall to the ground or onto surfaces rather than remaining in the air over long distances. People may also become infected by touching a contaminated surface and then touching their face. On surfaces, the amount of virus declines over time until it is insufficient to remain infectious, but it may be detected for hours or days. It is most contagious during the first three days after the onset of symptoms, although spread may be possible before symptoms appear and in later stages of the disease.

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

Recommended preventive measures include hand washing, covering one's mouth when coughing, maintaining distance from other people, wearing a face mask in public settings, and monitoring and self-isolation for people who suspect they are infected. Authorities worldwide have responded by implementing travel restrictions, quarantines, curfews and stay-at-home orders, workplace hazard controls, and facility closures. Many places have also worked to increase testing capacity and trace contacts of infected persons.

The pandemic has caused severe global socioeconomic disruption, including the largest global recession since the Great Depression. It has led to the postponement or cancellation of sporting, religious, political and cultural events, widespread supply shortages exacerbated by panic buying, and decreased emissions of pollutants and greenhouse gases. Schools, universities and colleges have closed either on a nationwide or local basis in 194 countries, affecting approximately 98.5 per cent of the world's student population. Misinformation about the virus has spread online, and there have been incidents of xenophobia and discrimination against Chinese people and against those perceived as being Chinese, or as being from areas with high infection rates.

Epidemiology

Health authorities in Wuhan, Hubei, China, reported a cluster of viral pneumonia cases of unknown cause on 31 December 2019, and an investigation was launched in early January 2020. These cases mostly had links to the Huanan Seafood Wholesale Market and so the virus is thought to have a zoonotic origin. The virus that caused the outbreak is known as SARS‑CoV‑2, a newly discovered virus closely related to bat coronaviruses, pangolin coronaviruses, and SARS-CoV. The scientific consensus is that COVID-19 has a natural origin.

The earliest known person with symptoms was later discovered to have fallen ill on 1 December 2019, and that person did not have visible connections with the later wet market cluster. Of the early cluster of cases reported that month, two-thirds were found to have a link with the market. On 13 March 2020, an unverified report from the South China Morning Post suggested a case traced back to 17 November 2019 (a 55-year-old from Hubei) may have been the first infection.

Cases refers to the number of people who have been tested for COVID-19, and whose test has been confirmed positive according to official protocols. As of 29 April, the countries that made public their testing data have on average performed a number of tests equal to only 1.4 per cent of their population, while no country has tested samples equal to more than 14 per cent of its population. Many countries have had official policies to not test those with only mild symptoms. An analysis of the early phase of the outbreak up to 23 January estimated 86 per cent of COVID-19 infections had not been detected, and that these undocumented infections were the source for 79 per cent of documented cases. Several other studies, using a variety of methods, have estimated that numbers of infections in many countries are likely to be considerably greater than the reported cases.

On 9 April 2020, preliminary results found that 15 per cent of people tested in Gangelt, the centre of a major infection cluster in Germany, tested positive for antibodies. Screening for COVID-19 in pregnant women in New York City, and blood donors in the Netherlands, has also found a number of positive tests that may indicate infections may be higher than reported. However, such antibody surveys can be unreliable due to a selection bias in who volunteers to take the tests, and due to false positives. Some results (such as the Gangelt study) have received substantial press coverage without first passing through peer review.

Initial estimates of the basic reproduction number (R 0) for COVID-19 in January were between 1.4 and 2.5, but a subsequent analysis has concluded that it may be about 5.7 (with a 95 percent confidence interval of 3.8 to 8.9).

Semi-log graph showing the total (cumulative) number of confirmed cases from the first reported date for the ten most affected countries

Official deaths from the COVID-19 generally refer to people who died after testing positive according to official protocols. This may ignore deaths of people who die without testing, e.g. at home or in nursing homes. Conversely, deaths of people who had underlying conditions may lead to overcounting. Comparison of statistics for deaths for all causes versus the seasonal average indicates excess mortality in many countries. In the worst affected areas, mortality has been several times higher than average. In New York City, deaths have been four times higher than average, in Paris twice as high, and in many European countries deaths have been on average 20 to 30 per cent higher than normal. This excess mortality may include deaths due to strained healthcare systems and bans on elective surgery.

Other measures include the case fatality rate (CFR), which reflects the percentage of diagnosed people who die from a disease, and the infection fatality rate (IFR), which reflects the percentage of infected (diagnosed and undiagnosed) who die from a disease. These statistics are not timebound and follow a specific population from infection through case resolution. Our World in Data states that as of 25 March 2020 the IFR cannot be accurately calculated as neither the total number of cases nor the total deaths, is known. In February the World Health Organization estimated the IFR at 0.37 per cent to 2.9 per cent. The University of Oxford's Centre for Evidence-Based Medicine (CEBM) estimates a global CFR of 0.72 per cent and IFR of 0.1 per cent to 0.41 per cent.

The WHO said on 11 March 2020 the pandemic could be controlled. The peak and ultimate duration of the outbreak are uncertain and may differ by location. Maciej Boni of Penn State University said, "Left unchecked, infectious outbreaks typically plateau and then start to decline when the disease runs out of available hosts. But it's almost impossible to make any sensible projection right now about when that will be". The Chinese government's senior medical adviser Zhong Nanshan argued that "it could be over by June" if all countries can be mobilised to follow the WHO's advice on measures to stop the spread of the virus. On 17 March, Adam Kucharski of the London School of Hygiene & Tropical Medicine said SARS‑CoV‑2 "is going to be circulating, potentially for a year or two". According to the Imperial College study led by Neil Ferguson, physical distancing and other measures will be required "until a vaccine becomes available (potentially 18 months or more)". William Schaffner of Vanderbilt University said, "I think it's unlikely that this coronavirus-because it's so readily transmissible-will disappear completely" and it "might turn into a seasonal disease, making a comeback every year". The virulence of the comeback would depend on herd immunity and the extent of mutation.

Signs and symptoms

Symptoms of COVID-19 can be relatively non-specific and infected people may be asymptomatic. The two most common symptoms are fever (88 per cent) and dry cough (68 per cent). Less common symptoms include fatigue, respiratory sputum production ( phlegm), loss of the sense of smell, loss of taste, shortness of breath, muscle and joint pain, sore throat, headache, chills, vomiting, hemoptysis, and diarrhea.

Further development of the disease can lead to potentially fatal complications including pneumonia, acute respiratory distress syndrome, sepsis, septic shock, and kidney failure.

Some of those infected may be asymptomatic, with no clinical symptoms but test results that confirm infection, so researchers have issued advice that those with close contact to confirmed infected people should be closely monitored and examined to rule out infection. Chinese estimates of the asymptomatic ratio range from few to 44 per cent. The usual incubation period (the time between infection and symptom onset) ranges from one to 14 days; it is most commonly five days.

Transmission

As COVID-19 is a new disease, many aspects as to how it spreads are being researched. The disease is spread during close contact, often by small droplets produced during coughing, sneezing, or talking. During close contact, (1 to 2 metres, 3 to 6 feet), people catch the disease after inhaling contaminated droplets that were exhaled by infected people. However, the droplets are relatively heavy and usually fall to the ground or surfaces, as opposed to being infectious over large distances.

Loud talking releases more droplets than normal talking.

After the droplets fall to floors or surfaces, they still can infect other people, if they touch contaminated surfaces and then their eyes, nose or mouth with unwashed hands. On surfaces the amount of active virus decreases over time until it can no longer cause infection. However, experimentally, the virus can survive on various surfaces for some time, (for example copper or cardboard for a few hours, and plastic or steel for a few days). Surfaces are easily decontaminated with household disinfectants which kill the virus outside the human body or on the hands. Notably, however, disinfectants or bleach should never be swallowed or injected as a treatment or preventative measure, as this is harmful to the body and potentially fatal.

Sputum and saliva carry large amounts of virus. Some medical procedures may result in the virus being transmitted easier than normal for such small droplets, known as airborne transmission.

The virus is most contagious during the first three days after onset of symptoms, although spread is known to occur up to two days before symptoms appear (presymptomatic transmission) and in later stages of the disease. Some people have been infected and recovered without showing symptoms, but uncertainties remain in terms of asymptomatic transmission.

Although COVID-19 is not a sexually transmitted infection, kissing, intimate contact, and faecal oral routes are suspected to transmit the virus.

Severe acute respiratory syndrome coronavirus2 (SARS‑CoV‑2) is a novel virus, first isolated from three people with pneumonia connected to the cluster of acute respiratory illness cases in Wuhan. All features of the novel SARS‑CoV‑2 virus occur in related coronaviruses in nature.

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

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

Viral testing

The standard test for current infection with SARS-CoV-2 uses RNA testing of respiratory secretions collected using a nasopharyngeal swab, though it is possible to test other samples. This test uses real-time rRT-PCR which detects presence of viral RNA fragments.

A number of laboratories and companies are developing serological tests, which detect antibodies produced by the body in response to infection. As of 6April 2020, none of these has been proved sufficiently accurate to be approved for widespread use.

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

Prevention

Strategies for preventing transmission of the disease include maintaining overall good personal hygiene, washing hands, avoiding touching the eyes, nose, or mouth with unwashed hands, and coughing or sneezing into a tissue and putting the tissue directly into a waste container. Those who may already have the infection have been advised to wear a surgical mask in public. Physical distancing measures are also recommended to prevent transmission. Health care providers taking care of someone who may be infected are recommended to use standard precautions, contact precautions, and eye protection.

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

Hand washing

Hand washing is recommended to prevent the spread of the disease. The CDC recommends that people wash hands often with soap and water for at least twenty seconds, especially after going to the toilet or when hands are visibly dirty; before eating; and after blowing one's nose, coughing, or sneezing. This is because outside the human body, the virus is killed by household soap, which bursts its protective bubble. CDC further recommended using an alcohol-based hand sanitiser with at least 60 per cent alcohol by volume when soap and water are not readily available. The WHO advises people to avoid touching the eyes, nose, or mouth with unwashed hands. It is not clear if washing hands with ash if soap is not available is effective at reducing the spread of viral infections.

Surface cleaning

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

Face masks and respiratory hygiene

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

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

Social distancing

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

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

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

In late March 2020, the WHO and other health bodies began to replace the use of the term "social distancing" with "physical distancing", to clarify that the aim is to reduce physical contact while maintaining social connections, either virtually or at a distance. The use of the term "social distancing" had led to implications that people should engage in complete social isolation, rather than encouraging them to stay in contact with others through alternative means.

Self-isolation

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

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

Management

Containment and mitigation

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

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

Contact tracing

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

Several mobile apps have been implemented or proposed for voluntary use, and as of 7April 2020 more than a dozen expert groups were working on privacy-friendly solutions such as using Bluetooth to log a user's proximity to other cellphones. Users could then receive a message if they've been in close contact with someone who has subsequently tested positive for COVID-19.

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

Health care

Increasing capacity and adapting healthcare for the needs of COVID-19 patients is described by the WHO as a fundamental outbreak response measure. The ECDC and the European regional office of the WHO have issued guidelines for hospitals and primary healthcare services for shifting of resources at multiple levels, including focusing laboratory services towards COVID-19 testing, cancelling elective procedures whenever possible, separating and isolating COVID-19 positive patients, and increasing intensive care capabilities by training personnel and increasing the number of available ventilators and beds.

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

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

There are several theories about where the very first case (the so-called patient zero) may have originated. The first known case may trace back to 1 December 2019 in Wuhan, Hubei, China. Over the next month, the number of coronavirus cases in Hubei gradually increased. According to official Chinese sources these were mostly linked to the Huanan Seafood Wholesale Market, which also sold live animals, and one theory is that the virus came from one of these animals.

A pneumonia cluster of unknown cause was observed on 26 December and treated by the doctor Zhang Jixian in Hubei Provincial Hospital, who informed the Wuhan Jianghan CDC on 27 December. On 30 December, a group of doctors at Wuhan Central Hospital alerted their colleagues of a "SARS-like coronavirus". Eight of these doctors, including Li Wenliang (punished on 3January), were then admonished by the police for spreading supposedly false rumours, and another, Ai Fen, was reprimanded by her superiors for raising the alarm.

The Wuhan Municipal Health Commission made the first public announcement of a pneumonia outbreak of unknown cause on 31 December, confirming 27 cases-enough to trigger an investigation.

During the early stages of the outbreak, the number of cases doubled approximately every seven and a half days. In early and mid-January 2020, the virus spread to other Chinese provinces, helped by the Chinese New Year migration and Wuhan being a transport hub and major rail interchange. On 20 January, China reported nearly 140 new cases in one day, including two people in Beijing and one in Shenzhen. Later official data shows 6,174 people had already developed symptoms by then, and more may have been infected. A report in on 24 January indicated human transmission, strongly recommended personal protective equipment for health workers, and said testing for the virus was essential due to its "pandemic potential". On 30 January, the WHO declared that the coronavirus was a public health emergency of international concern.

By 26 March, the United States had overtaken China and Italy with the highest number of confirmed cases in the world. Research on coronavirus genomes indicates the majority of COVID-19 cases in New York came from European travellers, rather than directly from China or any other Asian country. Retesting of prior samples found a person in France who had the virus on 27 December 2019 and a person in the United States who died from the disease on 6February 2020.

National responses

A total of 187 countries and territories have had at least one case of COVID-19 so far. Due to the pandemic in Europe, many countries in the Schengen Area have restricted free movement and set up border controls. National reactions have included containment measures such as quarantines and curfews (known as stay-at-home orders, shelter-in-place orders, or lockdowns).

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

By late April, around 300 million people were under lockdown in nations of Europe, including but not limited to Italy, Spain, France, and the United Kingdom, while around 200 million people were under lockdown in Latin America. Nearly 300 million people, or about 90 per cent of the population, were under some form of lockdown in the United States, around 100 million people in the Philippines, about 59 million people in South Africa, and 1.3 billion people have been under lockdown in India.

As of 30 April 2020, cases have been reported in all Asian countries except for Turkmenistan and North Korea, although some suspect that these countries also have cases.

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

On 20 January, the Chinese National Health Commission announced that human-to-human transmission of the coronavirus had already occurred. That same day, Chinese Communist Party general secretary Xi Jinping and State Council premier Li Keqiang issued their first public comments about the virus, telling people in infected areas to practice social distancing and avoid travel. During the Chinese New Year travel period in late January, Chinese authorities instigated a lockdown of the City of Wuhan. However, travellers from Wuhan had already transported the virus to some Asian countries, the Chinese government launched a radical campaign described on 10 February by paramount leader and Chinese Communist Party general secretary Xi as a " people's war" to contain the spread of the virus. In what has been described as "the largest quarantine in human history", a cordon sanitaire was announced on 23 January stopping travel in and out of Wuhan, which was extended to a total of fifteen cities in Hubei, affecting a total of about 57 million people. Private vehicle use was banned in the city. Chinese New Year (25 January) celebrations were cancelled in many places. The authorities also announced the construction of a temporary hospital, Huoshenshan Hospital, which was completed in ten days. Another hospital, Leishenshan Hospital, was built afterwards to handle additional patients. In addition to newly constructed hospitals, China also converted other facilities in Wuhan, such as convention centres and stadiums, into temporary hospitals.

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

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

On 23 March 2020, China had only one case transmitted domestically in the five days prior, in this instance via a traveller returning to Guangzhou from Istanbul. On 24 March, Chinese Premier Li Keqiang reported that the spread of domestically transmitted cases has been basically blocked and the outbreak has been controlled in China. The same day travel restrictions were eased in Hubei, apart from Wuhan, two months after the lockdown was imposed.

The State Council declared a day of mourning to begin with a national three-minute moment of silence on 4April, coinciding with Qingming Festival, although the central government asked families to pay their respects online in observance of physical distancing to avoid a renewed COVID-19 outbreak. On 25 April the last patients were discharged in Wuhan.

South Korea

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, largely attributed to a gathering in Daegu of the Shincheonji Church of Jesus. Shincheonji devotees visiting Daegu from Wuhan were suspected to be the origin of the outbreak. As of 22 February, among 9,336 followers of the church, 1,261 or about 13 per cent reported symptoms.

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

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

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 over what they said was government mishandling of the outbreak, or praising his response. On 23 March, it was reported that South Korea had the lowest one-day case total in four weeks. On 29 March it was reported that beginning 1April all new overseas arrivals will be quarantined for two weeks. Per media reports on 1April, South Korea has received requests for virus testing assistance from 121 different countries.

Iran reported its first confirmed cases of SARS‑CoV‑2 infections on 19 February in Qom, where, according to the Ministry of Health and Medical Education, two people died later that day. Early measures announced by the government included the cancellation of concerts and other cultural events, sporting events, and Friday prayers, and closures of universities, higher education institutions, and schools. Iran allocated five trillion rials to combat the virus. 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. Plans to limit travel between cities were announced in March, although heavy traffic between cities ahead of the Persian New Year Nowruz continued. Shia shrines in Qom remained open to pilgrims until 16 March.

Iran became a centre of the spread of the virus after China during February. More than ten countries had traced their cases back to Iran by 28 February, indicating the extent of the outbreak may have been more severe than the 388 cases reported by the Iranian government by that date. The Iranian Parliament was shut down, with 23 of its 290 members reported to have had tested positive for the virus on 3 March. On 15 March, the Iranian government reported a hundred deaths in a single day, the most recorded in the country since the outbreak began. At least twelve sitting or former Iranian politicians and government officials had died from the disease by 17 March. By 23 March, Iran was experiencing fifty new cases every hour and one new death every ten minutes due to coronavirus. According to a WHO official, there may be five times more cases in Iran than what is being reported. It is also suggested that U.S. sanctions on Iran may be affecting the country's financial ability to respond to the viral outbreak. The UN High Commissioner for Human Rights has demanded economic sanctions to be eased for nations most affected by the pandemic, including Iran. On 20 April it was reported that Iran had reopened shopping malls and other shopping areas across the country, though there is fear of a second wave of infection due to this move. On 27 April it was reported that 700 people had died from ingesting methanol, falsely believed to be a cure.

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

On 22 February, the Council of Ministers announced a new decree-law to contain the outbreak, including quarantining more than 50,000 people from eleven different municipalities in northern Italy. 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."

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

On 6 March, the Italian College of Anaesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) published medical ethics recommendations regarding triage protocols that might be employed. On 19 March, Italy overtook China as the country with the most coronavirus-related deaths in the world after reporting 3,405 fatalities from the pandemic. On 22 March, it was reported that Russia had sent nine military planes with medical equipment to Italy. As of 12 April, there were 152,271 confirmed cases, 19,468 deaths, and 32,534 recoveries in Italy, with the majority of those cases occurring in the Lombardy region. 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. On 19 April it was reported that the country had its lowest deaths at 433 in seven days, some businesses after six weeks of lockdown are asking for a loosening of restrictions.

United Kingdom

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

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

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

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

To ensure the health services always had sufficient capacity to treat people with COVID-19, a number of temporary critical care hospitals were built around the United Kingdom. The first to be operational was the 4000-bed capacity NHS Nightingale Hospital London, constructed within the ExCeL convention centre over nine days. On 4May, it was announced that the Nightingale Hospital in London would be placed on standby and remaining patients transferred to other facilities. This comes after reports that NHS Nightingale in London "treated 51 patients" within the first three weeks of opening.

Although it was originally thought that 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 tested positive for the virus on 27 December 2019 after retesting old samples. 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.

On 13 March, Prime Minister Édouard Philippe ordered the closure of all non-essential public places, and on 16 March, French President Emmanuel Macron announced mandatory home confinement, a policy which has been extended at least until 11 May. As of 23 April, France has reported over 120,804 confirmed cases, 21,856 deaths, and 42,088 recoveries, ranking fourth in number of confirmed cases. In April, there were riots in some Paris suburbs.

North America

The first cases in North America were reported in the United States in 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.

On 26 March 2020, the U.S. became the country with the highest number of confirmed COVID-19 infections, with over 82,000 cases. On 11 April 2020, the U.S. became the country with the highest official death toll for COVID-19, with over 20,000 deaths. As of May 2, 2020 the total cases of COVID-19 were 1,092,815, with 64,238 total deaths.

Canada reported 60,616 cases and 3,842 deaths on 4 May, while Mexico reported 23,471 cases and 2,154 deaths. The Dominican Republic and Cuba are the only Caribbean countries reporting more than 1,000 cases (7,954 and 1,649, respectively), while Panama and Honduras lead Central America with 7,197 and 1,055 cases, respectively.

United States

On 20 January, the first known case of COVID-19 was confirmed in the Pacific Northwest state of Washington in a man who had returned from Wuhan on 15 January. The White House Coronavirus Task Force was established on 29 January. On 31 January, the Trump administration declared a public health emergency, and restricted entry for travellers from China who were not citizens of the United States.

On 28 January 2020, the Centers for Disease Control and Prevention -the leading public health institute of the U.S. government-announced they had developed their own testing kit. Despite this, the United States had a slow start in testing, which obscured the extent of the outbreak. Testing was marred by defective test kits produced by the federal government in February, a lack of federal government approval for non-government test kits (by academia, companies and hospitals) until the end of February, and restrictive criteria for people to qualify for a test until early March (a doctor's order was required thereafter).

After the first death in the United States was reported in Washington state on 29 February, Governor Jay Inslee declared a state of emergency, an action soon followed by other states. Schools in the Seattle area cancelled classes on 3 March, and by mid-March, schools across the country were shutting down.

On 6 March 2020, the United States was advised of projections for the impact of the new coronavirus on the country by a group of scientists at Imperial College London. On the same day, President Trump signed the Coronavirus Preparedness and Response Supplemental Appropriations Act, which provided $8.3 billion in emergency funding for federal agencies to respond to the outbreak. Corporations imposed employee travel restrictions, cancelled conferences, and encouraged employees to work from home. Sports events and seasons were cancelled.

On 11 March, Trump announced travel restrictions for most of Europe for 30 days, effective 13 March. The following day, he expanded the restrictions to include the United Kingdom and Ireland. On 13 March, he declared a national emergency, which made federal funds available to respond to the crisis. Beginning on 15 March, many businesses closed or reduced hours throughout the U.S. to try to reduce the spread of the virus. By 17 March, the epidemic had been confirmed in all fifty states and in the District of Columbia.

On 25 March, New York's governor said social distancing seemed to be working, as estimates of case doubling slowed from 2.0 days to 4.7 days. On 26 March, the United States had more confirmed cases than any other country. U.S. federal health inspectors surveyed 323 hospitals in late March; reporting "severe shortages" of test supplies, "widespread shortages" of personal protective equipment (PPE), and other strained resources due to extended patient stays while awaiting test results.

As of 24 April, 889,309 cases have been confirmed in the United States, and 50,256 people have died. Media reports on 30 March said President Trump had decided to extend social distancing guidelines until 30 April. On the same day, the USNS Comfort, a hospital ship with about a thousand beds, made anchor in New York. On 3April, the U.S. had a record 884 deaths due to the coronavirus in a 24-hour period. In the state of New York, cases exceeded 100,000 people on 3April.

More than 30 million Americans lost their jobs and applied for government aid. The White House has been criticised for downplaying the threat and controlling the messaging by directing health officials and scientists to coordinate public statements and publications related to the virus with the office of Vice-President Mike Pence. Overall approval of Trump's management of the crisis has been polarised along partisan lines. Some U.S. officials and commentators criticised U.S. reliance on importation of critical materials, including essential medical supplies, from China.

On 14 April, President Trump halted funding to the World Health Organization, stating they had mismanaged the current pandemic. In late April, President Trump said he would sign an executive order to temporarily suspend immigration to the United States because of the pandemic. There were American claims that China had suppressed information, and on 22 April U.S. Secretary of State Mike Pompeo alleged on Fox News that China had denied U.S. scientists permission to enter the country to ascertain the origin of the current pandemic, but he did not give details of any requests for such visits. On 22 April it was reported that two Californians died from the virus (not, as previously thought, influenza) on 6and 17 February, three weeks before the first official coronavirus case in the U.S. had been acknowledged.

South America

The COVID-19 pandemic was confirmed to have reached South America on 26 February when Brazil confirmed a case in São Paulo. By 3 April, all countries and territories in South America had recorded at least one case. Brazil has the most number of reported cases in South America. Ecuador may be particularly strongly affected; it was described in April as emerging as the "epicentre" of the pandemic in Latin America, with thousand of excess deaths reported in one province alone compared to the figures for a normal period.

Cases have been confirmed in most African countries and territories. According to Michael Yao, WHO's head of emergency operations in Africa, early detection is vital because the continent's health systems "are already overwhelmed by many ongoing disease outbreaks". Advisers say that a strategy based on testing could allow African countries to minimise lockdowns that inflict enormous hardship on those who depend on income earned day by day to be able to feed themselves and their families. Even in the best scenario, the United Nations says 74 million test kits and 30,000 ventilators will be needed by the continent's 1.3 billion people in 2020. Most of the reported cases are from four countries: South Africa, Morocco, Egypt and Algeria, but it is believed that there is widespread under-reporting in other African countries with poorer health care systems. As of 2 May, cases have been confirmed in all African countries except for Lesotho. There have been no reported cases in the British Overseas Territory of Saint Helena, Ascension and Tristan da Cunha.

International responses

Travel restrictions

Evacuation of foreign citizens

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

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

International aid

Phase I: Aid to China

On 5 February, the Chinese foreign ministry said 21 countries (including Belarus, Pakistan, Trinidad and Tobago, Egypt, and Iran) had sent aid to China. Some Chinese students at American universities joined together to help send aid to virus-stricken parts of China, with a joint group in the greater Chicago area reportedly managing to send 50,000 N95 masks to hospitals in the Hubei province on 30 January.

The humanitarian aid organisation Direct Relief, in coordination with FedEx, sent 200,000 face masks along with other personal protective equipment, including gloves and gowns, by emergency airlift to the Wuhan Union Hospital by 30 January. On 5 February, Bill and Melinda Gates announced a $100 million donation to the WHO to fund vaccine research and treatment efforts along with protecting "at-risk populations in Africa and South Asia". Interaksyon reported that the Chinese government donated 200,000 masks to the Philippines on 6February, after Philippine senator Richard Gordon shipped 3.16 million masks to Wuhan. On 19 February, the Singapore Red Cross announced that it would send $2.26 million worth of aid to China.

Several countries donated masks, medical equipment or money to China, including Japan (one million face masks), Turkey, Russia, Malaysia (18 million medical gloves), Germany (10,000 Hazmat suits), and Canada. The U.S. State Department said on February7 it has facilitated the transportation of nearly 17.8 tons of medical supplies to China, including masks, gowns, gauze, respirators, and other vital materials. On the same day, U.S. Secretary of State Pompeo announced a $100 million pledge to China and other countries to assist with their fights against the virus, though on 21March, China said it had not received epidemic funding from U.S. government and reiterated that on 3April.

Phase II: Aid to the globe

After cases in China stabilised, the country began sending aid to other nations. In March, China, Cuba and Russia sent medical supplies and experts to help Italy deal with its coronavirus outbreak; China sent three medical teams and donated over forty tons of medical supplies to Italy. The Spectator USA, citing an unnamed senior Trump administration official, said China had sold back to Italy the same PPE Italy had donated to China. Businessman Jack Ma sent 1.1 million testing kits, 6 million face masks, and 60,000 protective suits to Addis Ababa, Ethiopia for distribution by the African Union. He later sent 5,000 testing kits, 100,000 face masks and 5 ventilators to Panama.

The Netherlands, Spain, Turkey, Georgia, and the Czech Republic expressed their concerns over Chinese-made masks and test kits. For instance, Spain withdrew 58,000 Chinese-made coronavirus testing kits with an accuracy rate of just 30 per cent, meanwhile, the Netherlands recalled 600,000 Chinese face masks which were said to defective, although this could have been due to misuse of these products. Belgium recalled 100,000 unusable masks, thought to be from China, but were in fact from Colombia. The Philippines had to stop using the test kits donated by China due to their 40 per cent accuracy. The Chinese government says many issues might be caused by not following product instructions, and that some products were not purchased directly from qualified companies certified by the Chinese government, On the other hand, Chinese aid has been well-received in parts of Latin America and Africa. On 2April, the World Bank launched emergency support operations for developing countries. According to a statement from Ministry of Foreign Affairs, Turkey provides the largest amount of humanitarian aid in the world while ranking third worldwide in supplying medical aid.

WHO response measures

The WHO has commended Chinese authorities, noting the contrast between the 2002-2004 SARS outbreak when they were accused of secrecy and the current crisis where the central government "has provided regular updates". Critics have said the WHO handled the pandemic inadequately, the public health emergency declaration and pandemic classification coming too late.

December 2019

China and Taiwan both notified the WHO of a new virus on 31 December 2019. Taiwan and the WHO later got into a dispute about the content of Taiwan's message and the WHO's lack of response to the state, which is not a WHO member due to diplomatic pressure from China.

January 2020

The WHO issued its first technical briefings on 10 and 11 January, warning nations about a strong possibility of human-to-human transmission and urged precautions due to the similarity to earlier SARS and MERS outbreaks. On 20 January, the WHO said it was "now very clear" that human-to-human transmission of the coronavirus had occurred, given that healthcare workers had been infected. On 27 January, the WHO assessed the risk of the outbreak to be "high at the global level".

On 30 January, the WHO declared the outbreak a Public Health Emergency of International Concern (PHEIC), warning that "all countries should be prepared for containment, including active surveillance, early detection, isolation and case management, contact tracing and prevention of onward spread" of the virus. The announcement came after an increase in the number of cases outside China. This was the sixth-ever PHEIC since the measure was first invoked during the 2009 swine flu pandemic. WHO Director-General Tedros Adhanom said the PHEIC was due to "the risk of global spread, especially to low- and middle-income countries without robust health systems [and] there is no reason for measures that unnecessarily interfere with international travel and trade. WHO doesn't recommend limiting trade and movement. We call on all countries to implement decisions that are evidence-based and consistent."

February 2020

On 11 February, the WHO in a press conference established COVID-19 as the name of the disease. On the same day, Tedros said UN Secretary-General António Guterres had agreed to provide the "power of the entire UN system in the response". A UN Crisis Management Team was activated as a result, allowing coordination of the entire United Nations response, which the WHO states will allow them to "focus on the health response while the other agencies can bring their expertise to bear on the wider social, economic and developmental implications of the outbreak".

On 25 February, the WHO declared that "the world should do more to prepare for a possible coronavirus pandemic," stating that while it was still too early to call it a pandemic, countries should nonetheless be "in a phase of preparedness".

On 28 February, WHO officials said the coronavirus threat assessment at the global level would be raised from "high" to "very high", its highest level of alert and risk assessment. Mike Ryan, executive director of the WHO's health emergencies program, warned that "This is a reality check for every government on the planet: Wake up. Get ready. This virus may be on its way and you need to be ready," urging that the right response measures could help the world avoid "the worst of it". Ryan further stated that the current data did not warrant public health officials to declare a global pandemic, saying such a declaration would mean "we're essentially accepting that every human on the planet will be exposed to that virus."

Public health

The pandemic has led to a reduction in hospital visits for reasons other than COVID-19. There has been 38 per cent fewer hospital visits for heart attack symptoms in the United States and 40 per cent fewer in Spain. 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." There is also concern that people with strokes and appendicitis are not seeking timely treatment.

The Chinese government has been criticised by the United States government, UK Minister for the Cabinet Office Michael Gove, and others for its handling of the pandemic. A number of provincial-level administrators of the Communist Party of China were dismissed over their handling of the quarantine efforts in central China, a sign of discontent with their response to the outbreak. Some commentators believed this move was intended to protect Chinese Communist Party general secretary Xi Jinping from the controversy. Some Chinese officials, including Zhao Lijian, rejected an earlier acknowledgement of the coronavirus outbreak starting in Wuhan, in favour of conspiracy theories that the virus originated in the U.S. or Italy. The United States government has referred to the coronavirus as "Chinese virus" or "Wuhan virus", which has been criticised for being racist and "distract[ing] from his administration's failure to contain the disease". The Daily Beast obtained a U.S. government cable outlining a communications strategy with apparent origins in the National Security Council, quoted as "Everything is about China. We're being told to try and get this messaging out in any way possible".

The U.S. intelligence community says China intentionally under-reported its number of coronavirus cases. Some outlets such as and Foreign Policy have said China's efforts to send aid to virus-stricken countries is part of a propaganda push for global influence. EU foreign policy chief Josep Borrell warned there is "a geo-political component including a struggle for influence through spinning and the 'politics of generosity'". Borrell also said "China is aggressively pushing the message that, unlike the U.S., it is a responsible and reliable partner." China has also called for the U.S. to lift its sanctions from Syria, Venezuela and Iran, while reportedly sending aid to the latter two countries. Jack Ma's donation of 100,000 masks to Cuba was blocked by U.S. sanctions on 3April. U.S. authorities have also been diverting aid meant for other nations to their own country. There have been mask-related disputes reported between other countries as well, including Australia, Austria, Germany, the Netherlands, Switzerland, Turkey, the Czech Republic and Italy.

In early March, the Italian government criticised the European Union's lack of solidarity with coronavirus-affected Italy, with Maurizio Massari, Italy's ambassador to the EU, saying that "only China responded bilaterally", not the EU. 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. President of Lombardy Attilio Fontana and Italian Foreign Minister Luigi Di Maio expressed their gratitude for the aid. Russia also sent a cargo plane with medical aid to the United States. Kremlin spokesman Dmitry Peskov said "when offering assistance to U.S. colleagues, [Putin] assumes that when U.S. manufacturers of medical equipment and materials gain momentum, they will also be able to reciprocate if necessary."

United States

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

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, will be held on a reduced scale. The Campaign for Nuclear Disarmament's general secretary Kate Hudson criticised the exercise, saying "it jeopardises the lives not only of the troops from the U.S. and the many European countries participating but the inhabitants of the countries in which they are operating."

The Iranian government has been heavily affected by the virus, with around two dozen parliament members infected as well as fifteen other current or former political figures. Iran's President Hassan Rouhani wrote a public letter to world leaders asking for help on 14 March 2020, saying his country was struggling to fight the outbreak due to lack of access to international markets as a result of the United States sanctions against Iran. Saudi Arabia, which launched a military intervention in Yemen in March 2015, declared a ceasefire.

Diplomatic relations between Japan and South Korea worsened due to the pandemic. 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. 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.

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. In the Philippines, lawmakers granted president Rodrigo Duterte temporary emergency powers during the pandemic. 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. In some countries, including Egypt, Turkey, and Thailand, opposition activists and government critics have been arrested for allegedly spreading fake news on coronavirus.

The pandemic has affected educational systems worldwide, leading to the near-total closures of schools, universities and colleges.

As of 27 April 2020, approximately 1.725 billion learners are currently affected due to school closures in response to the pandemic. According to UNICEF monitoring, 186 countries are currently implementing nationwide closures and 8 are implementing local closures, impacting about 98.5 per cent of the world's student population. On 23 March 2020, Cambridge International Examinations (CIE) released a statement announcing the cancellation of Cambridge IGCSE, Cambridge O Level, Cambridge International AS & A Level, Cambridge AICE Diploma, and Cambridge Pre-U examinations for the May/June 2020 series across all countries. International Baccalaureate exams have also been cancelled.

School closures impact not only students, teachers, and families, but have far-reaching economic and societal consequences. School closures in response to COVID-19 have shed light on various 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 was more severe for disadvantaged children and their families, causing interrupted learning, compromised nutrition, childcare problems, and consequent economic cost to families who could not work.

In response to school closures, UNESCO recommended the use of distance learning programmes and open educational applications and platforms that schools and teachers can use to reach learners remotely and limit the disruption of education.

Socioeconomics

Supply impacts

The coronavirus 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. The technology industry, in particular, has warned of delays to shipments of electronic goods. According to WHO director-general Tedros Adhanom, the 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. It has also caused a shortage of personal protective equipment worldwide, with the WHO warning that this will endanger health workers.

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

Economic impacts

The outbreak is a major destabilising threat to the global economy. Agathe Demarais of the Economist Intelligence Unit has forecast that markets will remain volatile until a clearer image emerges on potential outcomes. In January 2020, some analysts estimated the economic fallout of the epidemic on global growth could surpass that of the 2002-2004 SARS outbreak. 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. Global stock markets fell on 24 February due to a significant rise in the number of COVID-19 cases outside China. On 27 February, due to mounting worries about the coronavirus outbreak, U.S. stock indexes posted their sharpest falls since 2008, with the Dow falling 1,191 points (the largest one-day drop since the financial crisis of 2007-08) and all three major indexes ending the week down more than 10 per cent. On 28 February, Scope Ratings GmbH affirmed China's sovereign credit rating, but maintained a Negative Outlook. Stocks plunged again due to coronavirus fears, the largest fall being on 16 March. Many consider an economic recession likely.

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. The cruise line industry was hard hit, and several train stations and ferry ports have also been closed.

According to a United Nations Economic Commission for Latin America estimate, the pandemic-induced recession could leave 14-22million more people in extreme poverty in Latin America than would have been in that situation without the pandemic. The pandemic has disrupted global food supplies and threatens to trigger a new food crisis. David Beasley, head of the World Food Programme (WFP), said "we could be facing multiple famines of biblical proportions within a short few months."

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

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

The Vatican announced that Holy Week observances in Rome, which occur during the last week of the Christian penitential season of Lent, have been cancelled. Many dioceses have recommended older Christians to stay at home rather than attending Mass on Sundays; some churches have made church services available via radio, online live streaming or television while others are offering drive-in worship. With the Roman Catholic Diocese of Rome closing its churches and chapels and St. Peter's Square emptied of Christian pilgrims, other religious bodies also cancelled services and limited public gatherings in churches, mosques, synagogues, temples and gurdwaras. Iran's Health Ministry announced the cancellation of Friday prayers in areas affected by the outbreak and shrines were later closed, while Saudi Arabia banned the entry of foreign pilgrims as well as its residents to holy sites in Mecca and Medina.

The pandemic has caused the most significant disruption to the worldwide sporting calendar since the Second World War. Most major sporting events have been cancelled or postponed, including the 2019-20 UEFA Champions League, 2019-20 Premier League, UEFA Euro 2020, 2019-20 NBA season, and 2019-20 NHL season. The outbreak disrupted plans for the 2020 Summer Olympics, which were originally scheduled to start at the end of July; the International Olympic Committee announced on 24 March that they will be "rescheduled to a date beyond 2020 but not later than summer 2021".

The entertainment industry has also been affected, with many music groups suspending or cancelling concert tours. Many large theatres such as those on Broadway also suspended all performances. Some artists have explored ways to continue to produce and share work over the internet as an alternative to traditional live performance, such as live streaming concerts or creating web-based "festivals" for artists to perform, distribute, and publicise their work. Online, numerous coronavirus-themed Internet memes have spread as many turn to humour and distraction amid uncertainty.

Environment and climate

Xenophobia and racism

Since the start of the outbreak of COVID-19, heightened prejudice, xenophobia, and racism have been documented around the world toward people of Chinese and East Asian descent, Reports from February (when most cases were confined to China) documented racist sentiments expressed in groups worldwide about Chinese people deserving the virus. Citizens in countries including Malaysia, New Zealand, Singapore, Japan, Vietnam, and South Korea lobbied to ban Chinese people from entering their countries. Chinese people and other Asians in the United Kingdom and United States have reported increasing levels of racist abuse and assaults. U.S. president Donald Trump has been criticised for referring to the coronavirus as the "Chinese Virus", which critics say is racist and anti-Chinese.

Following the progression of the outbreak to new hotspot countries, people from Italy (the first country in Europe to experience a serious outbreak of COVID-19) were also subjected to suspicion and xenophobia, as were people from hotspots in other countries. Discrimination against Muslims in India escalated after public health authorities identified an Islamic missionary group's gathering in New Delhi in early March 2020 as a source of spread. Paris has seen riots break out over police treatment of ethnic minorities during the coronavirus lockdown.

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

Information dissemination

Many newspapers with paywalls have removed them for some or all of their coronavirus coverage. Many scientific publishers made scientific papers related to the outbreak available with open access. Some scientists chose to share their results quickly on preprint servers such as bioRxiv.

Misinformation

The pandemic has resulted in conspiracy theories and misinformation regarding its origin, scale, and the prevention, diagnosis, and treatment of COVID-19. False information, including intentional disinformation, has been spread through social media, text messages, and mass media, including the state media of countries such as China, Russia, Iran, and Turkmenistan. It has been propagated by celebrities, politicians (including heads of state in countries such as the United States, Iran, and Brazil), and other prominent public figures. Commercial scams have claimed to offer at-home tests, supposed preventives, and "miracle" cures. Other actors have claimed the virus is a bio-weapon with a patented vaccine, a population control scheme, or the result of a spy operation. The World Health Organization has declared an "infodemic" of incorrect information about the virus, which poses risks to global health.

References

^ Lau SK, Luk HK, Wong AC, Li KS, Zhu L, He Z, et al. (April 2020). "Possible Bat Origin of Severe Acute Respiratory Syndrome Coronavirus 2". Emerging Infectious Diseases. Centers for Disease Control and Prevention. 26 (7). doi:10.3201/eid2607.200092. ISSN 1080-6059. OCLC 1058036512. PMID 32315281. Archived from the original on 2 May 2020.

^ Bourouiba L (March 2020). "Turbulent Gas Clouds and Respiratory Pathogen Emissions: Potential Implications for Reducing Transmission of COVID-19". JAMA. doi:10.1001/jama.2020.4756. PMID 32215590.

^ "New coronavirus stable for hours on surfaces". National Institutes of Health. 17 March 2020. Archived from the original on 23 March 2020.

^ "Coronavirus disease 2019 (COVID-19) Situation Report-73" (PDF). World Health Organization. 2 April 2020.

Kuo L, Davidson H (29 March 2020). "'They see my blue eyes then jump back'-China sees a new wave of xenophobia". The Guardian.

^ Lau, Hien; Khosrawipour, Veria; Kocbach, Piotr; Mikolajczyk, Agata; Ichii, Hirohito; Schubert, Justyna; Bania, Jacek; Khosrawipour, Tanja (March 2020). "Internationally lost COVID-19 cases". Journal of Microbiology, Immunology and Infection. doi:10.1016/j.jmii.2020.03.013. PMID 32205091.

^ "Coronavirus COVID-19 Global Cases by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU)". ArcGIS. Johns Hopkins CSSE.

^ "Antal fall av covid-19 i Sverige - data uppdateras 11:30 och siffrorna är tillgängliga 14:00". Public Health Agency of Sweden - Official statistics at arcgis (in Swedish). Lay summary - Antal fall av covid-19 - Statistik - antal fall covid-19. Data updated daily at 11:30 [CEST]

^ "Chile contabiliza a los muertos como recuperados "porque ya no pueden contagiar"". La Vanguardia. 13 April 2020.

^ Ministerstwo Zdrowia [@MZ_GOV_PL] (5 May 2020). "Mamy 189 nowych i potwierdzonych przypadków zakażenia #koronawirus" (Tweet) (in Polish) - via Twitter.

^ @KUWAIT_MOH (5 May 2020). "تعلن #وزارة_الصحة عن تأكيد إصابة 526 حالة جديدة، وتسجيل 85 حالة شفاء، بـ #فيروس_كورونا_المستجدّ COVID19 ، ليصبح إجمالي عدد الحالات 5804 حالة" (Tweet) - via Twitter.

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COVID-19 pandemic Map of confirmed cases per capita as of 5 May 2020 10,000+ confirmed cases per million 3,000-10,000 confirmed cases per million 1,000-3,000 confirmed cases per million 300-1,000 confirmed cases per million 100-300 confirmed cases per million >0-100 confirmed cases per million No confirmed cases or no data Total

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As of 27 April 2020, approximately 1.725 billion learners are currently affected due to school closures in response to the pandemic.

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Health authorities in Wuhan, Hubei, China, reported a cluster of viral pneumonia cases of unknown cause on 31 December 2019

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The COVID-19 pandemic, also known as the coronavirus pandemic, is a 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 an outbreak in the Chinese city of Wuhan in December 2019. Attempts to contain it there failed, allowing the virus to spread to other areas of Asia and then worldwide in early 2020. The World Health Organization (WHO) declared the outbreak a public health emergency of international concern (PHEIC) on 30 January 2020. The WHO ended its PHEIC declaration on 5 May 2023. As of 28 November 2023, the pandemic had caused 772,165,753 cases and 6,981,250 confirmed deaths, ranking it fifth in the list of the deadliest epidemics and pandemics in history.

COVID-19 symptoms range from asymptomatic to deadly, but most commonly include fever, sore throat, nocturnal cough, and fatigue. Transmission of the virus is often through airborne particles. Mutations have produced many strains (variants) with varying degrees of infectivity and virulence.

COVID-19 vaccines were widely deployed in various countries beginning in December 2020. Treatments include novel antiviral drugs and symptom control. Common mitigation measures during the public health emergency included travel restrictions, lockdowns, business restrictions and closures, workplace hazard controls, mask mandates, quarantines, testing systems, and contact tracing of the infected.

The pandemic caused severe social and economic disruption around the world, including the largest global recession since the Great Depression. Widespread supply shortages, including food shortages, were caused by supply chain disruptions and panic buying. Reduced human activity led to an unprecedented decrease in pollution. Educational institutions and public areas were partially or fully closed in many jurisdictions, and events were cancelled or postponed during 2020 and 2021. Many white-collar workers began working from home. 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.

Terminology

During the initial outbreak in Wuhan, the virus and disease were commonly referred to as "coronavirus", "Wuhan coronavirus", "the coronavirus outbreak" and the "Wuhan coronavirus outbreak", with the disease sometimes called "Wuhan pneumonia". In January 2020, the WHO recommended 2019-nCoV and 2019-nCoV acute respiratory disease as interim names for the virus and disease per 2015 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. WHO finalized the official names COVID-19 and SARS-CoV-2 on 11 February 2020. Tedros Adhanom Ghebreyesus explained: COfor corona, VIfor virus, Dfor disease and 19 for when the outbreak was first identified (31 December 2019). WHO additionally uses "the COVID-19 virus" and "the virus responsible for COVID-19" in public communications.

WHO named variants of concern and variants of interest using Greek letters. The initial practice of naming them according to where the variants were identified (e.g. Delta began as the "Indian variant") is no longer common. A more systematic naming scheme reflects the variant's PANGO lineage (e.g., Omicron's lineage is B.1.1.529) and is used for other variants.

Epidemiology

Background

SARS-CoV-2 is a virus closely related to bat coronaviruses, pangolin coronaviruses, and SARS-CoV. The first known outbreak (the 2019-2020 COVID-19 outbreak in mainland China) started in Wuhan, Hubei, China, in December 2019. Many early cases were linked to people who had visited the Huanan Seafood Wholesale Market there, but it is possible that human-to-human transmission began earlier.

The scientific consensus is that the virus is most likely of a zoonotic origin, from bats or another closely related mammal. Controversies about the origins of the virus, including the lab leak theory, heightened geopolitical divisions, notably between the United States and China.

The earliest known infected person fell ill on 1December 2019. That individual did not have a connection with the later wet market cluster. However, an earlier case may have occurred on 17 November. Two-thirds of the initial case cluster were linked with the market. Molecular clock analysis suggests that the index case is likely to have been infected between mid-October and mid-November 2019.

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 whether or not they experienced symptomatic disease. Due to the effect of sampling bias, studies which obtain a more accurate number by extrapolating from a random sample have consistently found that total infections considerably exceed the reported case counts. Many countries, early on, had official policies to not test those with only mild symptoms. The strongest risk factors for severe illness are obesity, complications of diabetes, anxiety disorders, and the total number of conditions.

During the start of the COVID-19 pandemic it was not clear whether young people were less likely to be infected, or less likely to develop symptoms and be tested. A retrospective cohort study in China found that children and adults were just as likely to be infected.

Among more thorough studies, preliminary results from 9 April 2020, found that in Gangelt, the centre of a major infection cluster in Germany, 15 percent of a population sample tested positive for antibodies. 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. Seroprevalence-based estimates are conservative as some studies show that persons with mild symptoms do not have detectable antibodies.

Initial estimates of the basic reproduction number (R 0) for COVID-19 in January 2020 were between 1.4 and 2.5, but a subsequent analysis claimed that it may be about 5.7 (with a 95 percent confidence interval of 3.8 to 8.9).

In December 2021, the number of cases continued to climb due to several factors, including new COVID-19 variants. As of that 28December, 282,790,822 individuals worldwide had been confirmed as infected. As of 14 April 2022, over 500 million cases were confirmed globally. Most cases are unconfirmed, with the Institute for Health Metrics and Evaluation estimating the true number of cases as of early 2022 to be in the billions.

Global excess and reported COVID-19 deaths and deaths per 100,000 according to the WHO study[61]

As of 10 March 2023, more than 6.88million deaths had been attributed to COVID-19. The first confirmed death was in Wuhan on 9 January 2020. These numbers vary by region and over time, influenced by testing volume, healthcare system quality, treatment options, government response, time since the initial outbreak, and population characteristics, such as age, sex, and overall health.

Multiple measures are used to quantify mortality. Official death counts typically include people who died after testing positive. Such counts exclude deaths without a test. Conversely, deaths of people who died from underlying conditions following a positive test may be included. Countries such as Belgium include deaths from suspected cases, including those without a test, thereby increasing counts.

Official death counts have been claimed to underreport the actual death toll, because excess mortality (the number of deaths in a period compared to a long-term average) data show an increase in deaths that is not explained by COVID-19 deaths alone. Using such data, estimates of the true number of deaths from COVID-19 worldwide have included a range from 18.2 to 33.5 million (≈27.4 million) by 18 November 2023 by The Economist, as well as over 18.5 million by 1 April 2023 by the Institute for Health Metrics and Evaluation and ≈18.2 million (earlier) deaths between 1 January 2020, and 31 December 2021, by a comprehensive international study. Such deaths include deaths due to healthcare capacity constraints and priorities, as well as reluctance to seek care (to avoid possible infection). Further research may help distinguish the proportions directly caused by COVID-19 from those caused by indirect consequences of the pandemic.

A December 2022 WHO study estimated excess deaths from the pandemic during 2020 and 2021, again concluding ≈14.8 million excess early deaths occurred, reaffirming and detailing their prior calculations from May as well as updating them, addressing criticisms. These numbers do not include measures like years of potential life lost and may make the pandemic 2021's leading cause of death.

The time between symptom onset and death ranges from6 to 41 days, typically about 14 days. Mortality rates increase as a function of age. People at the greatest mortality risk are the elderly and those with underlying conditions.

Semi-log plot of weekly deaths due to COVID-19 in the world and top six current countries (mean with cases)

Infection fatality ratio (IFR)

The infection fatality ratio (IFR) is the cumulative number of deaths attributed to the disease divided by the cumulative number of infected individuals (including asymptomatic and undiagnosed infections and excluding vaccinated infected individuals). It is expressed in percentage points. Other studies refer to this metric as the infection fatality risk.

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%. IFRs rise as a function of age (from 0.002% at age 10 and 0.01% at age 25, to 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. For comparison, the IFR for middle-aged adults is two orders of magnitude higher than the annualised risk of a fatal automobile accident and much higher than the risk of dying from seasonal influenza.

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. This study reported that most of the differences reflected corresponding differences in the population's age structure and the age-specific pattern of infections. There have also been reviews that have compared the fatality rate of this pandemic with prior pandemics, such as MERS-CoV.

For comparison the infection mortality rate of seasonal flu in the United States is 0.1%, which is 13 times lower than COVID-19.

Case fatality ratio (CFR)

Several variants have been named by WHO and labelled as a variant of concern (VoC) or a variant of interest (VoI). Many of these variants have shared the more infectious D614G. As of May 2023, the WHO had downgraded all variants of concern to previously circulating as these were no longer detected in new infections. Sub-lineages of the Omicron variant (BA.1 - BA.5) were considered separate VoCs by the WHO until they were downgraded in March 2023 as no longer widely circulating.

World Health Organization video which describes how variants proliferate in unvaccinated areas

Signs and symptoms

Symptoms of COVID-19 are variable, ranging from mild symptoms to severe illness. Common symptoms include headache, loss of smell and taste, nasal congestion and runny nose, cough, muscle pain, sore throat, fever, diarrhoea, and breathing difficulties. 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 diarrhoea. 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.

Transmission

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. Infected people are more likely to transmit COVID-19 when they are physically close to other non-infected individuals. However, infection can occur over longer distances, particularly indoors.

SARS‑CoV‑2 belongs to the broad family of viruses known as coronaviruses. 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.

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.

The standard method of testing for presence of SARS-CoV-2 is a nucleic acid test, which detects the presence of viral RNA fragments. As these tests detect RNA but not infectious virus, its "ability to determine duration of infectivity of patients is limited." The test is typically done on respiratory samples obtained by a nasopharyngeal swab; however, a nasal swab or sputum sample may also be used. The WHO has published several testing protocols for the disease.

Prevention

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

A COVID-19 vaccine is 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. The initial focus of SARS-CoV-2 vaccines was on preventing symptomatic and severe illness. The COVID-19 vaccines are widely credited for their role in reducing the severity and death caused by COVID-19.

As of March 2023, more than 5.5 billion people had received one or more doses (11.8 billion in total) in over 197 countries. The Oxford-AstraZeneca vaccine was the most widely used. According to a June 2022 study, COVID-19 vaccines prevented an additional 14.4 million to 19.8 million deaths in 185 countries and territories from 8 December 2020 to 8 December 2021.

On 12 November 2022, the WHO released its Global Vaccine Market Report. The report indicated that "inequitable distribution is not unique to COVID-19 vaccines"; countries that are not economically strong struggle to obtain vaccines.

A critically ill patient receiving invasive ventilation in the intensive care unit of the Heart Institute, University of São Paulo in July 2020. Due to a shortage of mechanical ventilators, a bridge ventilator is being used to automatically actuate a bag valve mask.

For the first two years of the pandemic, no specific and effective treatment or cure was available. In 2021, the European Medicines Agency's (EMA) Committee for Medicinal Products for Human Use (CHMP) approved the oral antiviral protease inhibitor, Paxlovid (nirmatrelvir plus AIDS drug ritonavir), to treat adult patients. FDA later gave it an EUA.

Most cases of COVID-19 are mild. In these, supportive care includes medication such as paracetamol or NSAIDs to relieve symptoms (fever, body aches, cough), adequate intake of oral fluids and rest. Good personal hygiene and a healthy diet are also recommended.

Supportive care in severe cases includes treatment to relieve symptoms, fluid therapy, oxygen support and prone positioning, and medications or devices to support other affected vital organs. More severe cases may need treatment in hospital. In those with low oxygen levels, use of the glucocorticoid dexamethasone is recommended to reduce mortality. Noninvasive ventilation and, ultimately, admission to an intensive care unit for mechanical ventilation may be required to support breathing. Extracorporeal membrane oxygenation (ECMO) has been used to address the issue of respiratory failure.

Existing drugs such as hydroxychloroquine, lopinavir/ritonavir, and ivermectin are not recommended by US or European health authorities, as there is no good evidence they have any useful effect. 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), due to limited evidence of its efficacy.

The severity of COVID-19 varies. It 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. 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. 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 intensive care units (ICU).

Between 5% and 50% of COVID-19 patients experience long COVID, a condition characterized by long-term consequences persisting after the typical convalescence period of the disease. The most commonly reported clinical presentations are fatigue and memory problems, as well as malaise, headaches, shortness of breath, loss of smell, muscle weakness, low fever and cognitive dysfunction.

Strategies

Goals of mitigation include delaying and reducing peak burden on healthcare (flattening the curve) and lessening overall cases and health impact.[158][159] Moreover, progressively greater increases in healthcare capacity (raising the line) such as by increasing bed count, personnel, and equipment, help to meet increased demand.[160]

Many countries attempted to slow or stop the spread of COVID-19 by recommending, mandating or prohibiting behaviour changes, while others relied primarily on providing information. Measures ranged from public advisories to stringent lockdowns. Outbreak control strategies are divided into elimination and mitigation. Experts differentiate between elimination strategies (known as " zero-COVID") that aim to completely stop the spread of the virus within the community, and mitigation strategies (commonly known as " flattening the curve") that attempt to lessen the effects of the virus on society, but which still tolerate some level of transmission within the community. These initial strategies can be pursued sequentially or simultaneously during the acquired immunity phase through natural and vaccine-induced immunity.

Nature reported in 2021 that 90 percent of researchers who responded to a survey "think that the coronavirus will become endemic".

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. Screening is the starting point for containment. Screening is done by checking for symptoms to identify infected individuals, who can then be isolated or offered treatment. The Zero-COVID strategy involves using public health measures such as contact tracing, mass testing, border quarantine, lockdowns and mitigation software to stop community transmission of COVID-19 as soon as it is detected, with the goal of getting the area back to zero detected infections and resuming normal economic and social activities. Successful containment or suppression reduces Rt to less than 1.

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". This decreases the risk of overwhelming health services and provides more time for developing vaccines and treatments. Individual behaviour changed in many jurisdictions. Many people worked from home instead of at their traditional workplaces.

Non-pharmaceutical interventions

Non-pharmaceutical interventions that may reduce spread include personal actions such as wearing face masks, self-quarantine, and hand hygiene; community measures aimed at reducing interpersonal contacts such as closing workplaces and schools and cancelling large gatherings; community engagement to encourage acceptance and participation in such interventions; as well as environmental measures such as surface cleaning.

Other measures

More drastic actions, such as quarantining entire populations and strict travel bans have been attempted in various jurisdictions. The Chinese and Australian government approaches have included many lockdowns and are widely considered the most strict. The New Zealand government response included the most severe travel restrictions. As part of its K-Quarantine program, South Korea introduced mass screening and localised quarantines, and issued alerts on the movements of infected individuals. The Singaporean government's response included so-called " circuit breaker lockdowns" and financial support for those affected while also imposing large fines for those who broke quarantine.

Contact tracing

Contact tracing attempts to identify recent contacts of newly infected individuals, and to screen them for infection; the traditional approach is to request a list of contacts from infectees, and then telephone or visit the contacts. Contact tracing was widely used during the Western African Ebola virus epidemic in 2014.

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

Health care

WHO described increasing capacity and adapting healthcare as a fundamental mitigation. The ECDC and WHO's European regional office issued guidelines for hospitals and primary healthcare services for shifting resources at multiple levels, including focusing laboratory services towards testing, cancelling elective procedures, separating and isolating patients, and increasing intensive care capabilities by training personnel and increasing ventilators and beds. The pandemic drove widespread adoption of telehealth.

Improvised manufacturing

Due to supply chain capacity limitations, some manufacturers began 3D printing material such as nasal swabs and ventilator parts. 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. 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.

Herd immunity

The outbreak was discovered in Wuhan in November 2019. It is possible that human-to-human transmission was happening before the discovery. Based on a retrospective analysis starting from December 2019, the number of cases in Hubei gradually increased, reaching 60 by 20 December and at least 266 by 31 December.

A pneumonia cluster was observed on 26 December and treated by Chinese pulmonologist Zhang Jixian. She informed the Wuhan Jianghan CDC on 27 December. After analyzing pneumonia patient samples, a genetic sequencing company named Vision Medicals reported the discovery of a novel coronavirus to the China CDC (CCDC) on 28 December.

Official Chinese sources claimed that the early cases were mostly linked to the Huanan Seafood Wholesale Market, which also sold live animals. In May 2020, CCDC director George Gao initially ruled out the market as a possible origin, as animal samples collected there had tested negative.

On 11 January, WHO was notified by 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.

Initially, the number of cases doubled approximately every seven and a half days. In early and mid-January, the virus spread to other Chinese provinces, helped by the Chinese New Year migration. Wuhan was a transport hub and major rail interchange. On 10 January, the virus' genome was shared publicly. A retrospective study published in March found that 6,174 people had reported symptoms by 20 January. A 24 January report indicated human transmission was likely occurring, and recommended personal protective equipment for health workers. It also advocated testing, given the outbreak's "pandemic potential". 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."

On 30 January, 7,818 infections had been confirmed, leading WHO to declare the outbreak a Public Health Emergency of International Concern (PHEIC). On 11 March, WHO announced its assessment that the situation could be characterized as a pandemic.

By 31 January, Italy indicated its first confirmed infections had occurred, in two tourists from China. On 19 March, Italy overtook China as the country with the most reported deaths. By 26 March, the United States had overtaken China and Italy as the country with the highest number of confirmed infections. Genomic analysis indicated that the majority of New York's confirmed infections came from Europe, rather than directly from Asia. Testing of prior samples revealed a person who was infected in France on 27 December 2019 and a person in the United States who died from the disease on 6February.

In October, 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.

On 9 November, Pfizer released trial results for a candidate vaccine, showing a 90 percent effectiveness in preventing infection. That day, Novavax submitted an FDA Fast Track application for their vaccine.

On 14 December, Public Health England reported that a variant had been discovered in the UK's southeast, predominantly in Kent. The variant, later named Alpha, showed changes to the spike protein that could make the virus more infectious. As of 13 December, 1,108 infections had been confirmed in the UK.

On 2 January, the Alpha variant, first discovered in the UK, had been identified in 33 countries. On 6 January, the Gamma variant was first identified in Japanese travellers returning from Brazil. On 29 January, it was reported that the Novavax vaccine was 49 percent effective against the Beta variant in a clinical trial in South Africa. The CoronaVac vaccine was reported to be 50.4 percent effective in a Brazil clinical trial.

On 12 March, several countries stopped using the Oxford-AstraZeneca COVID-19 vaccine- due to blood clotting problems, specifically cerebral venous sinus thrombosis (CVST). On 20 March, the WHO and European Medicines Agency found no link to thrombosis, leading several countries to resume administering the vaccine. In March WHO reported that an animal host was the most likely origin, without ruling out other possibilities. The Delta variant was first identified in India. In mid-April, the variant was first detected in the UK and two months later it had become a full-fledged third wave in the country, forcing the government to delay reopening that was originally scheduled for June.

On 10 November, Germany advised against the Moderna vaccine for people under 30, due to a possible association with myocarditis. On 24 November, the Omicron variant was detected in South Africa; a few days later the World Health Organization declared it a VoC (variant of concern). The new variant is more infectious than the Delta variant.

Scanning electron micrograph (colorized) of cell infected with the Omicron strain of SARS-CoV-2 virus particles green

On 1 January, Europe passed 100 million cases amidst a surge in the Omicron variant. Later that month, the WHO recommended the rheumatoid arthritis drug Baricitinib for severe or critical patients. It also recommended the monoclonal antibody Sotrovimab in patients with non-severe disease, but only those who are at highest risk of hospitalization.

On 24 January, the Institute for Health Metrics and Evaluation estimated that about 57% of the world's population had been infected by COVID-19. By 6 March, it was reported that the total worldwide death count had surpassed 6 million people. By 6 July, Omicron subvariants BA.4 and BA.5 had spread worldwide. WHO Director-General Tedros Ghebreyesus stated on 14 September 2022, that "[The world has] never been in a better position to end the pandemic", citing the lowest number of weekly reported deaths since March 2020. He continued, "We are not there yet. But the end is in sight-we can see the finish line".

On 11 November, the WHO reported that deaths since the month of February had dropped 90 percent. Director-General Tedros said this was "cause for optimism". On 3 December, the WHO indicated that, "at least 90% of the world's population has some level of immunity to Sars-CoV-2". In early December, China began lifting some of its most stringent lockdown measures. Subsequent data from China's health authorities revealed that 248 million people, nearly 18 percent of its population, had been infected in the first 20 days of that month. On 29 December, the US joined Italy, Japan, Taiwan and India in requiring negative COVID-19 test results from all people traveling from China due to the new surge in cases. The EU refused similar measures, stating that the BF7 omicron variant had already spread throughout Europe without becoming dominant.

On 30 January, the three-year anniversary of the original declaration, the World Health Organization determined that COVID-19 still met the criteria for a public health emergency of international concern (PHEIC).

On 19 March, WHO Director-General Tedros indicated he was "confident" the COVID-19 pandemic would cease to be a public health emergency by the end of the year. On 5 May, the WHO downgraded COVID-19 from being a global health emergency, though it continued to refer to it as a pandemic. The WHO does not make official declarations of when pandemics end. The decision came after Tedros convened with the International Health Regulations Emergency Committee, wherein the Committee noted that due to the decrease in deaths and hospitalisations, and the prevalence of vaccinations and the level of general immunity, it was time to remove the emergency designation and "transition to long-term management". Tedros agreed, and the WHO reduced the classification to an "established and ongoing health issue". In a press conference, Tedros remarked that the diminishing threat from COVID-19 had "allowed most countries to return to life as we knew it before COVID-19".

In September the WHO said it had observed "concerning" trends in COVID-19 case numbers and hospitalisations, although analysis was hampered because many countries were no longer recording COVID-19 case statistics.

National reactions ranged from strict lockdowns to public education campaigns. WHO recommended that curfews and lockdowns should be short-term measures to reorganise, regroup, rebalance resources, and protect the health care system. As of 26 March 2020, 1.7 billion people worldwide were under some form of lockdown. This increased to 3.9 billion people by the first week of April-more than half the world's population.

As of the end of 2021, Asia's peak had come at the same time and at the same level as the world as a whole, in May 2021. However, cumulatively they had experienced only half of the global average in cases.

China opted for containment, instituting strict lockdowns to eliminate viral spread. The vaccines distributed in China included the BIBP, WIBP, and CoronaVac. It was reported on 11 December 2021, that China had vaccinated 1.162 billion of its citizens, or 82.5% of the total population of the country against COVID-19. China's large-scale adoption of zero-COVID had largely contained the first waves of infections of the disease. When the waves of infections due to the Omicron variant followed, China was almost alone in pursuing the strategy of zero-Covid to combat the spread of the virus in 2022. Lockdown continued to be employed in November to combat a new wave of cases; however, protests erupted in cities across China over the country's stringent measures, and in December that year, the country relaxed its zero-COVID policy. On 20 December 2022, the Chinese State Council narrowed its definition of what would be counted as a COVID-19 death to include solely respiratory failure, which led to skepticism by health experts of the government's total death count at a time when hospitals reported being overwhelmed with cases following the abrupt discontinuation of zero-COVID.

The first case in India was reported on 30 January 2020. India ordered a nationwide lockdown starting 24 March 2020, with a phased unlock beginning 1 June 2020. Six cities accounted for around half of reported cases- Mumbai, Delhi, Ahmedabad, Chennai, Pune and Kolkata. Post-lockdown, the Government of India introduced a contact tracking app called Aarogya Setu to help authorities manage contact tracing and vaccine distribution. India's vaccination program was considered to be the world's largest and most successful with over 90% of citizens getting the first dose and another 65% getting the second dose. A second wave hit India in April 2021, straining healthcare services. On 21 October 2021, it was reported that the country had surpassed 1 billion vaccinations.

Disinfection of Tehran Metro trains to prevent COVID-19 transmission. Similar measures have also been taken in other countries.[296]

Iran reported its first confirmed cases on 19 February 2020, in Qom. Early measures included the cancellation/closure of concerts and other cultural events, Friday prayers, and school and university campuses. Iran became a centre of the pandemic in February 2020. More than ten countries had traced their outbreaks to Iran by 28 February, indicating a more severe outbreak than the 388 reported cases. The Iranian Parliament closed, after 23 of its 290 members tested positive on 3March 2020. At least twelve sitting or former Iranian politicians and government officials had died by 17 March 2020. By August 2021, the pandemic's fifth wave peaked, with more than 400 deaths in 1 day.

COVID-19 was confirmed in South Korea on 20 January 2020. Military bases were quarantined after tests showed three infected soldiers. South Korea introduced what was then considered the world's largest and best-organised screening programme, isolating infected people, and tracing and quarantining contacts. Screening methods included mandatory self-reporting by new international arrivals through mobile application, combined with drive-through testing, and increasing testing capability to 20,000 people/day. Despite some early criticisms, South Korea's programme was considered a success in controlling the outbreak without quarantining entire cities.

The 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, and all had 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. By 13 March 2020, the World Health Organization (WHO) declared Europe the epicentre of the pandemic and it remained so until the WHO announced it had been overtaken by South America on 22 May. By 18 March 2020, more than 250 million people were in lockdown in Europe. Despite deployment of COVID-19 vaccines, Europe became the pandemic's epicentre once again in late 2021.

The Italian outbreak began on 31 January 2020, when two Chinese tourists tested positive for SARS-CoV-2 in Rome. Cases began to rise sharply, which prompted the government to suspend flights to and from China and declare a state of emergency. On 22 February 2020, the Council of Ministers announced a new decree-law to contain the outbreak, which quarantined more than 50,000 people in northern Italy. On 4 March, the Italian government ordered schools and universities closed as Italy reached a hundred deaths. Sport was suspended completely for at least one month. On 11 March, Italian Prime Minister Giuseppe Conte closed down nearly all commercial activity except supermarkets and pharmacies. On 19 April, the first wave ebbed, as 7-day deaths declined to 433. On 13 October, the Italian government again issued restrictive rules to contain the second wave. On 10 November, Italy surpassed 1 million confirmed infections. On 23 November, it was reported that the second wave of the virus had led some hospitals to stop accepting patients.

The virus was first confirmed to have spread to Spain on 31 January 2020, when a German tourist tested positive for SARS-CoV-2 on La Gomera in the Canary Islands. Post-hoc genetic analysis has shown that at least 15 strains of the virus had been imported, and community transmission began by mid-February. 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. 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. By September 2021, Spain was one of the countries with the highest percentage of its population vaccinated (76% fully vaccinated and 79% with the first dose). Italy is ranked second at 75%.

Sweden differed from most other European countries in that it mostly remained open. Per the Swedish constitution, the Public Health Agency of Sweden has autonomy that prevents political interference and the agency favoured remaining open. The Swedish strategy focused on longer-term measures, based on the assumption that after lockdown the virus would resume spreading, with the same result. By the end of June, Sweden no longer had excess mortality.

Devolution in the United Kingdom meant that each of its four countries developed its own response. England's restrictions were shorter-lived than the others. The UK government started enforcing social distancing and quarantine measures on 18 March 2020. On 16 March, Prime Minister Boris Johnson advised against non-essential travel and social contact, praising work from home and avoiding venues such as pubs, restaurants, and theatres. On 20 March, the government ordered all leisure establishments to close, and promised to prevent unemployment. On 23 March, Johnson banned gatherings and restricted 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. On 24 April 2020, it was reported that a promising vaccine trial had begun in England; the government pledged more than £50 million towards research. On 16 April 2020, 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 would be available. On 2 December 2020, the UK became the first developed country to approve the Pfizer vaccine; 800,000 doses were immediately available for use. In August 2022 it was reported that viral infection cases had declined in the UK.

North America

The virus arrived in the United States on 13 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.

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

Per Our World in Data, 103,436,829 confirmed cases have been reported in the United States with 1,138,309 deaths, the most of any country, and the nineteenth-highest per capita worldwide. COVID-19 is the deadliest pandemic in US history; it was the third-leading cause of death in the US in 2020, behind heart disease and cancer. From 2019 to 2020, US life expectancy dropped by 3years for Hispanic Americans, 2.9years for African Americans, and 1.2years for white Americans. These effects have persisted as US deaths due to COVID-19 in 2021 exceeded those in 2020. In the United States, COVID-19 vaccines became available under emergency use in December 2020, beginning the national vaccination program. The first COVID-19 vaccine was officially approved by the Food and Drug Administration on 23 August 2021. By 18 November 2022, while cases in the U.S. had declined, COVID variants BQ.1/BQ.1.1 had become dominant in the country.

In March 2020, as cases of community transmission were confirmed across Canada, all of its provinces and territories declared states of emergency. Provinces and territories, to varying degrees, implemented school and daycare closures, prohibitions on gatherings, closures of non-essential businesses and restrictions on entry. Canada severely restricted its border access, barring travellers from all countries with some exceptions. Cases surged across Canada, notably in the provinces of British Columbia, Alberta, Quebec and Ontario, with the formation of the Atlantic Bubble, a travel-restricted area of the country (formed of the four Atlantic provinces). Vaccine passports were adopted in all provinces and two of the territories. Per a report on 11 November 2022, Canadian health authorities saw a surge in influenza, while COVID-19 was expected to rise during winter.

South America

The COVID-19 pandemic was confirmed to have reached South America on 26 February 2020, when Brazil confirmed a case in São Paulo. By 3 April, all countries and territories in South America had recorded at least one case. 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 World Health Organization WHO declared South America the epicentre of the pandemic. 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.

The virus was confirmed to have spread to Brazil on 25 February 2020, when a man from São Paulo who had traveled to Italy tested positive for the virus. The disease had spread to every federative unit of Brazil by 21 March. On 19 June 2020, the country reported its one millionth case and nearly 49,000 reported deaths. One estimate of under-reporting was 22.62% of total reported COVID-19 mortality in 2020. As of 28 November 2023, Brazil, with 37,721,749 confirmed cases and 704,659 deaths, has the third-highest number of confirmed cases and second-highest death toll from COVID-19 in the world, behind only those of the United States and India.

US Air Force personnel unload a C-17 aircraft carrying medical supplies in Niamey, Niger, in April 2020.

The COVID-19 pandemic was confirmed to have spread to Africa on 14 February 2020, with the first confirmed case announced in Egypt. The first confirmed case in sub-Saharan Africa was announced in Nigeria at the end of February 2020. Within three months, the virus had spread throughout the continent; Lesotho, the last African sovereign state to have remained free of the virus, reported its first case on 13 May 2020. By 26 May, it appeared that most African countries were experiencing community transmission, although testing capacity was limited. Most of the identified imported cases arrived from Europe and the United States rather than from China where the virus originated. Many preventive measures were implemented by different countries in Africa including travel restrictions, flight cancellations, and event cancellations. Despite fears, Africa reported lower death rates than other, more economically developed regions.

In early June 2021, Africa faced a third wave of COVID infections with cases rising in 14 countries. 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. The World Health Organization labelled it Africa's 'Worst Pandemic Week Ever'. In October 2022, WHO reported that most countries on the African continent will miss the goal of 70 percent vaccination by the end of 2022.

The COVID-19 pandemic was confirmed to have reached Oceania on 25 January 2020, with the first confirmed case reported in Melbourne, Australia. It has since spread elsewhere in the region. 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 into the community.

On 9 September 2022 restrictions were significantly relaxed. The aircraft mask mandate was scrapped nationwide and daily reporting transitioned to weekly reporting. On 14 September, COVID-19 disaster payment for isolating persons was extended for mandatory isolation. By 22 September, all states had ended mask mandates on public transport, including in Victoria, where the mandate had lasted for approximately 800 days. On 30 September 2022, all Australian leaders declared the emergency response finished and announced the end of isolation requirements. These changes were due in part to high levels of 'hybrid immunity' and low case numbers.

Antarctica

Due to its remoteness and sparse population, Antarctica was the last continent to have confirmed cases of COVID-19. 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 were infected in the first outbreak in 2020, with several other outbreaks taking place in 2021 and 2022.

United Nations

The United Nations Conference on Trade and Development (UNSC) was criticised for its slow response, especially regarding the UN's global ceasefire, which aimed to open up humanitarian access to conflict zones. The United Nations Security Council was criticized due to the inadequate manner in which it dealt with the COVID-19 pandemic, namely the poor ability to create international collaboration during this crisis.

On 23 March 2020, United Nations Secretary-General António Manuel de Oliveira Guterres appealed for a global ceasefire; 172 UN member states and observers signed a non-binding supporting statement in June, and the UN Security Council passed a resolution supporting it in July.

The WHO spearheaded initiatives such as 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 COVAX program, co-led by the WHO, GAVI, and the Coalition for Epidemic Preparedness Innovations (CEPI), aimed to accelerate the development, manufacture, and distribution of COVID-19 vaccines, and to guarantee fair and equitable access across the world.

Restrictions

Travel restrictions

The pandemic led many countries and regions to impose quarantines, entry bans, or other restrictions, either for citizens, recent travellers to affected areas, or for all travellers. Travel collapsed worldwide, damaging the travel sector. The effectiveness of travel restrictions was questioned as the virus spread across the world. One study found that travel restrictions only modestly affected the initial spread, unless combined with other infection prevention and control measures. 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". The European Union rejected the idea of suspending the Schengen free travel zone.

Repatriation of foreign citizens

Several countries repatriated their citizens and diplomatic staff from Wuhan and surrounding areas, primarily through charter flights. Canada, the United States, Japan, India, Sri Lanka, Australia, France, Argentina, Germany and Thailand were among the first to do so. Brazil and New Zealand evacuated their own nationals and others. On 14 March, South Africa repatriated 112 South Africans who tested negative, while four who showed symptoms were left behind. Pakistan declined to evacuate its citizens.

On 15 February, the US announced it would evacuate Americans aboard the Diamond Princess cruise ship, and on 21 February, Canada evacuated 129 Canadians from the ship. In early March, the Indian government began repatriating its citizens from Iran. On 20 March, the United States began to withdraw some troops from Iraq.

The pandemic and responses to it damaged the global economy. On 27 February 2020, worries about the outbreak crushed US stock indexes, which posted their sharpest falls since 2008.

Tourism collapsed due to travel restrictions, closing of public places including travel attractions, and advice of governments against travel. Airlines cancelled flights, while British regional airline Flybe collapsed. The cruise line industry was hard hit, and train stations and ferry ports closed. International mail stopped or was delayed.

Hundreds of millions of jobs were lost, including more than 40 million jobs in the US. According to a report by Yelp, about 60% of US businesses that closed will stay shut permanently. The International Labour Organization (ILO) reported that the income generated in the first nine months of 2020 from work across the world dropped by 10.7 percent, or $3.5 trillion.

Supply shortages

Pandemic fears led to panic buying, emptying groceries of essentials such as food, toilet paper, and bottled water. Panic buying stemmed from perceived threat, perceived scarcity, fear of the unknown, coping behaviour and social psychological factors (e.g. social influence and trust).

Supply shortages were due to disruption to factory and logistic operations; shortages were worsened by supply chain disruptions from factory and port shutdowns, and labour shortages.

According to WHO Secretary-General Tedros Ghebreyesus, demand for personal protective equipment (PPE) rose one hundredfold, pushing prices up twentyfold. PPE stocks were exhausted everywhere.

In September 2021, the World Bank reported that food prices remained generally stable and the supply outlook remained positive. However, the poorest countries witnessed a sharp increase in food prices, reaching the highest level since the pandemic began. The Agricultural Commodity Price Index stabilized in the third quarter but remained 17% higher than in January 2021.

By contrast, petroleum products were in surplus at the beginning of the pandemic, as demand for gasoline and other products collapsed due to reduced commuting and other trips. The 2021 global energy crisis was driven by a global surge in demand as the world economy recovered. Energy demand was particularly strong in Asia.

Arts and cultural heritage

The performing arts and cultural heritage sectors were profoundly affected by the pandemic. Both organisations' and individuals' operations have been impacted 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. A 2021 UNESCO report estimated ten million job losses worldwide in the culture and creative industries. Some services continued through digital platforms, such as live streaming concerts or web-based arts festivals.

The pandemic affected political systems, causing suspensions of legislative activities, isolations or deaths of politicians, and rescheduled elections. Although they developed broad support among epidemiologists, NPIs (non-pharmaceutical interventions) were controversial in many countries. Intellectual opposition came primarily from other fields, along with heterodox epidemiologists.

The pandemic (and the response of Brazilian politicians to it) led to widespread panic, confusion, and pessimism in Brazil. When questioned regarding record deaths in the country in April 2020, Brazilian President Jair Bolsonaro said "So what? I'm sorry. What do you want me to do about it?" Bolsonaro disregarded WHO-recommended mitigation techniques and instead downplayed the risks of the virus, promoted increased economic activity, spread misinformation about the efficacy of masks, vaccines and public health measures, and distributed unproven treatments including hydroxychloroquine and ivermectin. A series of federal health ministers resigned or were dismissed after they refused to implement Bolsonaro's policies.

Disagreements between federal and state governments led to a chaotic and delayed response to the rapid spread of the virus, exacerbated by preexisting social and economic disparities in the country. Employment, investment and valuation of the Brazilian real plummeted to record lows. Brazil was also heavily affected by the Delta and Omicron variants. At the height of the outbreak in the spring of 2021, 3,000+ Brazilians were dying per day. Bolsonaro's loss to Lula da Silva in the 2022 presidential election is widely credited to the former's mishandling of the pandemic.

Multiple provincial-level administrators of the Chinese Communist Party (CCP) were dismissed over their handling of quarantine measures. Some commentators claimed this move was intended to protect CCP General Secretary Xi Jinping. The US intelligence community claimed that China intentionally under-reported its COVID-19 caseload. The Chinese government maintained that it acted swiftly and transparently. Journalists and activists in China who reported on the pandemic were detained by authorities, including Zhang Zhan, who was arrested and tortured.

In early March 2020, the Italian government criticised the EU's lack of solidarity with Italy. On 22 March 2020, after a phone call with Italian Prime Minister Giuseppe Conte, Russian President Vladimir Putin ordered the Russian army to send military medics, disinfection vehicles, and other medical equipment to Italy. In early April, Norway and EU states like Romania and Austria started to offer help by sending medical personnel and disinfectant, and European Commission President Ursula von der Leyen offered an official apology to the country .

United States

Anti-lockdown protesters rallied at Ohio Statehouse 20 April 2020.[523]

Beginning in mid-April 2020, protestors objected to government-imposed business closures and restrictions on personal movement and assembly. Simultaneously, essential workers protested unsafe conditions and low wages by participating in a brief general strike. Some political analysts claimed that the pandemic contributed to President Donald Trump's 2020 defeat.

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. The Kaiser Family Foundation estimated that preventable hospitalizations of unvaccinated Americans in the second half of 2021 cost US$13.8 billion.

Other countries

The number of journalists imprisoned or detained increased worldwide; some detentions were related to the pandemic. 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.

The Iranian government was heavily affected by the virus, which infected some two dozen parliament members and political figures. Iran President Hassan Rouhani wrote a public letter to world leaders asking for help on 14 March 2020, due to a lack of access to international markets. Saudi Arabia, which had launched a military intervention in Yemen in March 2015, declared a ceasefire.

Diplomatic relations between Japan and South Korea worsened. South Korea criticised Japan's "ambiguous and passive quarantine efforts" after Japan announced travellers from South Korea must quarantine for two weeks. South Korean society was initially polarised on President Moon Jae-in's response to the crisis; many Koreans signed petitions calling for Moon's impeachment or praising his response.

Some countries passed emergency legislation. Some commentators expressed concern that it could allow governments to strengthen their grip on power. In Hungary, the parliament voted to allow Prime Minister Viktor Orbán to rule by decree indefinitely, suspend parliament and elections, and punish those deemed to have spread false information. In countries such as Egypt, Turkey, and Thailand, opposition activists and government critics were arrested for allegedly spreading fake news. In India, journalists criticising the government's response were arrested or issued warnings by police and authorities.

Food systems

The pandemic disrupted food systems worldwide, hitting at a time when hunger and undernourishment were rising- an estimated 690 million people lacked food security in 2019. Food access fell - driven by falling incomes, lost remittances, and disruptions to food production. In some cases, food prices rose. The pandemic and its accompanying lockdowns and travel restrictions slowed movement of food aid. According to the WHO, 811 million people were undernourished in 2020, "likely related to the fallout of COVID-19".

The pandemic impacted educational systems in many countries. Many governments temporarily closed educational institutions, often replaced by online education. Other countries, such as Sweden, kept their schools open. As of September 2020, approximately 1.077 billion learners were affected due to school closures. School closures impacted students, teachers, and families with 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 was more severe for disadvantaged children. The Higher Education Policy Institute reported that around 63% of students claimed worsened mental health as a result of the pandemic.

The pandemic impacted global health for many conditions. Hospital visits fell. Visits for heart attack symptoms declined by 38% in the US and 40% in Spain. 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." People with strokes and appendicitis were less likely to seek treatment. Medical supply shortages impacted many people. The pandemic impacted mental health, increasing anxiety, depression, and post-traumatic stress disorder, affecting healthcare workers, patients and quarantined individuals.

In late 2022, during the first northern hemisphere autumn and winter seasons following the widespread relaxation of global public health measures, North America and Europe experienced a surge in respiratory viruses and coinfections in both adults and children. This formed the beginnings of the 2022-2023 pediatric care crisis and what some experts have termed a " tripledemic" of seasonal influenza, Respiratory Syncytial Virus (RSV), and SARS-CoV-2 throughout North America. In the United Kingdom, pediatric infections also began to spike beyond pre-pandemic levels, albeit with different illnesses, such as Group A streptococcal infection and resultant scarlet fever. As of mid-December 2022, 19 children in the UK had died due to Strep A and the wave of infections had begun to spread into North America and Mainland Europe.

The B/Yamagata lineage of influenza B might have become extinct in 2020/2021 due to COVID-19 pandemic measures. There have been no naturally occurring cases confirmed since March 2020. In 2023, the World Health Organization concluded that protection against the Yamagata lineage was no longer necessary in the seasonal flu vaccine, reducing the number of lineages targeted by the vaccine from four to three.

Environment

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).[581]

The pandemic and the reaction to it positively affected the environment and climate as a result of reduced human activity. During the " anthropause", fossil fuel use decreased, resource consumption declined, and waste disposal improved, generating less pollution. Planned air travel and vehicle transportation declined. In China, lockdowns and other measures resulted in a 26% decrease in coal consumption, and a 50% reduction in nitrogen oxides emissions.

A wide variety of largely mammalian species, both captive and wild, have been shown to be susceptible to SARS-CoV-2, with some encountering particularly fatal outcomes. In particular, both farmed and wild mink have developed highly symptomatic and severe COVID-19 infections, with a mortality rate as high as 35-55% according to one study. White-tailed deer, on the other hand, have largely avoided severe outcomes but have effectively become natural reservoirs of the virus, with large numbers of free-ranging deer infected throughout the US and Canada, including approximately 80% of Iowa's wild deer herd. An August 2023 study appeared to confirm the status of white-tailed deer as a disease reservoir, noting that the viral evolution of SARS-CoV-2 in deer occurs at triple the rate of its evolution in humans and that infection rates remained high, even in areas rarely frequented by humans.

Discrimination and prejudice

A socially distanced homeless encampment in San Francisco, California, in May 2020[591]

Age-based discrimination against older adults increased during the pandemic. This was attributed to their perceived vulnerability and subsequent physical and social isolation measures, which, coupled with their reduced social activity, increased dependency on others. Similarly, limited digital literacy left the elderly more vulnerable to isolation, depression, and loneliness.

In January 2022, Amnesty International urged Italy to change their anti-COVID-19 restrictions to avoid discrimination against unvaccinated people, saying that "the government must continue to ensure that the entire population can enjoy its fundamental rights." The restrictions included mandatory vaccination over the age of 50, and mandatory vaccination to use public transport.

Lifestyle changes

The pandemic triggered massive changes in behaviour, from increased Internet commerce to cultural changes in the workplace. Online retailers in the US posted $791.70 billion in sales in 2020, an increase of 32.4% from $598.02 billion the year before. Home delivery orders increased, while indoor restaurant dining shut down due to lockdown orders or low sales. Hackers, cybercriminals and scammers took advantage of the changes to launch new online attacks.

Education in some countries temporarily shifted from physical attendance to video conferencing. Massive layoffs shrank the airline, travel, hospitality, and other industries. Despite most corporations implementing measures to address COVID-19 in the workplace, a poll from Catalyst found that as many as 68% of employees around the world felt that these policies were only performative and "not genuine".

Historiography

A 2021 study noted that the COVID-19 pandemic had increased interest in epidemics and infectious diseases among both historians and the general public. Prior to the pandemic, these topics were usually overlooked by "general" history and only received attention in the history of medicine. Many comparisons were made between the COVID-19 and 1918 influenza pandemics, including the development of anti-mask movements, the widespread promotion of misinformation and the impact of socioeconomic disparities.

In some areas, religious groups exacerbated the spread of the virus, through large gatherings and the dissemination of misinformation. Some religious leaders decried what they saw as violations of religious freedom. In other cases, religious identity was a beneficial factor for health, increasing compliance with public health measures and protecting against the negative effects of isolation on mental wellbeing.

Information dissemination

Some news organizations removed their online paywalls for some or all of their pandemic-related articles and posts. Many scientific publishers provided pandemic-related journal articles to the public free of charge as part of the National Institutes of Health's COVID-19 Public Health Emergency Initiative. According to one estimate from researchers at the University of Rome, 89.5% of COVID-19-related papers were open access, compared to an average of 48.8% for the ten most deadly human diseases. The share of papers published on preprint servers prior to peer review increased dramatically.

Misinformation

Misinformation and conspiracy theories about the pandemic were widespread; they travelled through mass media, social media and text messaging. WHO declared an " infodemic" of incorrect information. Cognitive biases, such as confirmation bias, were linked to conspiracy beliefs, including COVID-19 vaccine hesitancy.

Culture and society

The COVID-19 pandemic had a major impact on popular culture. It was included in the narratives of ongoing pre-pandemic television series and become a central narrative in new ones, with mixed results. Writing for The New York Times about the then-upcoming BBC sitcom Pandemonium on 16 December 2020, David Segal asked, "Are we ready to laugh about Covid-19? Or rather, is there anything amusing, or recognizable in a humorous way, about life during a plague, with all of its indignities and setbacks, not to mention its rituals and rules."

The pandemic had driven some people to seek peaceful escapism in media, while others were drawn towards fictional pandemics (e.g. zombie apocalypses) as an alternate form of escapism. Common themes have included contagion, isolation and loss of control. Many drew comparisons to the fictional film (2011), praising its accuracies while noting some differences, such as the lack of an orderly vaccine rollout.

As people turned to music to relieve emotions evoked by the pandemic, Spotify listenership showed that classical, ambient and children's genres grew, while pop, country and dance remained relatively stable.

Transition to later phases

On 5 May 2023, the WHO declared that the pandemic was no longer a public health emergency of international concern. This led several media outlets to incorrectly report that this meant the pandemic was "over". The WHO commented to Full Fact that it was unlikely to declare the pandemic over "in the near future" and mentioned cholera, which it considers to have continued to be a pandemic since 1961. The WHO does not have an official category for pandemics or make declarations of when pandemics start or end.

Future endemic phase

In June 2022, an article in Human Genomics said that the pandemic was still "raging", but that "now is the time to explore the transition from the pandemic to the endemic phase."

A March 2022 review declared the transition to endemic status to be "inevitable". A June 2022 review predicted that the virus that causes COVID-19 would become the fifth endemic seasonal coronavirus, alongside four other human coronaviruses. A February 2023 review of the four common cold coronaviruses concluded that the virus would become seasonal and, like the common cold, cause less severe disease for most people. As of 2023 the transition to endemic COVID-19 may take years or decades.

Long-term effects

Despite strong economic rebounds following the initial lockdowns in early 2020, towards the latter phases of the pandemic, many countries began to experience long-term economic effects. Several countries saw high inflation rates which had global impacts, particularly in developing countries. Some economic impacts such as supply chain and trade operations were seen as more permanent as the pandemic exposed major weaknesses in these systems.

During the pandemic, a large percentage of workers in Canada came to prefer working from home, which had an impact on the traditional work model. Some corporations made efforts to force workers to return to work on-site, while some embraced the idea.

An increase in excess deaths from underlying causes not related to COVID-19 has been largely blamed on systematic issues causing delays in health care and screening during the pandemic, which has resulted in an increase of non-COVID-19 related deaths.

Immunizations

During the pandemic, millions of children missed out on vaccinations as countries focused efforts on combating COVID-19. Efforts were made to increase vaccination rates among children in low-income countries. These efforts were successful in increasing vaccination rates for some diseases, though the UN noted that post-pandemic measles vaccinations were still falling behind.

Some of the decrease in immunization was driven by an increase in mistrust of public health officials. This was seen in both low-income and high-income countries. Several African countries saw a decline in vaccinations due to misinformation around the pandemic flowing into other areas. Immunization rates have yet to recover in the United States and the United Kingdom.

^ Some refer to "fatality rate"; however, "fatality ratio" is more accurate as this is not per unit time.

References

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The COVID-19 pandemic, also known as the coronavirus pandemic, is a 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 an outbreak in the Chinese city of Wuhan in December 2019.