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Forty - 2019–20 coronavirus pandemic

These include recommendations to have sex only with someone you live with, and who does not have the virus or symptoms of the virus. As a result, the government received criticism for the perceived lack of pace and intensity in its response to concerns faced by the public. 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). Together with a decreased willingness to travel, the restrictions have had a negative economic and social impact on the travel sector in those regions. 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. 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. The Director-General said the WHO was "deeply concerned both by the alarming levels of spread and severity, and by the alarming levels of inaction". 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.
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Forty - 2019–20 coronavirus pandemic

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2019–20 coronavirus pandemic
Map of confirmed cases per capita as of 3 May 2020
  10,000+ confirmed cases per million
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Total confirmed cases map
Map of total confirmed cases as of 30 April 2020
  1,000,000+ confirmed cases
  100,000–999,999 confirmed cases
  10,000–99,999 confirmed cases
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Confirmed deaths per capita map
Map of confirmed deaths per capita as of 30 April 2020
  100+ confirmed deaths per million
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Confirmed cases per capita interactive timeline
Cumulative per capita confirmed COVID-19 cases
Cumulative per capita confirmed COVID-19 cases
Timeline map of confirmed cases per capita
(drag circle to adjust; may not work on mobile)
See larger version
  1,000+ confirmed cases per million
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(clockwise from top)
DiseaseCoronavirus disease 2019 (COVID-19)
Virus strainSevere acute respiratory syndrome
coronavirus 2
(SARS‑CoV‑2)[a]
SourceLikely bats, possibly via pangolins[2][3]
LocationWorldwide (list of locations)
First outbreakChina[4]
Index caseWuhan, Hubei, China
30°37′11″N 114°15′28″E / 30.61972°N 114.25778°E / 30.61972; 114.25778
DateDecember 2019[4] – present
(5 months)
Confirmed cases3,502,126[5][b]
Active cases2,130,892[5]
Recovered1,124,127[5]
Deaths
247,107[5]
Territories
187[5]

The 2019–20 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.[4] The World Health Organization declared the outbreak a Public Health Emergency of International Concern on 30 January, and a pandemic on 11 March.[6][7] As of 3 May 2020, more than 3.5 million cases of COVID-19 have been reported in 187 countries and territories, resulting in more than 247,000 deaths. More than 1.12 million people have recovered.[5]

The virus is primarily spread between people during close contact,[c] often via small droplets produced by coughing,[d] sneezing, or talking.[8][9][11] The droplets usually fall to the ground or onto surfaces rather than remaining in the air over long distances.[8] People may also become infected by touching a contaminated surface and then touching their face.[8][9] 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.[8][11][12][13] 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.[14]

Common symptoms include fever, cough, fatigue, shortness of breath, and loss of smell.[8][15][16] Complications may include pneumonia and acute respiratory distress syndrome.[17] The time from exposure to onset of symptoms is typically around five days, but may range from two to fourteen days.[18][19] There is no known vaccine or specific antiviral treatment.[8] Primary treatment is symptomatic and supportive therapy.[20]

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.[8][21] 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,[22] including the largest global recession since the Great Depression.[23] It has led to the postponement or cancellation of sporting, religious, political and cultural events,[24] widespread supply shortages exacerbated by panic buying,[25][26] and decreased emissions of pollutants and greenhouse gases.[27][28] 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.[29] Misinformation about the virus has spread online,[30] 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.[31][32][33]

Video summary (script) on the coronavirus disease
Video summary (script) on the coronavirus disease

Epidemiology

Locations[e] Cases[b] Deaths[f] Recov.[g] Ref.
Sort both small.svg227 Sort both small.svg3,502,126 Sort both small.svg247,107 Sort both small.svg1,124,127 [5]
United States[h] 1,183,526 68,268 153,200 [41]
Spain 217,466 25,264 118,902 [42]
Italy 210,717 28,884 81,654 [43][44]
United Kingdom[i] 186,599 28,446 [46][47]
Germany[j] 165,565 6,848 126,153 [48][49]
Russia[k] 134,686 1,280 16,639 [50]
France[l] 131,287 24,895 50,784 [51]
Turkey 126,045 3,397 63,151 [52]
Brazil 101,147 7,025 42,991 [53][54]
Iran 97,424 6,203 78,422 [55]
China[m] 82,877 4,633 77,713 [56]
Canada 59,474 3,682 24,908 [57]
Belgium[n] 49,906 7,844 12,309 [59]
Peru 45,928 1,286 13,550 [60][61]
Netherlands[o] 40,571 5,056 [63]
India 40,263 1,306 10,887 [64]
Switzerland 29,905 1,473 24,500 [65][66]
Ecuador 29,538 1,564 3,300 [67][68]
Saudi Arabia 27,011 184 4,134 [69]
Portugal 25,282 1,043 1,689 [70]
Sweden 22,317 2,679 1,543 [43][71]
Mexico 22,088 2,061 13,447 [72]
Ireland 21,506 1,303 13,386 [73]
Pakistan 20,084 457 5,114 [74]
Chile[p] 19,663 260 10,041 [81]
Singapore 18,205 18 1,408 [82][83]
Belarus 16,705 99 3,196 [84]
Israel[q] 16,193 230 9,634 [85]
Qatar 15,551 12 1,664 [86]
Austria 15,533 598 13,228 [87][88]
Japan[r] 15,078 536 3,981 [89][90]
United Arab Emirates 14,163 126 2,762 [91]
Poland 13,693 678 3,945 [43][92]
Romania 13,163 780 4,869 [93][94]
Ukraine[s] 11,913 288 1,547 [95]
Indonesia 11,192 845 1,876 [96]
South Korea 10,793 250 9,183 [97]
Denmark[t] 9,563 484 6,987 [98]
Serbia[u] 9,464 193 1,551 [99]
Bangladesh 9,455 177 1063 [100]
Philippines 9,223 607 1,214 [101]
Dominican Republic 7,954 333 1,606 [102]
Norway[v] 7,847 211 [105]
Czech Republic 7,781 248 3,587 [106]
Colombia 7,688 340 1,722 [107]
Panama 7,197 200 641 [108]
Australia[w] 6,801 95 5,817 [109]
South Africa 6,783 131 2,549 [110]
Egypt[x] 6,465 429 1,562 [111]
Malaysia 6,298 105 4,413 [112]
Finland[y] 5,254 230 3,000 [113]
Kuwait 4,983 38 1,776 [115][116]
Morocco[z] 4,903 174 1,438 [118][119]
Argentina[aa] 4,668 237 1,297 [121]
Algeria 4,474 463 1,936 [122][123]
Moldova[ab] 4,121 125 1,382 [124]
Kazakhstan 3,920 27 1,084 [125]
Luxembourg 3,824 96 3,379 [126]
Bahrain 3,383 8 1,718 [127]
Hungary 2,998 340 629 [128]
Thailand 2,969 54 2,739 [129]
Afghanistan 2,704 85 345 [130]
Greece 2,620 144 1,473 [131][132]
Oman 2,568 12 750 [133]
Nigeria 2,388 85 351 [134]
Armenia 2,386 35 1,035 [135]
Iraq 2,296 97 1,490
[136]
Ghana 2,169 18 229 [137]
Uzbekistan 2,149 10 1,319 [138]
Croatia 2,096 79 1,489 [139]
Cameroon 2,077 64 953 [140]
Azerbaijan[ac] 1,932 25 1,441 [141]
Bosnia & Herzegovina 1,857 77 825 [142]
Puerto Rico 1,808 97 [143][41]
Iceland 1,799 10 1,717 [144]
Estonia 1,700 55 259 [145]
Cuba[ad] 1,649 67 827 [146]
Bulgaria 1,618 73 308 [147]
Guinea 1,586 7 405 [148]
North Macedonia 1,511 84 8945 [149][150]
Bolivia 1,470 71 159 [151]
Slovenia 1,439 96 241 [152][153]
Lithuania 1,410 46 635 [154]
Slovakia 1,408 24 619 [155]
Ivory Coast 1,398 17 653 [156]
Senegal 1,182 9 372 [157]
New Zealand[ae] 1,136 20 1,266 [158]
Djibouti 1,112 2 686 [159]
USS Theodore Roosevelt[af] 1,102 1 53 [160]
Charles de Gaulle[ag] 1,081 0 0 [161]
Hong Kong 1,040 4 879 [165]
Tunisia 1,013 42 328 [166]
Honduras 1,010 76 116 [167]
Latvia 879 16 348 [43][168]
Cyprus[ah] 872 15 296 [169]
Kosovo 851 22 381 [170]
Albania 795 31 531 [171]
Kyrgyzstan 795 10 564 [172]
Niger 750 36 518 [173]
Andorra 747 44 472 [174]
Costa Rica 739 6 386 [175]
Lebanon 737 25 200 [176]
Somalia[ai] 722 32 44 [177]
Sri Lanka 718 7 184 [178]
Diamond Princess[r] 712 13 651 [89][179]
Guatemala 688 17 72 [180]
DR Congo[aj] 674 33 75 [181]
Burkina Faso 662 45 540 [182]
Uruguay[ak] 655 17 442 [183]
Sudan 592 41 52 [184][185]
Georgia[al] 589 9 221 [186]
San Marino 582 41 86 [187]
Mali 563 27 213 [188][189]
Maldives 527 1 18 [190][191]
Palestine 522 2 77 [192]
El Salvador 490 11 154 [193]
Tanzania 480 16 167 [194]
Malta 477 4 392 [195][196]
Kenya 465 24 167 [197]
Jamaica 463 8 33 [198]
Jordan 460 9 367 [199]
Taiwan[am] 432 6 332 [201]
Paraguay 370 10 119 [202]
Venezuela 345 10 148 [203]
Gabon 335 5 85 [204]
Mauritius 332 10 315 [205]
Montenegro 322 8 249 [206]
Isle of Man[an] 321 22 271 [207]
Equatorial Guinea 315 1 9 [208]
Jersey 286 23 197 [209]
Vietnam 271 0 219 [210]
Rwanda 259 0 124 [211][212]
Guinea-Bissau 257 1 19 [213]
Guernsey 252 13 217 [214]
Congo[ao] 229 9 25 [215]
Faroe Islands 187 0 184 [216]
Sierra Leone 166 8 29 [217]
Cape Verde 165 2 33 [218]
Myanmar 155 6 43 [219]
Liberia 155 18 58 [220][221]
Madagascar 149 0 98 [222]
Costa Atlantica 148 0 0 [223]
Guam[af] 146 5 128 [41][224]
Gibraltar 144 0 132 [225]
Brunei 138 1 128 [226][227]
Ethiopia 135 3 75 [228]
Luhansk PR[ap] 129 1 12 [229]
Tajikistan 128 2 0 [230]
Greg Mortimer[ak] 128 0 [231]
Togo 124 9 67 [232]
Zambia 124 3 78 [233]
Cambodia 122 0 120 [234]
Chad 117 10 39 [235]
Trinidad & Tobago 116 8 88 [236]
Bermuda 114 7 51 [237]
Eswatini 112 1 12 [238]
Donetsk PR[ap] 110 4 16 [239]
Northern Cyprus[aq] 108 4 103 [240]
Aruba 100 2 81 [241]
Monaco 95 4 78 [242]
Benin 90 2 42 [243]
Uganda 89 0 52 [244]
Haiti 85 8 10 [245]
Bahamas 82 11 24 [246]
Guyana 82 9 24 [247]
Liechtenstein 82 1 55 [248][249]
Barbados 81 7 44 [250]
Mozambique 80 0 19 [251]
USS Kidd 78 0 0 [160]
Sint Maarten 76 13 44 [252]
Nepal 75 0 16 [253][254]
Cayman Islands 74 1 10 [255]
Central African Republic 72 0 10 [256]
U.S. Virgin Islands 66 4 51 [257]
Libya 63 3 22 [258]
French Polynesia 58 0 51 [259]
South Sudan 46 0 0 [260]
Macau 45 0 39 [261]
Syria[ar] 44 3 27 [262]
Eritrea 39 0 26 [263]
Malawi 39 3 9 [264]
Mongolia 39 0 10 [265]
Angola 35 2 11 [266]
Zimbabwe 34 4 5 [267][268]
Antigua & Barbuda 24 3 11 [269]
East Timor 24 0 16 [270]
Botswana 23 1 8 [271][272]
Grenada 21 0 13 [273]
Laos 19 0 9 [274]
Belize 18 2 13 [275]
Fiji 18 0 14 [276]
New Caledonia 18 0 17 [277]
Saint Lucia 17 0 15 [278]
Saint Vincent[as] 17 0 9 [279][280]
The Gambia 17 1 9 [281]
Curaçao 16 1 13 [282]
Dominica 16 0 13 [283]
Namibia 16 0 8 [284][285]
São Tomé & Príncipe 16 1 4 [286]
Burundi 15 1 7 [287]
Saint Kitts & Nevis 15 0 8 [288]
Nicaragua 14 4 7 [43][289]
Northern Mariana Islands 14 2 11 [290]
Falkland Islands 13 0 13 [291]
MS Zaandam[at] 13 4 [294][295]
Coral Princess[au] 12 2 [297]
Turks & Caicos Islands 12 1 6 [298]
Greenland 11 0 11 [299]
Montserrat 11 1 6 [300]
Seychelles 11 0 7 [301]
Vatican City 11 0 2 [302]
Suriname 10 1 9 [303]
Yemen 10 2 1 [304]
HNLMS Dolfijn[av] 8 0 [305]
Mauritania 8 1 6 [308]
Papua New Guinea 8 0 0 [309]
Artsakh[aw] 7 0 0 [310]
Bhutan 7 0 5 [311]
British Virgin Islands 6 1 3 [312]
Somaliland[ax] 6 0 1 [313]
Abkhazia[ay] 3 0 2 [314][315]
Anguilla 3 0 3 [316]
Comoros 3 0 0 [317]
Bonaire 2 0 2 [318]
Saba 2 0 0 [319]
Sint Eustatius 2 0 1 [320]
Saint Pierre & Miquelon 1 0 0 [321]
As of 3 May 2020 (UTC) · History of cases: China, international
For notes, see the Notes section.


Health authorities in Wuhan, Hubei, China, reported a cluster of viral pneumonia cases of unknown cause on 31 December 2019,[322][323] and an investigation was launched in early January 2020.[324] These cases mostly had links to the Huanan Seafood Wholesale Market and so the virus is thought to have a zoonotic origin.[325] The virus that caused the outbreak is known as SARS‑CoV‑2, a newly discovered virus closely related to bat coronaviruses,[326] pangolin coronaviruses,[327][328] and SARS-CoV.[329] The scientific consensus is that COVID-19 has a natural origin.[330][331]

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.[332][333] Of the early cluster of cases reported that month, two-thirds were found to have a link with the market.[334][335][336] 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.[337][338]

Cases

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.[339] 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.[340] Many countries have had official policies to not test those with only mild symptoms.[341][342] An analysis of the early phase of the outbreak up to 23 January estimated 86 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.[343] Several other studies, using a variety of methods, have estimated that numbers of infections in many countries are likely to be considerably greater than the reported cases.[344][345]

On 9 April 2020, preliminary results found that 15 per cent of people tested in Gangelt, the centre of a major infection cluster in Germany, tested positive for antibodies.[346] Screening for COVID-19 in pregnant women in New York City, and blood donors in the Netherlands, has also found a number of positive tests that may indicate infections may be higher than reported.[347][348] However, such antibody surveys can be unreliable due to a selection bias in who volunteers to take the tests, and due to false positives. Some results (such as the Gangelt study) have received substantial press coverage without first passing through peer review.[349]

Analysis by age in China indicates that a relatively low proportion of cases occur in individuals under 20.[350] It is not clear whether this is because young people are actually less likely to be infected, or less likely to develop serious symptoms and seek medical attention and be tested.[351]

Initial estimates of the basic reproduction number (R0) for COVID-19 in January were between 1.4 and 2.5,[352] 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).[353]

  • Total confirmed cases of COVID-19 per million people[354]
    Total confirmed cases of COVID-19 per million people[354]
  • Epidemic curve of COVID-19 by date of report
    Epidemic curve of COVID-19 by date of report
  • Semi-log graph showing the total (cumulative) number of confirmed cases from the first reported date for the ten most affected countries[355]
    Semi-log graph showing the total (cumulative) number of confirmed cases from the first reported date for the ten most affected countries[355]
  • Semi-log plot of daily new cases of Covid-19 (three-day average) in the world and top five countries (mean with deaths)
    Semi-log plot of daily new cases of Covid-19 (three-day average) in the world and top five countries (mean with deaths)
  • Semi-log plot of cases in some countries with high growth rates (post-China) with three-day projections based on the exponential growth rates
    Semi-log plot of cases in some countries with high growth rates (post-China) with three-day projections based on the exponential growth rates
  • Daily confirmed cases per million by country[356]
    Daily confirmed cases per million by country[356]
  • Linear plot of worldwide COVID-19 cases, recoveries, and deaths[357]
    Linear plot of worldwide COVID-19 cases, recoveries, and deaths[357]
  • COVID-19 total cases per 100 000 population from selected countries[358]
    COVID-19 total cases per 100 000 population from selected countries[358]

Deaths

Deceased in a 53-foot 'mobile morgue' outside a hospital in Hackensack, New Jersey, United States on April 27
Deceased in a 53-foot 'mobile morgue' outside a hospital in Hackensack, New Jersey, United States on April 27

Most people who contract COVID-19 recover. For those who do not, the time between the onset of symptoms and death ranges between 6 and 41 days, typically about 14 days.[359] As of 3 May 2020, approximately 247,000[5] deaths had been attributed to COVID-19. In China, as of 5 February, about 80 per cent of deaths were recorded in those aged over 60, and 75 per cent had pre-existing health conditions including cardiovascular diseases and diabetes.[360]

The first confirmed death was in Wuhan on 9 January 2020.[361] The first death outside China occurred on 1 February in the Philippines,[362] and the first death outside Asia was in France on 14 February.[363]

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.[364] Conversely, deaths of people who had underlying conditions may lead to overcounting.[365] Comparison of statistics for deaths for all causes versus the seasonal average indicates excess mortality in many countries.[366][367] 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.[366]

Several measures are commonly used to quantify mortality.[368] These numbers vary by region and over time, and are influenced by the volume of testing, healthcare system quality, treatment options, time since initial outbreak, and population characteristics, such as age, sex, and overall health.[369] Some countries (like Belgium) include deaths from suspected cases of COVID-19, whether or not the person was tested, resulting in higher numbers when compared to countries that include only test-confirmed cases.[370]

The death-to-case ratio reflects the number of deaths attributed to COVID-19 divided by the number of diagnosed cases within a given time interval. Based on Johns Hopkins University statistics, the global death-to-case ratio is 7.1 per cent (247,107 deaths for 3,502,126 cases) as of 3 May 2020.[5] The number varies by region.[371]

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.[372] The World Health Organization estimated the IFR at 0.37 per cent to 2.9 per cent.[373] 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 0.36 per cent.[374]

  • Total confirmed deaths due to COVID-19 per million people[375]
    Total confirmed deaths due to COVID-19 per million people[375]
  • Semi-log plot of daily deaths due to Covid-19 (three-day average) in the world and top five countries (mean with cases)
    Semi-log plot of daily deaths due to Covid-19 (three-day average) in the world and top five countries (mean with cases)
  • Case fatality rate of COVID-19 by country and confirmed cases
    Case fatality rate of COVID-19 by country and confirmed cases
  • Ongoing case fatality rate of COVID-19 by country
    Ongoing case fatality rate of COVID-19 by country
  • COVID-19 deaths per 100 000 population from selected countries[376]
    COVID-19 deaths per 100 000 population from selected countries[376]

Duration

The WHO said on 11 March 2020 the pandemic could be controlled.[7] 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".[377] 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.[377] 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".[378] 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)".[379] 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.[380]

Signs and symptoms

Symptoms of COVID-19[381]
Symptoms of COVID-19[381]

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 (initially estimated at 30 per cent[382] but later at only 15 per cent[383]), loss of taste, shortness of breath, muscle and joint pain, sore throat, headache, chills, vomiting, hemoptysis, and diarrhea.[384][15][385][386]

The WHO says approximately one person in five becomes seriously ill and has difficulty breathing.[8] The U.S. Centers for Disease Control and Prevention (CDC) lists emergency symptoms as difficulty breathing, persistent chest pain or pressure, sudden confusion, difficulty waking, and bluish face or lips; immediate medical attention is advised if these symptoms are present.[16]

Further development of the disease can lead to potentially fatal complications including pneumonia, acute respiratory distress syndrome, sepsis, septic shock, and kidney failure.[385]

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.[387] Chinese estimates of the asymptomatic ratio range from few to 44 per cent.[388] The usual incubation period (the time between infection and symptom onset) ranges from one to 14 days; it is most commonly five days.[389][8]

Cause

Transmission

Respiratory droplets produced when a man sneezes, visualised using Tyndall scattering
Respiratory droplets produced when a man sneezes, visualised using Tyndall scattering
A video discussing the basic reproduction number and case fatality rate in the context of the pandemic
A video discussing the basic reproduction number and case fatality rate in the context of the pandemic

As COVID-19 is a new disease, many aspects as to how it spreads are being researched.[8][9][11] The disease is spread during close contact, often by small droplets produced during coughing, sneezing, or talking.[8][11] The droplets are transmitted, and cause new infection, when inhaled by people in close contact (1 to 2 metres, 3 to 6 feet). They are produced during breathing out, however as they are relatively heavy, they usually fall to the ground or surfaces.[8][11]

Loud talking releases more droplets than normal talking.[390] A study in Singapore found that an uncovered cough can lead to droplets travelling up to 4.5 metres (15 feet).[391] An article published in March 2020 argued that advice on droplet distance might be based on 1930s research which ignored the effects of warm moist exhaled air surrounding the droplets and that an uncovered cough or sneeze can travel up to 8.2 metres (27 feet).[10]

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.[8] On surfaces the amount of active virus decreases over time until it can no longer cause infection.[11] 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).[11][13] Surfaces are easily decontaminated with household disinfectants which kill the virus outside the human body or on the hands.[8] Notably, however disinfectants or bleach should never be swallowed or injected as a treatment or preventative measure, as this is harmful or potentially fatal.[392]

Sputum and saliva carry large amounts of virus.[393][8][9][11] Some medical procedures may result in the virus being transmitted easier than normal for such small droplets, known as airborne transmission.[8][11]

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.[9][11][394][395] Some people have been infected and recovered without showing symptoms, but uncertainties remain in terms of asymptomatic transmission.[11]

Although COVID-19 is not a sexually transmitted infection, kissing, intimate contact, and faecal oral routes are suspected to transmit the virus.[396][397]

Virology

Illustration of SARSr‑CoV virion
Illustration of SARSr‑CoV virion

Severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) is a novel virus, first isolated from three people with pneumonia connected to the cluster of acute respiratory illness cases in Wuhan.[329] All features of the novel SARS‑CoV‑2 virus occur in related coronaviruses in nature.[398]

SARS‑CoV‑2 is closely related to SARS‑CoV, and is thought to have a zoonotic origin.[326] 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[384] and 92 per cent identical to pangolin coronavirus.[399]

Diagnosis

Demonstration of a swab for COVID-19 testing

COVID-19 can be provisionally diagnosed on the basis of symptoms and confirmed using reverse transcription polymerase chain reaction (rRT-PCR) testing of infected secretions or CT imaging of the chest.[400][401]

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.[402]

A number of laboratories and companies are developing serological tests, which detect antibodies produced by the body in response to infection.[403] As of 6 April 2020, none of these has been proved sufficiently accurate to be approved for widespread use.[404]

Imaging

A CT scan of the chest of a person with COVID‑19. It shows light patches in the lungs.
A CT scan of the chest of a person with COVID‑19. It shows light patches in the lungs.

Characteristic imaging features on chest radiographs and computed tomography (CT) of people who are symptomatic include asymmetric peripheral ground-glass opacities without pleural effusions.[405] The Italian Radiological Society is compiling an international online database of imaging findings for confirmed cases.[406] Due to overlap with other infections such as adenovirus, imaging without confirmation by rRT-PCR is of limited specificity in identifying COVID-19.[405] 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.[401]

Prevention

Infographic by the United States CDC, describing how to stop the spread of germs
Infographic by the United States CDC, describing how to stop the spread of germs

Strategies for preventing transmission of the disease include maintaining overall good personal hygiene, washing hands, avoiding touching the eyes, nose, or mouth with unwashed hands, and coughing or sneezing into a tissue and putting the tissue directly into a waste container. Those who may already have the infection have been advised to wear a surgical mask in public.[407][408] Physical distancing measures are also recommended to prevent transmission.[409][410] Health care providers taking care of someone who may be infected are recommended to use standard precautions, contact precautions, and eye protection.[411]

Many governments have restricted or advised against all non-essential travel to and from countries and areas affected by the outbreak.[412] The virus has already spread within communities in large parts of the world, with many not knowing where or how they were infected.[413]

Misconceptions are circulating about how to prevent infection; for example, rinsing the nose and gargling with mouthwash are not effective.[414] There is no COVID-19 vaccine, though many organisations are working to develop one.[415]

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.[21] 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.[407] The WHO advises people to avoid touching the eyes, nose, or mouth with unwashed hands.[408][416] It is not clear if washing hands with ash if soap is not available is effective at reducing the spread of viral infections.[417]

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.[418] 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.[419]

Face masks and respiratory hygiene

Taiwan President Tsai Ing-wen wearing a mask
Taiwan President Tsai Ing-wen wearing a mask

Recommendations for wearing masks have been a subject of debate.[420] 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.[421] 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.[422][423] Several national and local governments have made wearing masks mandatory.[424]

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.[421]

Social distancing

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

Social distancing (also known as physical distancing) includes infection control actions intended to slow the spread of disease by minimising close contact between individuals. Methods include quarantines; travel restrictions; and the closing of schools, workplaces, stadiums, theatres, or shopping centres. Individuals may apply social distancing methods by staying at home, limiting travel, avoiding crowded areas, using no-contact greetings, and physically distancing themselves from others.[408][425] Many governments are now mandating or recommending social distancing in regions affected by the outbreak.[426][427] Non-cooperation with distancing measures in some areas has contributed to the further spread of the pandemic.[428]

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.[429] On 22 March 2020, Germany banned public gatherings of more than two people.[430] 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.[431]

The pandemic in Peru resulted in curfews enforced by the Peruvian Armed Forces.
The pandemic in Peru resulted in curfews enforced by the Peruvian Armed Forces.

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.[432][433]

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.[434][435]

Some authorities have issued sexual health guidelines for use during the pandemic. These include recommendations to have sex only with someone you live with, and who does not have the virus or symptoms of the virus.[436][437]

Self-isolation

Transmission of COVID-19 depends on many factors, most obviously physical distance.
Transmission of COVID-19 depends on many factors, most obviously physical distance.

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.[438][439]

Many governments have mandated or recommended self-quarantine for entire populations living in affected areas.[440][441] 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.[8][18][442]

Management

Containment and mitigation

Goals of mitigation include delaying and reducing peak burden on healthcare (flattening the curve) and lessening overall cases and health impact.[443][444] Moreover, progressively greater increases in healthcare capacity (raising the line) such as by increasing bed count, personnel, and equipment, helps to meet increased demand.[445]
Goals of mitigation include delaying and reducing peak burden on healthcare (flattening the curve) and lessening overall cases and health impact.[443][444] Moreover, progressively greater increases in healthcare capacity (raising the line) such as by increasing bed count, personnel, and equipment, helps to meet increased demand.[445]
Mitigation attempts that are inadequate in strictness or duration—such as premature relaxation of distancing rules or stay-at-home orders—can allow a resurgence after the initial surge and mitigation.[443][446]
Mitigation attempts that are inadequate in strictness or duration—such as premature relaxation of distancing rules or stay-at-home orders—can allow a resurgence after the initial surge and mitigation.[443][446]

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.[447] Suppression requires more extreme measures so as to reverse the pandemic by reducing the basic reproduction number to less than 1.[379]

Part of managing an infectious disease outbreak is trying to delay and decrease the epidemic peak, known as flattening the epidemic curve.[443] This decreases the risk of health services being overwhelmed and provides more time for vaccines and treatments to be developed.[443] Non-pharmaceutical interventions that may manage the outbreak include personal preventive measures, such as hand hygiene, wearing face masks, and self-quarantine; community measures aimed at physical distancing such as closing schools and cancelling mass gathering events; community engagement to encourage acceptance and participation in such interventions; as well as environmental measures such surface cleaning.[448]

More drastic actions aimed at containing the outbreak were taken in China once the severity of the outbreak became apparent, such as quarantining entire cities and imposing strict travel bans.[449] Other countries also adopted a variety of measures aimed at limiting the spread of the virus. South Korea introduced mass screening and localised quarantines, and issued alerts on the movements of infected individuals. Singapore provided financial support for those infected who quarantined themselves and imposed large fines for those who failed to do so. Taiwan increased face mask production and penalised hoarding of medical supplies.[450]

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.[379]

Contact tracing

Contact tracing is an important method for health authorities to determine the source of an infection and to prevent further transmission.[451] 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.[452]

Several mobile apps have been implemented or proposed for voluntary use, and as of 7 April 2020 more than a dozen expert groups were working on privacy-friendly solutions such as using Bluetooth to log a user's proximity to other cellphones.[452] Users could then receive a message if they've been in close contact with someone who has subsequently tested positive for COVID-19.[452]

On 10 April 2020 Google and Apple jointly announced an initiative for privacy-preserving contact tracing based on Bluetooth technology and cryptography.[453][454] 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.[455] In Europe and in the U.S., Palantir Technologies is also providing COVID-19 tracking services.[456]

Health care

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

Increasing capacity and adapting healthcare for the needs of COVID-19 patients is described by the WHO as a fundamental outbreak response measure.[457] 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.[457][458]

Due to capacity limitations in the standard supply chains, some manufacturers are 3D printing healthcare material such as nasal swabs and ventilator parts.[459][460] 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.[461][462][463] On 23 April 2020, NASA reported building, in 37 days a ventilator which is currently undergoing further testing. NASA is seeking fast-track approval.[464][465]

Treatment

Antiviral medications are under investigation for COVID-19, as well as medications targeting the immune response.[466] None have been so far shown to be clearly effective on mortality in published randomized controlled trials.[466] Remdesivir, however may have an effect on the time it takes to recover from the virus.[467] Emergency use authorization for remdesivir was granted in the US on May 1, 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.[468] Taking over-the-counter cold medications,[469] drinking fluids, and resting may help alleviate symptoms.[407] Depending on the severity, oxygen therapy, intravenous fluids, and breathing support may be required.[470] The use of steroids may worsen outcomes.[471] Several compounds which were previously approved for treatment of other viral diseases are being investigated for use in treating COVID-19.[472]

History

Cases by country plotted on a logarithmic scale[473]
Cases by country plotted on a logarithmic scale[473]

There are several theories about where the very first case (the so-called patient zero) may have originated.[474] The first known case may trace back to 1 December 2019 in Wuhan, Hubei, China.[332] Within a 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.[325]

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.[475][476] 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 3 January),[477] were then admonished by the police for spreading supposedly false rumours, and another, Ai Fen, was reprimanded by her superiors for raising the alarm.[478]

The Wuhan Municipal Health Commission made the first public announcement of a pneumonia outbreak of unknown cause on 31 December, confirming 27 cases[322][479][480]—enough to trigger an investigation.[324]

During the early stages of the outbreak, the number of cases doubled approximately every seven and a half days.[481] 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.[384] On 20 January, China reported nearly 140 new cases in one day, including two people in Beijing and one in Shenzhen.[482] Later official data shows 6,174 people had already developed symptoms by then,[483] and more may have been infected.[484] A report in The Lancet on 24 January indicated human transmission, strongly recommended personal protective equipment for health workers, and said testing for the virus was essential due to its "pandemic potential".[334][485] On 30 January, the WHO declared that the coronavirus was a public health emergency of international concern.[484]

By 26 March, the United States had overtaken China and Italy with the highest number of confirmed cases in the world.[486] 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.[487]

As of 23 April 2020, more than 3.5 million cases have been reported worldwide; more than 247,000 people have died and more than 1.12 million have recovered.[488][489]

National responses

Map of national and subnational lockdowns as of 30 March 2020 (table; more details)   National lockdown  Subnational lockdown  No lockdown
Map of national and subnational lockdowns as of 30 March 2020 (table; more details)
  National lockdown
  Subnational lockdown
  No lockdown

A total of 187[5] countries and territories have had at least one case of COVID-19 so far. Due to the pandemic in Europe, many countries in the Schengen Area have restricted free movement and set up border controls.[490] National reactions have included containment measures such as quarantines and curfews (known as stay-at-home orders, shelter-in-place orders, or lockdowns).[491]

By 26 March, 1.7 billion people worldwide were under some form of lockdown,[492] which increased to 3.9 billion people by the first week of April—more than half the world's population.[493][494]

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.[495] Nearly 300 million people, or about 90 per cent of the population, were under some form of lockdown in the United States,[496] around 100 million people in the Philippines,[495] about 59 million people in South Africa,[497] and 1.3 billion people have been under lockdown in India.[498][499]

Asia

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.[500]

China

Confirmed cases of COVID-19 per 100,000 inhabitants by province, as of 13 April.   Hubei Province — 114.40 cases per 100,000   1.5–2.5 cases per 100,000   1–1.5 cases per 100,000   0.5–1 cases per 100,000   >0–0.5 cases per 100,000
Confirmed cases of COVID-19 per 100,000 inhabitants by province, as of 13 April.
  Hubei Province — 114.40 cases per 100,000
  1.5–2.5 cases per 100,000
  1–1.5 cases per 100,000
  0.5–1 cases per 100,000
  >0–0.5 cases per 100,000
Semi-log graph of new cases and deaths in China during the COVID-19 epidemic showing the lockdown and lifting
Semi-log graph of new cases and deaths in China during the COVID-19 epidemic showing the lockdown and lifting

The first confirmed case of COVID-19 has been traced back to 1 December 2019 in Wuhan;[332] one unconfirmed report suggests the earliest case was on 17 November.[337] 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.[501][502] Initial genetic testing of patient samples on 27 December 2019 indicated the presence of a SARS-like coronavirus.[501] A public notice was released by Wuhan Municipal Health Commission on 31 December, confirming 27 cases and suggesting wearing face masks.[480] The WHO was informed on the same day.[322] As these notifications occurred, doctors in Wuhan were warned by police for "spreading rumours" about the outbreak.[503] The Chinese National Health Commission initially said there was no "clear evidence" of human-to-human transmission.[504] 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.[505] 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.[506]

On 20 January, the Chinese National Health Commission announced that human-to-human transmission of the coronavirus had already occurred.[507] 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.[508][509] During the Chinese New Year travel period in late January, Chinese authorities instigated a lockdown of the City of Wuhan.[510] However, travellers from Wuhan had already transported the virus to some Asian countries,[511][512][513] 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.[514] In what has been described as "the largest quarantine in human history",[515] a cordon sanitaire was announced on 23 January stopping travel in and out of Wuhan,[516][517] which was extended to a total of fifteen cities in Hubei, affecting a total of about 57 million people.[518] Private vehicle use was banned in the city.[519] Chinese New Year (25 January) celebrations were cancelled in many places.[520] The authorities also announced the construction of a temporary hospital, Huoshenshan Hospital, which was completed in ten days.[521] Another hospital, Leishenshan Hospital, was built afterwards to handle additional patients.[522] In addition to newly constructed hospitals, China also converted other facilities in Wuhan, such as convention centres and stadiums, into temporary hospitals.[523]

Wuhan Leishenshan Hospital, an emergency specialty field hospital built in response to the 2019–20 coronavirus pandemic
A temporary hospital for treating mild cases of COVID-19 in Wuhan, one of more than ten such hospitals in the city[524]

On 26 January, the government instituted further measures to contain the COVID-19 outbreak, including issuing health declarations for travellers[525] and extending the Spring Festival holiday.[526] Universities and schools around the country were also closed.[527][528][529] The regions of Hong Kong and Macau instituted several measures, particularly in regard to schools and universities.[530] Remote working measures were instituted in several Chinese regions.[531] Travel restrictions were enacted in and outside of Hubei.[531][532] Public transport was modified,[533] and museums throughout China were temporarily closed.[531][534][535] 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.[536] In January and February 2020, during the height of the epidemic in Wuhan, about 5 million people lost their jobs.[537] Many of China's nearly 300 million rural migrant workers have been stranded at home in inland provinces or trapped in Hubei province.[538][539]

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.[540] At the same time, a strong anti-foreigner sentiment quickly took hold,[541] and foreigners experienced harassment by the general public[542] and forced evictions from apartments and hotels.[33][543]

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.[544] The same day travel restrictions were eased in Hubei, apart from Wuhan, two months after the lockdown was imposed.[545]

The Chinese Ministry of Foreign Affairs announced on 26 March that entry for visa or residence permit holders would be suspended from 28 March onwards, with no specific details on when this policy would end. Those wishing to enter China must to apply for visas in Chinese embassies or consulates.[546][547] The Chinese government encouraged businesses and factories to re-open on 30 March, and provided monetary stimulus packages for firms.[548]

The State Council declared a day of mourning to begin with a national three-minute moment of silence on 4 April, coinciding with Qingming Festival, although the central government asked families to pay their respects online in observance of physical distancing to avoid a renewed COVID-19 outbreak.[549] On 25 April the last patients were discharged in Wuhan.[550]

South Korea

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

COVID-19 was confirmed to have spread to South Korea on 20 January 2020 from China. The nation's health agency reported a significant increase in confirmed cases on 20 February,[551] largely attributed to a gathering in Daegu of the Shincheonji Church of Jesus.[551][552] Shincheonji devotees visiting Daegu from Wuhan were suspected to be the origin of the outbreak.[553][554] As of 22 February, among 9,336 followers of the church, 1,261 or about 13 per cent reported symptoms.[555]

South Korea declared the highest level of alert on 23 February 2020.[556] On 28 February, more than 2,000 confirmed cases were reported,[557] rising to 3,150 on 29 February.[558] All South Korean military bases were quarantined after tests showed three soldiers had the virus.[553] Airline schedules were also changed.[559][560]

A banner in Seoul shares coronavirus infection prevention tips.
A banner in Seoul shares coronavirus infection prevention tips.

South Korea introduced what was considered the largest and best-organised programme in the world to screen the population for the virus, isolate any infected people, and trace and quarantine those who contacted them.[561][562] Screening methods included mandatory self-reporting of symptoms by new international arrivals through mobile application,[563] drive-through testing for the virus with the results available the next day,[564] and increasing testing capability to allow up to 20,000 people to be tested every day.[565] South Korea's programme is considered a success in controlling the outbreak without quarantining entire cities.[561][566]

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 claimed to be government mishandling of the outbreak, or praising his response.[567] On 23 March, it was reported that South Korea had the lowest one-day case total in four weeks.[565] On 29 March it was reported that beginning 1 April all new overseas arrivals will be quarantined for two weeks.[568] Per media reports on 1 April, South Korea has received requests for virus testing assistance from 121 different countries.[569]

Iran

Disinfection of Tehran Metro trains against coronavirus. Similar measures have also been taken in other countries.[570]
Disinfection of Tehran Metro trains against coronavirus. Similar measures have also been taken in other countries.[570]

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.[571][572] Early measures announced by the government included the cancellation of concerts and other cultural events,[573] sporting events,[574] and Friday prayers,[575] and closures of universities, higher education institutions, and schools.[576] Iran allocated five trillion rials to combat the virus.[577] 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.[578] Plans to limit travel between cities were announced in March,[579] although heavy traffic between cities ahead of the Persian New Year Nowruz continued.[580] Shia shrines in Qom remained open to pilgrims until 16 March.[581][582]

Iran became a centre of the spread of the virus after China during February.[583][584] 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.[584][585] The Iranian Parliament was shut down, with 23 of its 290 members reported to have had tested positive for the virus on 3 March.[586] On 15 March, the Iranian government reported a hundred deaths in a single day, the most recorded in the country since the outbreak began.[587] At least twelve sitting or former Iranian politicians and government officials had died from the disease by 17 March.[588] By 23 March, Iran was experiencing fifty new cases every hour and one new death every ten minutes due to coronavirus.[589] 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.[590] The UN High Commissioner for Human Rights has demanded economic sanctions to be eased for nations most affected by the pandemic, including Iran.[591] 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.[592] On 27 April it was reported that 700 people had died from ingesting methanol, falsely believed to be a cure.[593]

Europe

Confirmed cases of SARS‑CoV‑2 infected people in relation to the population of the country (cases per million inhabitants).[489] The numbers are not comparable, as the testing strategy differs among countries and time periods.
Confirmed cases of SARS‑CoV‑2 infected people in relation to the population of the country (cases per million inhabitants).[489] The numbers are not comparable, as the testing strategy differs among countries and time periods.

As of 13 March 2020, the World Health Organization (WHO) considered Europe the active centre of the pandemic. Cases by country across Europe had doubled over periods of typically 3 to 4 days, with some countries (mostly those at earlier stages of detection) showing doubling every 2 days.[594]

As of 17 March, all countries within Europe had a confirmed case of COVID-19, with Montenegro being the last European country to report at least one case.[595] At least one death has been reported in all European countries, apart from the Vatican City.

As of 18 March, more than 250 million people are in lockdown in Europe.[596]

Italy

The outbreak was confirmed to have spread to Italy on 31 January, when two Chinese tourists tested positive for SARS‑CoV‑2 in Rome.[597] Cases began to rise sharply, which prompted the Italian government to suspend all flights to and from China and declare a state of emergency.[598] An unassociated cluster of COVID-19 cases was later detected, starting with 16 confirmed cases in Lombardy on 21 February.[599]

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

On 22 February, the Council of Ministers announced a new decree-law to contain the outbreak, including quarantining more than 50,000 people from eleven different municipalities in northern Italy.[600] 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."[601][602]

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,[603] but on 9 March, all sport was suspended completely for at least one month.[604] On 11 March, Prime Minister Conte ordered stoppage of nearly all commercial activity except supermarkets and pharmacies.[605][606]

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.[607][608][609] 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.[610][611] On 22 March, it was reported that Russia had sent nine military planes with medical equipment to Italy.[612] 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.[613] 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.[614] 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.[615]

Spain

Residents of Valencia, Spain, maintaining social distancing while queueing
Residents of Valencia, Spain, maintaining social distancing while queueing

The pandemic was confirmed to have spread to Spain on 31 January 2020, when a German tourist tested positive for SARS-CoV-2 in La Gomera, Canary Islands.[616] Post-hoc genetic analysis has shown that at least 15 strains of the virus were imported and community transmission had begun by mid-February.[617] By 13 March, cases had been confirmed in all 50 provinces of the country.[citation needed]

A state of alarm and national lockdown was imposed on 14 March.[618] On 29 March it was announced that, beginning the following day, all non-essential workers were to stay home for the next 14 days.[619] By late March, the Community of Madrid has recorded the most cases and deaths in the country. Medical professionals and those who live in retirement homes have experienced especially high infection rates.[620] On 25 March 2020, the death toll in Spain surpassed that reported in mainland China and only Italy had a higher death toll globally.[621] On 2 April, 950 people died of the virus in a 24-hour period—at the time, the most by any country in a single day.[622] The next day Spain surpassed Italy in total cases and is now second only to the United States.[623]

As of 3 May 2020, there have been 217,466 PCR-confirmed cases with 118,902 recoveries and 25,264 deaths in Spain.[624] The actual number of cases, however, is likely to be much higher, as many people with only mild or no symptoms are unlikely to have been tested.[625][626] The number of deceased is also believed to be an underestimate due to lack of testing and reporting, perhaps by as much as 10,000 according to excess mortality analysis.[627]

United Kingdom

NHS Nightingale Hospital London, temporarily established in a converted convention centre
NHS Nightingale Hospital London, temporarily established in a converted convention centre

Before 18 March 2020, the British government did not impose any form of social distancing or mass quarantine measures on its citizens.[628][629] As a result, the government received criticism for the perceived lack of pace and intensity in its response to concerns faced by the public.[630][631]

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.[632][633] On 20 March, the government announced that all leisure establishments such as pubs and gyms were to close as soon as possible,[634] 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.[635]

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.[636]

To ensure the health services always had sufficient capacity to treat COVID-19 patients, a number of temporary critical care hospitals were built around the United Kingdom.[637] The first to be operational was the 4000-bed capacity NHS Nightingale Hospital London, constructed within the ExCeL convention centre over nine days.[638] 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.[639]

France

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

The pandemic reached France on 24 January 2020, when the first COVID-19 case in Europe was confirmed in Bordeaux. 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.[640][641]

On 13 March, Prime Minister Édouard Philippe ordered the closure of all non-essential public places,[642] and on 16 March, French President Emmanuel Macron announced mandatory home confinement, a policy which has been extended at least until 11 May.[643][644][645] As of 23 April, France has reported over 120,804 confirmed cases, 21,856 deaths, and 42,088 recoveries,[646] ranking fourth in number of confirmed cases.[647] In April, there were riots in some Paris suburbs.[648]

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.[649]

On 26 March 2020, the U.S. became the country with the highest number of confirmed COVID-19 infections, with over 82,000 cases.[650] On 11 April 2020, the U.S. became the country with the highest official death toll for COVID-19, with over 20,000 deaths.[651]

As of May 2, 2020 the total cases of COVID-19 were 1,092,815, with 64,238 total deaths.[652]

United States

Confirmed cases of COVID-19 per million inhabitants by state, as of 22 April 2020
Confirmed cases of COVID-19 per million inhabitants by state, as of 22 April 2020

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.[653] The White House Coronavirus Task Force was established on 29 January.[654] On 31 January, the Trump administration declared a public health emergency,[655] and restricted entry for travellers from China who were not citizens of the United States.[656]

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.[657] Despite this, the United States had a slow start in testing, which obscured the extent of the outbreak.[658][659] 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).[658][659]

After the first death in the United States was reported in Washington state on 29 February,[660] Governor Jay Inslee declared a state of emergency,[661] an action soon followed by other states.[662][663] Schools in the Seattle area cancelled classes on 3 March,[664] and by mid-March, schools across the country were shutting down.[665]

President Trump signs the Coronavirus Preparedness and Response Supplemental Appropriations Act into law on 6 March 2020.
President Trump signs the Coronavirus Preparedness and Response Supplemental Appropriations Act into law on 6 March 2020.

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.[666] 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.[667] Corporations imposed employee travel restrictions, cancelled conferences,[668] and encouraged employees to work from home.[669] Sports events and seasons were cancelled.[24]

On 11 March, Trump announced travel restrictions for most of Europe for 30 days, effective 13 March.[670] The following day, he expanded the restrictions to include the United Kingdom and Ireland.[671] On 13 March, he declared a national emergency, which made federal funds available to respond to the crisis.[672] Beginning on 15 March, many businesses closed or reduced hours throughout the U.S. to try to reduce the spread of the virus.[673] By 17 March, the epidemic had been confirmed in all fifty states and in the District of Columbia.[674]

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.[675] On 26 March, the United States had more confirmed cases than any other country.[486] 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.[676]

The hospital ship USNS Comfort arrived in Manhattan on 30 March
The hospital ship USNS Comfort arrived in Manhattan on 30 March

As of 24 April, 889,309 cases have been confirmed in the United States, and 50,256 people have died.[677] Media reports on 30 March said President Trump had decided to extend social distancing guidelines until 30 April.[678] On the same day, the USNS Comfort, a hospital ship with about a thousand beds, made anchor in New York.[679] On 3 April, the U.S. had a record 884 deaths due to the coronavirus in a 24-hour period.[680] In the state of New York, cases exceeded 100,000 people on 3 April.[681]

More than 30 million Americans lost their jobs and applied for government aid.[682][683] 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.[684] Overall approval of Trump's management of the crisis has been polarised along partisan lines.[685] Some U.S. officials and commentators criticised U.S. reliance on importation of critical materials, including essential medical supplies, from China.[686][687]

On 14 April, President Trump halted funding to the World Health Organization, stating they had mismanaged the current pandemic.[688] In late April, President Trump said he would sign an executive order to temporarily suspend immigration to the United States because of the pandemic.[689] 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.[690] On 22 April it was reported that two Californians died from the virus (not, as previously thought, influenza) three weeks before the first official coronavirus case in the U.S. had been acknowledged.[691]

South America

Workers being trained to disinfect buses in Olinda, Pernambuco, Brazil, 16 March 2020
Workers being trained to disinfect buses in Olinda, Pernambuco, Brazil, 16 March 2020
The 2019–20 coronavirus pandemic was confirmed to have reached South America, first reported on 26 February when Brazil confirmed a case in São Paulo.[692] By 3 April, all countries and territories in South America, including the French overseas department of French Guiana, and the British Overseas Territory of the Falkland Islands, have 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,[693] with thousand of excess deaths reported in one province alone compared to the figures for a normal period.[694]

Africa

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".[695][696] 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.[697] 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.[698] As of 30 April, 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.

Oceania

Cases have been confirmed in Australia, Easter Island, Fiji, French Polynesia, Guam, Hawaii, New Caledonia, New Zealand, the Northern Mariana Islands and Papua New Guinea. The first confirmed case was in Melbourne, Victoria on 25 January.[699] Many small Pacific island nations have thus far avoided the outbreak by closing their international borders.

International responses

Travel restrictions

Some of the countries that have imposed a global travel ban in response to the COVID-19 pandemic, as of 23 April 2020   Current ban on foreign travellers  Former ban on foreign travellers
Some of the countries that have imposed a global travel ban in response to the COVID-19 pandemic, as of 23 April 2020
  Current ban on foreign travellers
  Former ban on foreign travellers
The near-empty arrival hall of Seoul–Incheon International Airport in South Korea on 6 March 2020
The near-empty arrival hall of Seoul–Incheon International Airport in South Korea on 6 March 2020

As a result of the pandemic, many countries and regions have imposed quarantines, entry bans, or other restrictions for citizens of or recent travellers to the most affected areas.[700] Other countries and regions have imposed global restrictions that apply to all foreign countries and territories, or prevent their own citizens from travelling overseas.[701]

Together with a decreased willingness to travel, the restrictions have had a negative economic and social impact on the travel sector in those regions. A possible long-term impact has been a decline of business travel and international conferencing, and the rise of their virtual, online equivalents.[702] Concerns have been raised over the effectiveness of travel restrictions to contain the spread of COVID-19.[703]

The European Union rejected the idea of suspending the Schengen free travel zone and introducing border controls with Italy,[704] a decision which has been criticised by some European politicians.[705][706] After some EU member states announced complete closure of their national borders to foreign nationals,[707] the European Commission President Ursula von der Leyen said that "Certain controls may be justified, but general travel bans are not seen as being the most effective by the World Health Organization."[708] A few days later the EU closed its external borders.[709]

A study in Science found that travel restrictions had only modest effects, delaying the initial spread of COVID-19, unless combined with infection prevention and control measures to considerably reduce transmissions.[710] Researchers came to the conclusion 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".[711]

Evacuation of foreign citizens

Ukraine evacuates Ukrainian and foreign citizens from Wuhan, China.
Ukraine evacuates Ukrainian and foreign citizens from Wuhan, China.

Owing to the effective quarantine of public transport in Wuhan and Hubei, several countries evacuated their citizens and diplomatic staff from the area, primarily through chartered flights of the home nation, with Chinese authorities providing clearance. Canada, the United States, Japan, India, Sri Lanka, Australia, France, Argentina, Germany, and Thailand were among the first to plan the evacuation of their citizens.[712] Brazil and New Zealand also evacuated their own nationals and some other people.[713][714] On 14 March, South African repatriated 112 South Africans who tested negative for the virus from Wuhan,[715] while four who showed symptoms were left behind to mitigate risk.[715] Pakistan said it would not evacuate citizens from China.[716]

On 15 February, the U.S. announced it would evacuate Americans aboard the cruise ship Diamond Princess,[717] and on 21 February, Canada evacuated 129 Canadian passengers from the ship.[718] In early March, the Indian government began evacuating its citizens from Iran.[719][720] On 20 March, the United States began to partially withdraw its troops from Iraq due to the pandemic.[721]

International aid

Phase I: Aid to China

Digital billboard conveying support with the words "Be Strong China" in various languages in Shibuya, Tokyo on 10 February 2020
Digital billboard conveying support with the words "Be Strong China" in various languages in Shibuya, Tokyo on 10 February 2020

On 5 February, the Chinese foreign ministry said 21 countries (including Belarus, Pakistan, Trinidad and Tobago, Egypt, and Iran) had sent aid to China.[722] 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.[723]

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.[724] 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".[725] Interaksyon reported that the Chinese government donated 200,000 masks to the Philippines on 6 February, after Philippine senator Richard Gordon shipped 3.16 million masks to Wuhan.[726] On 19 February, the Singapore Red Cross announced that it would send $2.26 million worth of aid to China.[727]

Tehran's Azadi Tower lights in the colours of the flag of China.
Tehran's Azadi Tower lights in the colours of the flag of China.

Several countries donated masks, medical equipment or money to China, including Japan (one million face masks),[728] Turkey, Russia,[729] Malaysia (18 million medical gloves),[730] Germany (10,000 Hazmat suits),[731] and Canada.[732][733] The U.S. State Department said on February 7 it has facilitated the transportation of nearly 17.8 tons of medical supplies to China, including masks, gowns, gauze, respirators, and other vital materials.[734] 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,[735] though on 21 March, China said it had not received epidemic funding from U.S. government and reiterated that on 3 April.[736]

Several corporations have also donated money or medical equipment to China, including Apple,[737] 3M, Bayer, BD, J&J, Medtronic, Qiagen, and other medtech companies including Varian, Roche, ResMed, GE Healthcare, Danaher Corp. and Cepheid.[738]

Phase II: Aid to the globe

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

After cases in China stabilised, the country began sending aid to other nations.[739][740] In March, China, Cuba and Russia sent medical supplies and experts to help Italy deal with its coronavirus outbreak;[741][742] China sent three medical teams and donated over forty tons of medical supplies to Italy.[743] The Spectator USA, citing an unnamed senior Trump administration official, claimed China had sold back to Italy the same PPE Italy had donated to China.[744] 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.[745] He later sent 5,000 testing kits, 100,000 face masks and 5 ventilators to Panama.[746]

The Netherlands, Spain, Turkey, Georgia, and the Czech Republic expressed their concerns over Chinese-made masks and test kits.[747] 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 claimed to defective,[748] although this could have been due to misuse of these products.[749] Belgium recalled 100,000 unusable masks, thought to be from China, but were in fact from Colombia.[750] The Philippines had to stop using the test kits donated by China due to their 40 per cent accuracy.[751] 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,[752][753] On the other hand, Chinese aid has been well-received in parts of Latin America and Africa.[754][755] On 2 April, the World Bank launched emergency support operations for developing countries.[756] 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.[757][758]

WHO response measures

The WHO has commended the efforts of Chinese authorities in managing and containing the epidemic.[759] The WHO noted the contrast between the 2002–2004 SARS outbreak, where Chinese authorities were accused of secrecy that impeded prevention and containment efforts, and the current crisis where the central government "has provided regular updates to avoid panic ahead of Lunar New Year holidays".[760] Critics have said the WHO handled the pandemic inadequately, the public health emergency declaration and pandemic classification coming too late.[761]

December 2019

China and Taiwan both notified the WHO of a new virus on 31 December 2019.[762] 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.[763][764]

January 2020

WHO Director-General Tedros Adhanom
WHO Director-General Tedros Adhanom

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.[765][766] 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.[767] On 27 January, the WHO assessed the risk of the outbreak to be "high at the global level".[768]

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.[6][769] 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."[6][770][771]

February 2020

WHO representatives with Tehran city managers
WHO representatives with Tehran city managers

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".[772]

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".[773]

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."[774]

March 2020

On 11 March, the WHO declared the coronavirus outbreak a pandemic.[775] The Director-General said the WHO was "deeply concerned both by the alarming levels of spread and severity, and by the alarming levels of inaction".[7]

Economic and social policy responses

International governmental organisations are addressing the economic and social impacts of the COVID-19 crisis. The Organisation for Economic Co-operation and Development has launched a platform to provide timely and comprehensive information on policy responses in countries around the world, as well as viewpoints and advice. From policies to strengthen health systems and the world economy to addressing the effects of lock-down and restrictions on travel, the digital hub includes a Country Policy Tracker, and aims to help countries learn from each other and to facilitate a co-ordinated global response to the coronavirus challenge.[776]

Impact

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.[777] 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."[778] There is also concern that people with strokes and appendicitis are not seeking timely treatment.[778]

Politics

The pandemic has affected the political systems of multiple countries, causing suspensions of legislative activities,[779] isolations or deaths of multiple politicians,[780] and rescheduling of elections due to fears of spreading the virus.[781]

China

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

The Chinese government has been criticised by the United States government,[782] UK Minister for the Cabinet Office Michael Gove,[783] and others[784] 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.[785] 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.[786][787] The United States government has referred to the coronavirus as "Chinese virus" or "Wuhan virus", which has been criticised for being racist[788][789] and "distract[ing] from his administration's failure to contain the disease".[790] 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".[791]

The U.S. intelligence community says China intentionally under-reported its number of coronavirus cases.[792] Some outlets such as Politico and Foreign Policy have said China's efforts to send aid to virus-stricken countries is part of a propaganda push for global influence.[793][794] 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'".[795] Borrell also said "China is aggressively pushing the message that, unlike the U.S., it is a responsible and reliable partner."[796] China has also called for the U.S. to lift its sanctions from Syria,[797] Venezuela[798] and Iran,[799] while reportedly sending aid to the latter two countries.[800][801] Jack Ma's donation of 100,000 masks to Cuba was blocked by U.S. sanctions on 3 April.[802] U.S. authorities have also been diverting aid meant for other nations to their own country.[803][804] There have been mask-related disputes reported between other countries as well, including Australia, Austria, Germany, the Netherlands, Switzerland,[805] Turkey, the Czech Republic and Italy.[806]

Italy

In early March, the Italian government criticised the European Union's lack of solidarity with coronavirus-affected Italy,[807][808] with Maurizio Massari, Italy's ambassador to the EU, saying that "only China responded bilaterally", not the EU.[793] 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.[809] President of Lombardy Attilio Fontana and Italian Foreign Minister Luigi Di Maio expressed their gratitude for the aid.[810] Russia also sent a cargo plane with medical aid to the United States.[811] 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."[812]

United States

Several hundred anti-lockdown protesters rallied at the Ohio Statehouse April 20.[813]
Several hundred anti-lockdown protesters rallied at the Ohio Statehouse April 20.[813]

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.[814][815][816] Political analysts anticipated it may negatively affect Donald Trump's chances of re-election in the 2020 presidential election.[817][818] Beginning in mid-April 2020, there were protests in several U.S. states against government-imposed business closures and restricted personal movement and association.[819]

Other countries

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

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.[820][821] 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."[822]

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.[585][823] 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.[824] Saudi Arabia, which launched a military intervention in Yemen in March 2015, declared a ceasefire.[825]

Diplomatic relations between Japan and South Korea worsened due to the pandemic.[826] 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.[827] 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.[567]

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.[828][829] In the Philippines, lawmakers granted president Rodrigo Duterte temporary emergency powers during the pandemic.[830] 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.[831] In some countries, including Egypt,[832] Turkey,[833] and Thailand,[830] opposition activists and government critics have been arrested for allegedly spreading fake news on coronavirus.[834]

Education

Learners affected by school closures caused by COVID-19 as of 22 April 2020[update]   Country-wide school closures   Localized school closures   No school closures   No data
Learners affected by school closures caused by COVID-19 as of 22 April 2020
  Country-wide school closures
  Localized school closures
  No school closures
  No data

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 percent of the world's student population.[835] 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.[836] International Baccalaureate exams have also been cancelled.[837]

School closures impact not only students, teachers, and families, but have far-reaching economic and societal consequences.[838][839] School closures in response to COVID-19 have shed light on various social and economic issues, including student debt,[840] digital learning,[841][842] food insecurity,[843] and homelessness,[844][845] as well as access to childcare,[846] health care,[847] housing,[848] internet,[849] and disability services.[850] 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.[29][851]

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.[852]

Socioeconomics

Supply impacts

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

The 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.[853] The technology industry, in particular, has warned of delays to shipments of electronic goods.[854] 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.[855][856] It has also caused a shortage of personal protective equipment worldwide, with the WHO warning that this will endanger health workers.[857]

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.[858] Price increases and shortages in these illegal drugs have been noticed on the street of the UK.[859] U.S. law enforcement also told the New York Post Mexican drug cartels were having difficulty in obtaining precursors.[860]

Economic impacts

"Those who can, put something in; those who can't, help yourself." Bologna, April 2020.
"Those who can, put something in; those who can't, help yourself." Bologna, April 2020.
A highway sign on the Highway 417 in Ottawa discouraging non-essential travel
A highway sign on the Highway 417 in Ottawa discouraging non-essential travel

The outbreak is a major destabilising threat to the global economy. Agathe Demarais of the Economist Intelligence Unit has forecast that markets will remain volatile until a clearer image emerges on potential outcomes. In January 2020, some analysts estimated the economic fallout of the epidemic on global growth could surpass that of the 2002–2004 SARS outbreak.[861] 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.[862] Global stock markets fell on 24 February due to a significant rise in the number of COVID-19 cases outside China.[863][864] 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)[865] and all three major indexes ending the week down more than 10 per cent.[866] On 28 February, Scope Ratings GmbH affirmed China's sovereign credit rating, but maintained a Negative Outlook.[867] Stocks plunged again due to coronavirus fears, the largest fall being on 16 March.[868] Many consider an economic recession likely.[869][870]

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.[871] The cruise line industry was hard hit,[872] and several train stations and ferry ports have also been closed.[873]

The retail sector has been impacted globally, with reductions in store hours or temporary closures.[874] Visits to retailers in Europe and Latin America declined by 40 per cent. North America and Middle East retailers saw a 50–60 per cent drop.[875] This also resulted in a 33–43 per cent drop in foot traffic to shopping centres in March compared to February. Shopping mall operators around the world imposed additional measures, such as increased sanitation, installation of thermal scanners to check the temperature of shoppers, and cancellation of events.[876]

According to a United Nations Economic Commission for Latin America estimate, the pandemic-induced recession could leave 14–22 million more people in extreme poverty in Latin America than would have been in that situation without the pandemic.[877] The pandemic has disrupted global food supplies and threatens to trigger a new food crisis.[878][879] David Beasley, head of the World Food Programme (WFP), said "we could be facing multiple famines of biblical proportions within a short few months."[880]

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.[881] 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.[882] June prices were down but in the positive range, with a barrel of West Texas trading above $20.[882]

Culture

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

The performing arts and cultural heritage sectors have been profoundly affected by the pandemic, impacting organisations' operations as well as individuals—both employed and independent—globally. Arts and culture sector organisations attempted to uphold their (often publicly funded) mission to provide access to cultural heritage to the community, maintain the safety of their employees and the public, and support artists where possible. By March 2020, across the world and to varying degrees, museums, libraries, performance venues, and other cultural institutions had been indefinitely closed with their exhibitions, events and performances cancelled or postponed.[883] In response there were intensive efforts to provide alternative services through digital platforms.[884]

Another recent and rapidly accelerating fallout of the disease is the cancellation of religious services, major events in sports, and other social events, such as music festivals and concerts, technology conferences, and fashion shows. The film industry has also experienced disruption.[885][886]

Door of a public library in Island Bay, New Zealand
Door of a public library in Island Bay, New Zealand

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.[885] 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.[887][888][885] With the Roman Catholic Diocese of Rome closing its churches and chapels and St. Peter's Square emptied of Christian pilgrims,[885] other religious bodies also cancelled services and limited public gatherings in churches, mosques, synagogues, temples and gurdwaras.[885] Iran's Health Ministry announced the cancellation of Friday prayers in areas affected by the outbreak and shrines were later closed,[575][582] while Saudi Arabia banned the entry of foreign pilgrims as well as its residents to holy sites in Mecca and Medina.[889][890]

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,[891] 2019–20 Premier League,[892] UEFA Euro 2020, 2019–20 NBA season,[893] and 2019–20 NHL season.[894] 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".[895][896]

The entertainment industry has also been affected, with many music groups suspending or cancelling concert tours.[897][898] Many large theatres such as those on Broadway also suspended all performances.[899] 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[900] or creating web-based "festivals" for artists to perform, distribute, and publicise their work.[901] Online, numerous coronavirus-themed Internet memes have spread as many turn to humour and distraction amid uncertainty.[902]

Environment and climate

Images from the NASA Earth Observatory show a stark drop in pollution in Wuhan, China, when comparing NO2 levels in early 2019 (top) and early 2020 (bottom).[903]
Images from the NASA Earth Observatory show a stark drop in pollution in Wuhan, China, when comparing NO2 levels in early 2019 (top) and early 2020 (bottom).[903]
The worldwide disruption caused by the pandemic has resulted in numerous impacts on the environment and the climate. The severe decline in planned travel[904] has caused many regions to experience a drop in air pollution. In China, lockdowns and other measures resulted in a 25 percent reduction in carbon emissions,[905] which one Earth systems scientist estimated may have saved at least 77,000 lives over two months.[906] However, the outbreak has also disrupted environmental diplomacy efforts, including causing the postponement of the 2020 United Nations Climate Change Conference,[907] and the economic fallout from it is predicted to slow investment in green energy technologies.[908]

Xenophobia and racism

Since the start of the outbreak of COVID-19, heightened prejudice, xenophobia, and racism have been noted around the world toward people of Chinese and East Asian descent,[909][910][911] Reports from February (when most cases were confined to China) documented racist sentiments expressed in groups worldwide about Chinese people deserving the virus.[912][913][914] Citizens in countries including Malaysia,[915] New Zealand,[916] Singapore,[917] Japan,[918] Vietnam,[919] and South Korea lobbied to ban Chinese people from entering their countries.[920] Chinese people and other Asians in the United Kingdom and United States have reported increasing levels of racist abuse and assaults.[921][32][922] 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.[788][923]

Houston's Chinatown experienced a reduction in business early during the outbreak when there were still only a few cases.[924]
Houston's Chinatown experienced a reduction in business early during the outbreak when there were still only a few cases.[924]

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,[925][926] 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.[927] Paris has seen riots break out over police treatment of ethnic minorities during the coronavirus lockdown.[928]

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".[929] 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.[930] Chinese racism and xenophobia was criticised by foreign governments and diplomatic corps,[931] and China apologised for discriminatory practices such as restaurants excluding black customers,[932] although these and other accusations of harassment, discrimination and eviction of black people in China continued.[933]

Information dissemination

Many newspapers with paywalls have removed them for some or all of their coronavirus coverage.[934] Many scientific publishers made scientific papers related to the outbreak available with open access.[935] Some scientists chose to share their results quickly on preprint servers such as bioRxiv.[936]

Misinformation

Fake medical advice, unproven treatments, state-sponsored narratives, and conspiracy theories abound.
Fake medical advice, unproven treatments, state-sponsored narratives, and conspiracy theories abound.
The pandemic has resulted in conspiracy theories and misinformation regarding its origin, scale, and the prevention, diagnosis, and treatment of COVID-19.[937][938][939] False information, including intentional disinformation, has been spread through social media,[938][940] text messages,[941] and mass media,[942] including the state media of countries such as China,[943][944] Russia,[945][946] Iran,[947] and Turkmenistan.[938][948] It has been propagated by celebrities, politicians[949][950] (including heads of state in countries such as the United States,[951][952] Iran,[953] and Brazil[954]), and other prominent public figures.[955] Commercial scams have claimed to offer at-home tests, supposed preventives, and "miracle" cures.[956][957] 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.[939][940][958] The World Health Organization has declared an "infodemic" of incorrect information about the virus, which poses risks to global health.[938]

See also

Notes

  1. ^ In summary, this article is about the coronavirus pandemic, which is caused by the disease COVID-19, which is caused by the virus SARS‑CoV‑2.[1]
  2. ^ a b This number shows the cumulative number of confirmed human cases reported to date. The actual number of infections and cases is likely to be higher than reported.[34]
    The total number of cases may not necessarily add up due to the frequency of values being updated for each location.
    Reporting criteria and testing capacity varies between countries.
  3. ^ Close contact is defined as one metre (three feet) by the WHO[8] and two metres (six feet) by the CDC.[9]
  4. ^ An uncovered cough can travel up to 8.2 metres (27 feet).[10]
  5. ^ Countries, territories, and international conveyances where cases were diagnosed. The nationality of the infected and the origin of infection may vary. For some countries, cases are split into respective territories and noted accordingly.
  6. ^ Total deaths may not necessarily add up due to the frequency of values updating for each location. Reporting criteria varies between countries.
  7. ^ Reported recoveries. May not correspond to actual current figures and not all recoveries may be reported. Total recoveries may not necessarily add up due to the frequency of values updating for each location.
    "—" denotes that no reliable or up-to-date data is currently available for that territory, not that the value is zero.
  8. ^ United States
    1. Figures include cases identified on the Grand Princess.
    2. Figures do not include the unincorporated territories of Puerto Rico, Guam, Northern Mariana Islands, and U.S. Virgin Islands, all of which are listed separately.
    3. Not all states or overseas territories report recovery data.
    4. Cases include clinically diagnosed cases as per CDC guidelines.[35]
    5. Recoveries and deaths include probable deaths and people released from quarantine as per CDC guidelines.[36][37][38]
    6. Figures from the United States Department of Defense are only released on a branch-by branch basis since April 2020, without distinction between domestic and foreign deployment, and cases may be reported to local health authorities.[39]
    7. Cases for the USS Theodore Roosevelt, currently docked at Guam, are reported separate from national figures but included in the Navy's totals.
    8. There is also one case reported from Guantanamo Bay Naval Base not included in any other nation or territory's counts.[40] Since April 2020, the United States Department of Defense has directed all bases, including Guantanamo Bay, to not publicize case statistics.[39]
  9. ^ United Kingdom
    1. Excluding all British Overseas Territories and Crown dependencies.
    2. As of 23 March 2020, the UK government does not publish the number of recoveries. The last update on 22 March reported 135 recovered patients.[45]
  10. ^ Germany
    1. Not all state authorities count recoveries.[48]
    2. Recoveries include estimations by the Robert Koch Institute.[48][49]
  11. ^ Russia
    1. Including cases from the disputed Crimea and Sevastopol.
    2. Excluding the cases from Diamond Princess cruise ship which are classified as "on an international conveyance".
  12. ^ France
    1. Including French overseas regions Saint Martin and Saint Barthélemy.
    2. Excluding collectivities of New Caledonia, French Polynesia and Saint Pierre and Miquelon.
    3. Recoveries only include hospitalized cases.[51]
    4. Figures for total confirmed cases and total deaths include data from both hospital and nursing home (ESMS: établissements sociaux et médico-sociaux).[51]
  13. ^ China
    1. Excluding 968 asymptomatic cases under medical observation as of 2 May 2020.
    2. Asymptomatic cases were not reported before 31 March 2020.
    3. Excluding Special Administrative Regions of Hong Kong and Macau.
    4. Does not include Taiwan.
  14. ^ Belgium
    1. The number of deaths also includes untested cases and cases in retirement homes that presumably died because of COVID-19, whilst most countries only include deaths of tested cases in hospitals.[58]
  15. ^ Netherlands
    1. All four constituent countries of the Kingdom of the Netherlands (i.e. the country of the Netherlands [in this table row], Aruba, Curaçao, and Sint Maarten) and the special municipalities of the Caribbean Netherlands (Bonaire, Saba and Sint Eustatius) are listed separately.
    2. The Dutch Government agency RIVM, responsible for the constituent country the Netherlands, does not count its number of recoveries.[62]
  16. ^ Chile
    1. Including the special territory of Easter Island.
    2. On 29 April 2020, the Chilean government started to inform the number of asymptomatic confirmed cases, separated from the official number of confirmed cases.[75] Since 30 April, all confirmed cases (no matter their symptoms) are included in the official number.
    3. Chilean authorities define a person as "recovered" after 14 days since the detection of the virus because "they are no longer contagious".[76] Initially, patients who have died of coronavirus were counted as recovered, following the same criteria, according to Health Minister Jaime Mañalich;[77][78][79] however, this was changed later and Chilean reports inform the number of recovered separated from the deceased.[80]
  17. ^ Israel
    1. Including cases from the disputed Golan Heights.
    2. Excluding cases from the State of Palestine.
  18. ^ a b Diamond Princess and Japan
    1. The British cruise ship Diamond Princess was in Japanese waters, and the Japanese administration was asked to manage its quarantine, with the passengers having not entered Japan. Therefore, this case is included in neither the Japanese nor British official counts. The World Health Organization classifies the cases as being located "on an international conveyance".
  19. ^ Ukraine
    1. Excluding cases from the disputed Crimea and Sevastopol. Cases in these territories are included in the Russian total.
    2. Excluding cases from the unrecognized Donetsk and Lugansk People's Republics.
  20. ^ Denmark
    1. The autonomous territories of the Faroe Islands and Greenland are listed separately.
  21. ^ Serbia
    1. Excluding cases from the disputed Kosovo.
  22. ^ Norway
    1. Estimation of the number of infected:
      • As of 23 March 2020, according to figures from just over 40 per cent of all GPs in Norway, 20,200 patients have been registered with the "corona code" R991. The figure includes both cases where the patient has been diagnosed with coronavirus infection through testing, and where the GP has used the "corona code" after assessing the patient's symptoms against the criteria by the Norwegian Institute of Public Health.[103]
      • As of 24 March 2020, the Norwegian Institute of Public Health estimates that between 7,120 and 23,140 Norwegians are infected with the coronavirus.[104]
  23. ^ Australia
    1. Excluding the cases from Diamond Princess cruise ship which are classified as "on an international conveyance". Ten cases, including one fatality recorded by the Australian government.
  24. ^ Egypt
    1. Includes cases identified on the MS River Anuket.
  25. ^ Finland
    1. Including the autonomous region of the Åland Islands.
    2. The number of recoveries is an estimate based on reported cases which were reported at least two weeks ago and there is no other monitoring data on the course of the disease.[113] The exact number of recoveries is not known, as only a small proportion of patients have been hospitalized.[114]
  26. ^ Morocco
    1. Including cases in the disputed Western Sahara territory controlled by Morocco. There are no confirmed cases in the rest of Western Sahara.[117]
  27. ^ Argentina
    1. Excluding confirmed cases on the claimed territory of the Falkland Islands. Since 11 April, the Argentine Ministry of Health includes them in their official reports.[120]
  28. ^ Moldova
    1. Including the disputed territory of Transnistria.
  29. ^ Azerbaijan
    1. Excluding the self-declared state of Artsakh.
  30. ^ Cuba
    1. Includes cases on the MS Braemar.
    2. Excluding cases from Guantanamo Bay, which is governed by the United States.
  31. ^ New Zealand
    1. The case number supplied here is that of confirmed cases; recoveries include recoveries from uncounted probable cases.
  32. ^ a b Guam and USS Theodore Roosevelt
    1. Cases for the USS Theodore Roosevelt, currently docked at Guam, are reported separately.
  33. ^ Charles de Gaulle
    1. Including cases on the escort frigate Chevalier Paul.
    2. Florence Parly, Minister of the Armed Forces, reported to the National Assembly's National Defense and Armed Forces Committee [fr] that 2010 sailors of the carrier battle group led by Charles de Gaulle had been tested, with 1081 tests returning positive so far.[161] Many of these cases were aboard Charles de Gaulle, some of the cases were reportedly aboard French frigate Chevalier Paul, and it is unclear if any other ships in the battle group had cases on board.[162][163][164]
  34. ^ Cyprus
  35. ^ Somalia
    1. Excluding the de facto state of Somaliland.
  36. ^ DR Congo
  37. ^ a b Greg Mortimer and Uruguay
    1. Although currently anchored off the coast of Uruguay, cases for the Greg Mortimer are currently reported separately. Six have been transferred inland for hospitalization.
  38. ^ Georgia
    1. Excluding the de facto state of Abkhazia.
  39. ^ Taiwan
    1. Including cases from the ROCS Pan Shi.[200]
  40. ^ Isle of Man
    1. Recoveries are presumed. Defined as "An individual testing positive for coronavirus who completes the 14 day self-isolation period from the onset of symptoms who is at home on day 15, or an individual who is discharged from hospital following more severe symptoms."[207]
  41. ^ Congo
    1. Also known as the Republic of the Congo and not to be confused with the DR Congo.
  42. ^ a b Donetsk and Luhansk People's Republic
    1. Note that these territories are distinct from the Ukraine-administered regions of the Donetsk and Luhansk Oblasts.
  43. ^ Northern Cyprus
    1. Cases from this de facto state are not counted by Cyprus.
  44. ^ Syria
    1. Excluding cases from the disputed Golan Heights.
  45. ^ Saint Vincent
    1. The sovereign state of Saint Vincent and the Grenadines.
  46. ^ MS Zaandam
    1. Including cases from MS Rotterdam.
    2. The MS Rotterdam rendezvoused with the Zaandam on March 26 off the coast of Panama City to provide support and evacuate healthy passengers. Both have since docked in Florida.[292][293]
    3. MS Zaandam and Rotterdam's numbers are currently not counted in any national figures.
  47. ^ Coral Princess
    1. The cruise ship Coral Princess has tested positive cases since early April 2020 and has since docked in Miami.[296]
    2. Coral Princess's numbers are currently not counted in any national figures.
  48. ^ HNLMS Dolfijn
    1. All 8 cases currently associated with Dolfijn were reported while the submarine was at sea in the waters between Scotland and the Netherlands.[305]
    2. It is unclear whether the Netherlands National Institute for Public Health and the Environment (RIVM) is including these cases in their total count, but neither their daily update details nor their daily epidemiological situation reports appear to have mentioned the ship, with a breakdown of cases listing the twelve provinces of the country of the Netherlands (as opposed to the kingdom) accounting for all the cases in the total count.[306][307]
    3. As RIVM does not report recoveries, and militaries are generally less transparent than most government agencies due to operations security concerns, it is assumed that no official report on recoveries is forthcoming.
  49. ^ Artsakh
    1. Cases from this de facto state are not counted by Azerbaijan.
  50. ^ Somaliland
    1. Cases from this de facto state are not counted by Somalia.
  51. ^ Abkhazia
    1. Cases from this de facto state are not counted by Georgia.

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