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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).[7][b] The outbreak was identified in Wuhan, China, in December 2019,[4] declared to be a Public Health Emergency of International Concern on 30 January 2020, and recognized as a pandemic on 11 March 2020.[9][10] As of 11 April 2020, more than 1.76 million cases[5] of COVID-19 have been reported in 210 countries and territories,[6] resulting in more than 108,000 deaths. More than 401,000 people have recovered,[5] although there may be a possibility of reinfection.[11][12][13] The case fatality rate was estimated to be 4 percent in China,[14] but varies significantly between countries.[15]

The virus is mainly spread between people during close contact,[c] often via small droplets produced during coughing,[d] sneezing, or talking.[16][17][19] While these droplets are produced when breathing out, they usually fall to the ground or surfaces rather than being infectious over large distances.[16][20][21] People may also become infected by touching a contaminated surface and then their face.[16][17] The virus can survive on surfaces for up to 72 hours.[22] Coronavirus is most contagious during the first three days after onset of symptoms, although spread may be possible before symptoms appear and in later stages of the disease.[23]

Common symptoms include fever, cough and shortness of breath.[24] Complications may include pneumonia and acute respiratory distress syndrome.[25] The time from exposure to onset of symptoms is typically around five days, but may range from two to fourteen days.[24][26] There is no known vaccine or specific antiviral treatment.[16] Primary treatment is symptomatic and supportive therapy.[27]

Recommended preventive measures include hand washing, covering one's mouth when coughing, maintaining distance from other people, and monitoring and self-isolation for people who suspect they are infected.[16][28] Authorities worldwide have responded by implementing travel restrictions, quarantines, curfews, workplace hazard controls, and facility closures.

The pandemic has led to severe global socioeconomic disruption,[29] the postponement or cancellation of sporting, religious, political and cultural events,[30] and widespread shortages of supplies exacerbated by panic buying.[31][32] Schools, universities and colleges have closed either on a nationwide or local basis in 193 countries, affecting approximately 99.4 percent of the world's student population.[33] Misinformation about the virus has spread online,[34][35] 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.[36][37][38][39] Due to reduced travel and closures of heavy industry, there has been a decrease in air pollution and carbon emissions.[40][41]

Video summary (script) on the coronavirus disease.

Epidemiology

Countries and territories[e] Cases[a] Deaths[f] Recov.[g] Ref.
Sort both small.svg230 Sort both small.svg1,767,855 Sort both small.svg108,281 Sort both small.svg401,873 [5]
United States[h] 529,768 20,456 31,186 [51]
Spain[i] 163,027 16,606 59,109 [54]
Italy[j] 152,271 19,468 32,534 [57]
Germany[k] 125,452 2,871 51,853 [58][59]
France[l] 93,790 13,832 26,391 [61][62]
China (mainland)[m] 81,953 3,339 77,525 [63]
United Kingdom[n] 78,991 9,875 [65][66]
Iran[o] 70,029 4,357 41,947 [72]
Turkey 52,167 1,101 2,965 [73][74]
Belgium 28,018 3,346 5,986 [75]
Switzerland 25,107 1,036 12,100 [76]
Netherlands[p] 24,413 2,643 [78]
Canada 23,318 653 6,458 [79]
Brazil[q] 20,727 1,124 [82][83]
Portugal 15,987 470 266 [84]
Austria 13,806 337 6,604 [85][86]
Russia[r] 13,584 106 1,045 [87]
Israel[s] 10,743 101 1,341 [88]
South Korea 10,480 211 7,243 [89]
Sweden[t] 10,151 887 [90]
Ireland 8,928 320 25 [91]
India 7,529 242 653 [92]
Ecuador 7,257 315 411 [93]
Chile 6,927 73 1,864 [94]
Peru 6,848 181 1,739 [95][96]
Norway[u] 6,452 119 [97]
Poland 6,356 208 375 [82][100]
Australia[v] 6,292 56 3,141 [101]
Japan[w] 6,005 94 762 [102]
Denmark[x] 5,996 260 1,955 [104]
Romania 5,990 282 758 [105][106]
Czech Republic 5,902 129 411 [107]
Pakistan 5,011 77 762 [108]
Malaysia 4,530 73 1,995 [109]
Philippines 4,428 247 157 [110][111]
Saudi Arabia 4,033 52 720 [112]
Mexico 3,844 233 633 [113][114]
Indonesia 3,842 327 286 [115]
United Arab Emirates 3,736 20 588 [116]
Serbia[y] 3,380 74 118 [118]
Luxembourg 3,223 54 412 [119]
Panama 2,974 74 17 [120][121]
Finland[z] 2,905 49 [125][126]
Dominican Republic 2,759 135 108 [127]
Qatar 2,728 6 247 [128]
Thailand 2,518 35 1,135 [129][130]
Ukraine[aa] 2,511 73 79 [131]
Colombia 2,473 80 197 [132]
Singapore 2,299 8 528 [133][134]
Belarus 2,226 23 172 [135]
Greece 2,081 93 269 [136][137]
South Africa 2,028 25 410 [138]
Argentina 1,975 82 375 [139]
Egypt[ab] 1,939 146 542 [140][141]
Algeria 1,825 275 460 [142][143]
Iceland 1,689 7 841 [144]
Moldova[ac] 1,560 30 75 [145]
Morocco[ad] 1,545 111 146 [147]
Croatia 1,534 21 323 [148]
Iraq 1,318 72 601
[149]
Hungary 1,310 85 115 [150]
Estonia 1,304 24 93 [151]
Slovenia 1,188 50 148 [152]
Kuwait 1,154 1 133 [153]
Azerbaijan[ae] 1,058 11 200 [154]
Bahrain 1,040 6 555 [155]
New Zealand 1,035 4 422 [156]
Lithuania 1,026 23 54 [157]
Hong Kong 1,001 4 336 [158]
Armenia 967 13 173 [159]
Bosnia and Herzegovina 941 37 139 [160]
Kazakhstan 865 10 81 [161]
Cameroon 820 12 98 [162]
Puerto Rico 788 42 [163]
Uzbekistan 767 3 42 [164]
North Macedonia 760 34 41 [165][166]
Slovakia 728 2 23 [167]
Diamond Princess[w] 712 12 619 [168]
Tunisia 685 28 43 [169]
Bulgaria 661 28 62 [170]
Latvia 630 3 16 [82][171]
Cuba[af] 620 16 77 [172]
Lebanon 619 20 77 [173]
Cyprus[ag] 606 10 58 [174]
Andorra 601 26 71 [175]
Costa Rica 577 3 49 [176]
Afghanistan 555 18 32 [177]
Theodore Roosevelt[ah] 550 0 0 [178]
Oman 546 3 109 [179]
Ivory Coast 533 4 58 [180][181]
Uruguay[ai] 494 7 214 [182]
Niger 491 11 50 [183]
Burkina Faso 484 27 155 [184]
Bangladesh 482 30 36 [185][186]
Albania 433 23 197 [187]
Ghana 408 8 4 [188]
Honduras 392 24 7 [189]
Réunion[aj] 388 0 40 [190]
Taiwan 385 6 99 [191][192]
Jordan 381 7 177 [193]
Malta 370 3 16 [194][195]
San Marino 356 35 53 [196]
Kyrgyzstan 339 5 44 [197]
Mauritius 319 9 28 [198]
Nigeria 318 10 70 [199]
Kosovo[ak] 283 7 58 [200]
Senegal 278 2 137 [201][202]
Bolivia 275 20 2 [203]
Palestine 268 2 57 [204]
Montenegro 263 2 5 [205]
Vietnam 258 0 144 [206]
Guinea 250 0 17 [207]
Georgia[al] 242 3 60 [208]
Isle of Man[am] 226 1 112 [209]
DR Congo 223 20 16 [210]
Guernsey 209 6 48 [211]
Jersey 198 3 [212]
Sri Lanka 198 7 54 [213]
Mayotte 196 3 59 [214]
Kenya 191 7 22 [215]
Djibouti 187 2 36 [216]
Faroe Islands 184 0 145 [217]
Venezuela 175 9 84 [218]
Martinique 155 6 50 [219]
Guadeloupe 143 8 67 [220]
Guatemala 137 3 19 [221]
Brunei 136 1 99 [222][223]
Guam[ah] 133 5 41 [51][224]
Paraguay 133 6 18 [82][225]
Gibraltar 129 0 84 [226]
Greg Mortimer[an] 128 0 0 [227]
Cambodia 120 0 75 [228]
El Salvador 118 6 19 [229]
Rwanda 118 0 7 [230][231]
Trinidad and Tobago 109 8 3 [232]
Madagascar 102 0 11 [233]
Northern Cyprus[ao] 99 3 44 [234]
Aruba 92 0 29 [235]
Monaco 92 1 5 [236]
Mali 87 7 22 [237]
French Guiana[ap] 86 0 51 [62][238]
Liechtenstein 79 1 55 [239][240]
Togo 76 3 25 [241]
Jamaica 69 4 13 [242][243]
Ethiopia 69 3 10 [244][245]
Barbados 67 4 11 [246]
Republic of the Congo 60 5 0 [247]
Uganda 53 0 0 [248]
French Polynesia 51 0 0 [249]
U.S. Virgin Islands 51 1 43 [250]
Charles de Gaulle 50 0 0 [251]
Sint Maarten 50 8 3 [252]
Bermuda 48 4 25 [253]
Gabon 46 1 1 [254]
Cayman Islands 45 1 6 [255]
Guyana 45 6 8 [256][257]
Macau 45 0 10 [258]
Bahamas 42 8 5 [259]
Zambia 40 2 25 [260]
Guinea-Bissau 38 0 0 [261]
Liberia 37 5 3 [262]
Benin 35 1 5 [263]
Eritrea 34 0 0 [264]
Saint Martin 33 3 13 [265]
Tanzania 32 3 5 [266]
Haiti 31 2 [267][268]
Myanmar 31 3 2 [269]
Syria 25 2 5 [270]
Libya 24 1 8 [271]
Antigua and Barbuda 21 2 0 [272][273]
Somalia[aq] 21 1 1 [274]
Mozambique 20 0 2 [275]
Angola 19 2 2 [276]
Maldives 19 0 13 [277]
Sudan 19 2 2 [278]
Donetsk PR[ar] 18 0 0 [280][281]
Equatorial Guinea 18 0 3 [282]
Laos 18 0 0 [283]
New Caledonia 18 0 1 [284]
Dominica 16 0 5 [285]
Fiji 16 0 0 [286]
Mongolia 16 0 11 [287]
Namibia 16 0 2 [288][289]
Saint Lucia 15 0 0 [290]
Curaçao 14 1 7 [291]
Grenada 14 0 0 [292]
Belize 13 2 11 [293][294]
Botswana 13 1 0 [295]
MS Zaandam[as] 13 4 0 [298][299]
Zimbabwe 13 3 0 [300]
Coral Princess[at] 12 2 0 [302]
Eswatini 12 0 7 [303]
Malawi 12 2 0 [304]
Saint Kitts and Nevis 12 0 0 [305]
St. Vincent[au] 12 0 1 [306]
Chad 11 0 9 [307]
Seychelles 11 0 0 [308]
Greenland 11 0 11 [309]
N. Mariana Islands 11 2 [310]
Akrotiri and Dhekelia 10 0 0 [311]
Åland Islands 10 0 0 [312]
Sierra Leone 10 0 0 [313]
Suriname 10 1 4 [314]
Gambia 9 1 2 [315]
Montserrat 9 0 0 [295]
Nepal 9 0 1 [316][317]
Cape Verde 8 1 0 [318]
Central African Republic 8 0 0 [319]
Luhansk PR[ar] 8 0 1 [320][321]
Nicaragua 8 1 2 [322][323]
Turks & Caicos Islands 8 1 [324]
Vatican City 8 0 2 [325]
Mauritania 7 1 2 [326]
Saint Barthélemy 6 0 1 [265]
Artsakh 5 0 0 [327]
Burundi 5 0 0 [328]
Bhutan 5 0 2 [329]
Falkland Islands 5 0 0 [330]
São Tomé and Príncipe 4 0 0 [331]
South Sudan 4 0 0 [332]
Anguilla 3 0 0 [333]
British Virgin Islands 3 0 0 [334]
East Timor 2 0 0 [335]
Papua New Guinea 2 0 0 [336]
Sint Eustatius 2 0 0 [337][338]
Somaliland 2 0 0 [339][340]
Abkhazia 1 0 0 [341]
Guantanamo Bay[av] 1 0 0 [342]
Saint Pierre and Miquelon 1 0 0 [343]
Guayana Esequiba 1 0 0 [344]
Yemen 1 0 0 [345]
As of 11 April 2020 (UTC) · History of cases: China, international
For notes, see the Notes section.

Health authorities in Wuhan, China (the capital of Hubei province), reported a cluster of pneumonia cases of unknown cause on 31 December 2019,[346] and an investigation was launched in early January 2020.[347] The cases mostly had links to the Huanan Seafood Wholesale Market and so the virus is thought to have a zoonotic origin.[348] The virus that caused the outbreak is known as SARS-CoV-2, a newly discovered virus closely related to bat coronaviruses,[349] pangolin coronaviruses,[10] and SARS-CoV.[350]

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.[351][352] Of the early cluster of cases reported in December 2019, two-thirds were found to have a link with the market.[353][354][355] On 13 March 2020, an unverified report from the South China Morning Post suggested that a case traced back to 17 November 2019, in a 55-year-old from Hubei province, may have been the first.[356][357]

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.[358] As of 23 March, no country had tested more than 3% of its population,[359] and many countries have had official policies not to test those with only mild symptoms, such as Italy,[360] the Netherlands,[361] Spain,[362] and Switzerland.[363] An analysis of the early phase of the outbreak estimated that up to 23 January, 86% of COVID-19 infections had not been detected, and that these undocumented infections were the infection source for 79% of documented cases.[364] Several other statistical studies, using a variety of methods, have estimated that numbers of infections in many countries were considerably greater than the reported cases.[365][366]

Analysis by age in China indicates that a relatively low proportion of cases occur in individuals below 20 years of age.[367]

Initial estimates of the basic reproduction number (R0) for COVID-19 in January were between 1.4 and 2.5,[368] but a subsequent statistical analysis has concluded that it may be much higher.[369]

Deaths

Most people with COVID-19 recover. For those who do not, the time from development of symptoms to death has been between 6 and 41 days, with the most common being 14 days.[372] As of 11 April 2020, approximately 108,000[5] deaths had been attributed to COVID-19. In China, as of 5 February about 80% of deaths were in those over 60, and 75% had pre-existing health conditions including cardiovascular diseases and diabetes.[373]

Official tallies of deaths from the COVID-19 pandemic generally refer to dead people who tested positive for COVID-19 according to official protocols. The number of true fatalities from COVID-19 may be much higher, as it may not include people who die without testing—e.g. at home or in nursing homes.[374] Partial data from Italy found that the number of excess deaths during the pandemic exceeded the official COVID-19 death tally by a factor of 4–5x.[375] A spokesperson for the U.S. Centers for Disease Control and Prevention (CDC) acknowledged "We know that [the stated death toll] is an underestimation",[376] a statement corroborated by anecdotal reports of undercounting in the U.S.[377] There are indications of undercounting of deaths in Brazil,[378] China,[379] Iran,[380] North Korea,[381] Russia,[382] UK,[383] and the US.[384] Such underestimation often occurs in pandemics, such as the 2009 H1N1 swine flu epidemic.[376]

The first confirmed death was in Wuhan on 9 January 2020.[385] The first death outside mainland China occurred on 1 February in the Philippines,[386] and the first death outside Asia was in France on 14 February.[387] By 28 February, outside mainland China, more than a dozen deaths each were recorded in Iran, South Korea, and Italy.[388][389][390] By 13 March, more than forty countries and territories had reported deaths, on every continent except Antarctica.[391]

Several measures are commonly used to quantify mortality.[392] 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.[393]

The death-to-case ratio reflects the number of deaths divided by the number of diagnosed cases within a given time interval. Based on Johns Hopkins University statistics, the global death-to-case ratio is 6.1% (108,281/1,767,855) as of 11 April 2020.[5] The number varies by region.[394] In China, estimates for the death-to-case ratio decreased from 17.3% (for those with symptom onset 1–10 January 2020) to 0.7% (for those with symptom onset after 1 February 2020).[395]

Other measures include the case fatality rate (CFR), which reflects the percent of diagnosed people who die from a disease, and the infection fatality rate (IFR), which reflects the percent 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. A number of academics have attempted to calculate these numbers for specific populations.[396][397] The University of Oxford's Centre for Evidence-Based Medicine estimates that the infection fatality rate for the pandemic as a whole is between 0.1% and 0.39%.[398] The upper estimate of this range is consistent with the results from the first random testing for COVID-19 in Germany, and a statistical study analysing the impact of testing on CFR estimates.[399][366]

Duration

The WHO asserts that the pandemic can be controlled.[10] The peak and ultimate duration of the outbreak are uncertain and may differ by location. Maciej Boni of Penn State University stated, "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".[401] The Chinese government's senior medical adviser Zhong Nanshan argued that "it could be over by June" if all countries can be mobilized to follow the WHO's advice on measures to stop the spread of the virus.[401] On 17 March, Adam Kucharski of the London School of Hygiene & Tropical Medicine stated that SARS-CoV-2 "is going to be circulating, potentially for a year or two".[402] 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)".[403] William Schaffner of Vanderbilt University stated, "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.[404]

Signs and symptoms

Symptoms of COVID-19[405]

Symptoms of COVID-19 can be relatively non-specific and infected people may be asymptomatic. The two most common symptoms are fever (88%) and dry cough (68%). Less common symptoms include fatigue, respiratory sputum production (phlegm), loss of the sense of smell, shortness of breath, muscle and joint pain, sore throat, headache, chills, vomiting, hemoptysis, diarrhea, or cyanosis.[2][406][407][408]

The WHO states that approximately one person in six becomes seriously ill and has difficulty breathing.[409] 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.[410]

Further development of the disease can lead to severe pneumonia, acute respiratory distress syndrome, sepsis, septic shock and death. Some of those infected may be asymptomatic, with no clinical symptoms but with 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.[353][411][412][413] Chinese estimates of the asymptomatic ratio range from few to 44%.[414] The usual incubation period (the time between infection and symptom onset) ranges from one to 14 days; it is most commonly five days.[415][416]

As an example of uncertainty, the estimate of the fraction of people with COVID-19 who lost their sense of smell was initially 30%[417] and later fell to 15%.[418]

Cause

Transmission

Cough/sneeze droplets visualized in dark background using Tyndall scattering
Respiratory droplets, produced when a man is sneezing.
A video discussing the basic reproduction number and case fatality rate in the context of the pandemic

Some details about how the disease is spread are still being determined.[17] The disease is believed to be primarily spread during close contact and by small droplets produced during coughing, sneezing, or talking;[16][17][19] with close contact being within 1 to 2 metres (3 to 6 feet).[16][17] Both sputum and saliva can carry large viral loads.[419] Studies have found that an uncovered coughing can lead to droplets travelling up to 4.5 metres (15 feet) to 8.2 metres (27 feet).[420][18] Some have proposed that the virus may also be transmitted by small droplets that stay for more prolonged periods in the air, that may be generated during speech.[421]

Respiratory droplets may also be produced during breathing out, including when talking, though the virus is not generally airborne.[16][422] The droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into the lungs.[423] Some medical procedures such as intubation and cardiopulmonary resuscitation (CPR) may cause respiratory secretions to be aerosolized and thus result in airborne spread.[422] It may also spread when one touches a contaminated surface, including skin, and then touches their eyes, nose, or mouth.[16] While there are concerns it may spread by faeces, this risk is believed to be low.[16][17] The Government of China denied the possibility of faecal-oral transmission of SARS-CoV-2.[424]

The virus is most contagious during the first three days after onset of symptoms, although spread may be possible before symptoms appear and in later stages of the disease.[17][425] People have tested positive for the disease up to three days before onset of symptoms suggesting transmission is possible before developing significant symptoms.[425][426] Only few reports of laboratory-confirmed asymptomatic cases exist, but asymptomatic transmission has been identified by some countries during contact tracing investigations.[citation needed] The European Centre for Disease Prevention and Control (ECDC) states that while it is not entirely clear how easily the disease spreads, one person generally infects two to three others.[19]

The virus survives for hours to days on surfaces.[19][427] Specifically, the virus was found to be detectable for up to three days on plastic (polypropylene) and 304 stainless steel, for one day on cardboard, and for up to four hours on copper.[22] This, however, varies based on the humidity and temperature.[428]

Pets and other animals have tested positive for COVID-19. There is no evidence animals can pass the virus on to humans,[429][430] though British authorities advise washing one's hands after contact with animals, like after contact with other potentially contaminated surfaces.[431][432]

Virology

Illustration of SARSr-CoV virion

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel virus, first isolated from three people with pneumonia connected to the cluster of acute respiratory illness cases in Wuhan.[350] All features of the novel SARS-CoV-2 virus occur in related coronaviruses in nature.[433]

Outside the human body, the virus is killed by household soap, which dissolves its protective envelope.[434]

SARS-CoV-2 is closely related to the original SARS-CoV.[435] It is thought to have a zoonotic origin. Genetic analysis has revealed that the coronavirus genetically clusters with the genus Betacoronavirus, in subgenus Sarbecovirus (lineage B) together with two bat-derived strains. It is 96% identical at the whole genome level to other bat coronavirus samples (BatCov RaTG13).[2] In February 2020, Chinese researchers found that there is only one amino acid difference in certain parts of the genome sequences between the viruses from pangolins and those from humans. Whole-genome comparison to date has found at most 92% of genetic material shared between pangolin coronavirus and SARS-CoV-2, which is insufficient to prove pangolins to be the intermediate host.[3]

Diagnosis

Demonstration of a swab for COVID-19 testing.

Infection by the virus can be provisionally diagnosed on the basis of symptoms, though confirmation is ultimately by reverse transcription polymerase chain reaction (rRT-PCR) of infected secretions or CT imaging.[436][437] A study comparing PCR to CT in Wuhan has suggested that CT is significantly more sensitive than PCR, though less specific, with many of its imaging features overlapping with other pneumonias and disease processes.[437] As of March 2020, the American College of Radiology recommends that "CT should not be used to screen for or as a first-line test to diagnose COVID-19".[438]

Viral testing

The WHO has published several RNA testing protocols for SARS-CoV-2, with the first issued on 17 January.[439][440][441] The test uses real-time reverse transcription polymerase chain reaction (rRT-PCR).[442] The test can be done on respiratory or blood samples.[443] Results are generally available within a few hours to days.[444][445] Generally this test is carried out on a nasopharyngeal swab though a throat swab may also be used.[446]

A number of laboratories and companies are developing serological tests, which detect antibodies.[447] As of 6 April 2020, none of these has been proved sufficiently accurate to be approved for widespread use.[448] In the US a serological test developed by Cellex has been approved for emergency use by certified laboratories only.[449]

Imaging

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

Characteristic imaging features on radiographs and computed tomography (CT) of people who are symptomatic include asymmetric peripheral ground glass opacities and absent pleural effusions.[450] The Italian Radiological Society is compiling an international online database of imaging findings for confirmed cases.[451] Due to overlap with other infections such as adenovirus, imaging without confirmation by PCR is of limited specificity in identifying COVID-19.[450] 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, suggesting its consideration as a screening tool in epidemic areas.[452] Artificial intelligence-based convolutional neural networks have been developed to detect imaging features of the virus with both radiographs[453] and CT.[454]

Prevention

Infographic by Public Health Agency of Sweden, describing how to protect yourself and others from infection in response to COVID-19.

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.[455][456][457] Physical distancing measures are also recommended to prevent transmission.[458][459]

Many governments have restricted or advised against all non-essential travel to and from countries and areas affected by the outbreak.[460] However, the virus has reached the stage of community spread in large parts of the world. This means that the virus is spreading within communities, and some community members don't know where or how they were infected.[461]

Health care providers taking care of someone who may be infected are recommended to use standard precautions, contact precautions, and eye protection.[462]

Contact tracing is an important method for health authorities to determine the source of an infection and to prevent further transmission.[463] The use of location data from mobile phones by governments for this purpose has prompted privacy concerns, with Amnesty International and over 100 other organizations issuing a statement calling for limits on this kind of surveillance.[464] Various mobile apps have been implemented or proposed for voluntary use, and as of 7 April 2020, over a dozen expert groups were working on privacy-friendly solutions, such as using Bluetooth to log a user's proximity to other cellphones.[464] Users then receive a message if they've been in close contact with someone who has tested positive for COVID-19.[464]

On 10 April 2020 Google and Apple, jointly announced an initiative for privacy-preserving contact tracing based on Bluetooth technology and cryptography.[465] They also published specifications of the core technologies used in the system.[466] According to an announcement by Google, the system is intended to allow governments to create official privacy-preserving coronavirus tracking apps, with the eventual goal of integration of this functionality directly into the iOS and Android mobile platforms.[467]

Misconceptions are circulating about how to prevent infection; for example, rinsing the nose and gargling with mouthwash are not effective.[468] There is no COVID-19 vaccine, though many organizations are working to develop one.[469]

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.[28] CDC further recommended using an alcohol-based hand sanitizer with at least 60% alcohol by volume when soap and water are not readily available.[455] The WHO advises people to avoid touching the eyes, nose, or mouth with unwashed hands.[456][470]

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% ethanol, 50–100% isopropanol, 0.1% sodium hypochlorite, 0.5% hydrogen peroxide, and 0.2–7.5% povidone-iodine. Other solutions, such as benzalkonium chloride and chrohexidine gluconate, are less effective. The CDC recommends that if a COVID 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.[471][472]

Face masks and respiratory hygiene

Taiwan President Tsai Ing-wen wearing a mask.

Health organizations recommended that people cover their mouth and nose with a bent elbow or a tissue when coughing or sneezing, and disposing of any tissue immediately.[456][473] Surgical masks are recommended for those who may be infected,[474][475][476] as wearing a mask can limit the volume and travel distance of expiratory droplets dispersed when talking, sneezing, and coughing.[477] The WHO has issued instructions on when and how to use masks.[478]

Masks have also been recommended for use by those taking care of someone who may have the disease.[476] The WHO has recommended the wearing of masks by healthy people only if they are at high risk, such as those who are caring for a person with COVID-19, although they also acknowledge that wearing masks may help people avoid touching their face.[476] Several countries encourage the use of face masks more generally by members of the public.[479][480]

Social distancing

Social distancing by maintaining physical separation at a London pharmacy on 23 March 2020.

Social distancing (also known as physical distancing) includes infection control actions intended to slow the spread of disease by minimizing 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.[481][482] Many governments are now mandating or recommending social distancing in regions affected by the outbreak.[483][484] The maximum gathering size recommended by US government bodies and health organizations was swiftly reduced from 250 people (if there was no known COVID-19 spread in a region) to 50 people, and later to 10 people.[485] On 22 March 2020, Germany banned public gatherings of more than two people.[486]

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.[487][488]

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.[489][490][491]

Some authorities have issued sexual health guidelines for use during the pandemic. These include recommendations to only have sex with someone you live with, who does not have the virus or symptoms of the virus.[492][493]

Self-isolation

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.[494][495]

Many governments have mandated or recommended self-quarantine for entire populations living in affected areas.[496][497] 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.[16][24][498][499]

Containment and mitigation

Key goals of community mitigation are delaying and reducing peak burden on healthcare—known as flattening the curve—and lessening overall cases and health impact.[500][501]
If mitigation is inadequate in strictness or duration—such as through premature relaxation of physical distancing rules or stay-at-home orders—there can be a resurgence after the initial surge and mitigation.[500][502]

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.[503] Suppression requires more extreme measures so as to reverse the pandemic by reducing the basic reproduction number to less than 1.[504]

Part of managing an infectious disease outbreak is trying to decrease the epidemic peak, known as flattening the epidemic curve.[500] This decreases the risk of health services being overwhelmed and provides more time for vaccines and treatments to be developed.[500] 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.[505]

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.[506] Other countries also adopted a variety of measures aimed at limiting the spread of the virus. South Korea introduced mass screening and localized 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 penalized hoarding of medical supplies.[507]

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 2/3 and deaths by half, but still result in hundreds of thousands of deaths and health systems being overwhelmed. 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, if that comes first), as transmission otherwise quickly rebounds when measures are relaxed. Long-term intervention to suppress the pandemic causes social and economic costs.[504]

Management

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

Treatment

There are no specific antiviral medications approved for COVID-19, but development efforts are underway, including testing of existing medications. Taking over-the-counter cold medications,[508] drinking fluids, and resting may help alleviate symptoms.[455] Depending on the severity, oxygen therapy, intravenous fluids, and breathing support may be required.[509] The use of steroids may worsen outcomes.[510] Several compounds that were previously approved for treatment of other viral diseases are being investigated for use in treating COVID-19.[511] The WHO also stated that some "traditional and home remedies" can provide relief of the symptoms caused by SARS-CoV-2.[512]

Health care capacity

Increasing capacity and adapting healthcare for the needs of COVID-19 patients is described by the WHO as a fundamental outbreak response measure.[513] 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.[513][514]

History

Cases by country plotted on a logarithmic scale

There are various theories about where the very first case (the so-called patient zero) may have originated.[515] The first known case of the novel coronavirus may trace back to 1 December 2019 in Wuhan, Hubei, China.[351] Within a month, the number of coronavirus cases in Hubei gradually increased. 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 kinds of animals; or, in other words, has a zoonotic origin.[348]

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.[516][517] 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,[518] were admonished by the police for spreading false rumours, and another, Ai Fen, was reprimanded by her superiors for raising the alarm.[519] The Wuhan Municipal Health Commission later released a public notice on 31 December and informed the World Health Organization (WHO).[346][520][521] Enough cases of unknown pneumonia had been reported to health authorities in Wuhan to trigger an investigation in early January.[347]

During the early stages of the outbreak, the number of cases doubled approximately every seven and a half days.[522] 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.[2] On 20 January, China reported nearly 140 new cases in one day, including two people in Beijing and one in Shenzhen.[523] Later official data shows that 6,174 people had already developed symptoms by 20 January 2020.[524]

As of 26 March, the United States has overtaken China and Italy with the highest number of confirmed cases in the world.[525]

As of 9 April 2020, more than 1.76 million cases have been reported worldwide; more than 108,000 people have died and more than 401,000 have recovered.[526][6]

Domestic responses

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

Around 200 countries and territories have had at least one case.[6] Due to the pandemic in Europe, many countries in the Schengen Area have restricted free movement and set up border controls.[527] National reactions have included containment measures such as quarantines (known as stay-at-home orders, shelter-in-place orders, or lockdowns) and curfews.[528]

As of 2 April, nearly 300 million people, or about 90% of the population, are under some form of lockdown in the United States,[529] more than 50 million people are in lockdown in the Philippines,[530] about 59 million people are in lockdown in South Africa,[531] and 1.3 billion people are in lockdown in India.[532][533] On 26 March, 1.7 billion people worldwide were under some form of lockdown,[534] which increased to 2.6 billion people two days later—around a third of the world's population.[535][536]

Asia

As of 7 April 2020, cases have been reported in all Asian countries except for Tajikistan and Turkmenistan.

China

Confirmed cases of COVID-19 per 100,000 inhabitants by province, as of 23 March 2020.
Aerial video from China News Service shows mostly empty roads after motor vehicles were banned in central urban areas of Wuhan. Video shown on 26 January 2020.

The first confirmed case of COVID-19 has been traced back to 1 December 2019 in Wuhan;[351] one unconfirmed report suggests the earliest case was on 17 November.[356] 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.[537][538] Initial genetic testing of patient samples on 27 December 2019 indicated the presence of a SARS-like coronavirus.[537] A public notice was released by Wuhan Municipal Health Commission on 31 December.[521] The WHO was informed on the same day.[346] As these notifications occurred, doctors in Wuhan were warned by police for "spreading rumours" about the outbreak.[539] The Chinese National Health Commission initially claimed that there was no "clear evidence" of human-to-human transmission.[540]

A temporary hospital for treating mild cases of COVID-19 in Wuhan, one of more than 10 such hospitals in the city[541]

In late January, the Chinese government launched a radical campaign later described by the Chinese Communist Party general secretary Xi Jinping as a "people's war" to contain the spread of the virus.[542] In what has been described as "the largest quarantine in human history",[543] a cordon sanitaire was announced on 23 January stopping travel in and out of Wuhan,[544][545] which was extended to a total of 15 cities in Hubei, affecting a total of about 57 million people.[546] Private vehicle use was banned in the city.[547] Chinese New Year (25 January) celebrations were cancelled in many places.[548] The authorities also announced the construction of a temporary hospital, Huoshenshan Hospital, which was completed in 10 days.[549] Another hospital was built afterwards, Leishenshan Hospital, to handle additional patients.[citation needed] In addition to newly constructed hospitals, China also converted 14 other facilities in Wuhan, such as convention centres and stadiums, into temporary hospitals.[550]

On 26 January, the government instituted further measures to contain the COVID-19 outbreak, including issuing health declarations for travellers[551] and extending the Spring Festival holiday.[552] Universities and schools around the country were also closed.[553][554][555] The regions of Hong Kong and Macau instituted several measures, particularly in regard to schools and universities.[556] Remote working measures were instituted in several Chinese regions.[557] Travel restrictions were enacted in and outside of Hubei.[557][558] Public transport was modified,[559] and museums throughout China were temporarily closed.[557][560][561] Control of public movement was applied in many cities, and it has been estimated that about 760 million people (more than half the population) faced some form of outdoor restriction.[562]

After the outbreak entered its global phase in March, Chinese authorities took strict measures to prevent the virus from "importing" from other countries. For example, Beijing has imposed a 14-day mandatory quarantine for all international travellers entering the city.[563]

On 23 March, mainland China only one case had transmitted domestically in the five days prior, in this instance via a traveller returning to Guangzhou from Istanbul. On 24 March 2020, Chinese Premier Li Keqiang reported that the spread of domestically transmitted cases has been basically blocked and the outbreak has been controlled in China.[564] The same day travel restrictions were eased in Hubei, apart from Wuhan, two months after the lockdown was imposed.[565]

The Chinese Ministry of Foreign Affairs announced on 26 March 2020 that entry for visa or residence permit holders would be suspended from 28 March onwards, with no specific details on when this policy will end. Those who wish to enter China will have to apply for visas in Chinese embassies or consulates.[566][567] The Chinese government encouraged businesses and factories to re-open on 30 March, and provided monetary stimulus packages for firms.[568]

The State Council declared a day of mourning to begin with a national three-minute moment of silence on 10:00 4 April, coinciding with Qingming Festival, although the central government asked families to pay their respects online in observance of physical distancing as to avoid a renewed COVID-19 outbreak.[569]

South Korea

Coronavirus infection prevention tips banner in Seoul, South Korea.

COVID-19 was confirmed to have spread to South Korea on 20 January 2020 from China. The nation's health agency reported a significant increase in confirmed cases on 20 February,[570] largely attributed to a gathering in Daegu of a new religious movement known as the Shincheonji Church of Jesus.[570][571] Shincheonji devotees visiting Daegu from Wuhan were suspected to be the origin of the outbreak.[572][573] As of 22 February, among 9,336 followers of the church, 1,261 or about 13% reported symptoms.[574]

South Korea declared the highest level of alert on 23 February 2020.[575] On 28 February, more than 2,000 confirmed cases were reported in Korea,[576] rising to 3,150 on 29 February.[577] All South Korean military bases were quarantined after tests confirmed that three soldiers were positive for the virus.[572] Airline schedules were also affected and therefore they were changed.[578][579]

South Korea introduced what was considered the largest and best-organized programme in the world to screen the population for the virus, and isolate any infected people as well as tracing and quarantining those who contacted them.[580][581] Screening methods included mandatory self-reporting of symptoms by new international arrivals through mobile application,[582] drive-thru testing for the virus with the results available the next day,[583] and increasing testing capability to allow up to 20,000 people to be tested every day.[584] South Korea's programme is considered to be a success in controlling the outbreak despite not quarantining entire cities.[580][585]

The South Korean society was initially polarized on President Moon Jae-in's response to the crisis. Many Koreans signed petitions either calling for the impeachment of Moon over what they claimed to be government mishandling of the outbreak, or praising his response.[586] On 23 March, it was reported that South Korea had the lowest one-day case total in four weeks.[584] On 29 March it was reported that beginning 1 April all new overseas arrivals will be quarantined for two weeks.[587] Per media reports on 1 April, South Korea has received requests for virus testing assistance from 121 different countries.[588]

Iran

Disinfection of Tehran Metro trains against coronavirus

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.[589][590] Early measures announced by the government included the cancellation of concerts and other cultural events,[591] sporting events,[592] and Friday prayers,[593] and closures of universities, higher education institutions, and schools.[594] Iran allocated five trillion rials to combat the virus.[595] President Hassan Rouhani said on 26 February 2020 that there were no plans to quarantine areas affected by the outbreak, and only individuals would be quarantined.[596] Plans to limit travel between cities were announced in March,[597] although heavy traffic between cities ahead of the Persian New Year Nowruz continued.[598] Shia shrines in Qom remained open to pilgrims until 16 March 2020.[599][600]

Iran became a centre of the spread of the virus after China during February.[601][602] Amidst claims of a cover-up of the extent of the outbreak in Iran,[603] more than ten countries had traced their cases back to Iran by 28 February, indicating that the extent of the outbreak may be more severe than the 388 cases reported by the Iranian government by that date.[602][604] The Iranian Parliament was shut down, with 23 of its 290 members reported to have had tested positive for the virus on 3 March.[605] On 12 March, the Human Rights Watch urged the Iranian prison authorities to unconditionally release the human rights defenders detained for peaceful dissent, and to also temporarily release all the eligible prisoners. It stated that there is a greater risk of the virus to spread in closed institutions like detention centres, which also lack adequate medical care.[606] On 15 March, the Iranian government reported 100 deaths in a single day, the most recorded in the country since the outbreak began.[607] At least 12 sitting or former Iranian politicians and government officials had died from the disease by 17 March.[608] By 23 March, Iran was experiencing 50 new cases every hour and one new death every ten minutes due to coronavirus.[609] 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.[610] The UN High Commissioner for Human Rights has demanded economic sanctions to be eased for nations most affected by the pandemic, including Iran.[611]

Europe

Confirmed cases of SARS-CoV-2 infected people in relation to the population of the country (cases per million inhabitants).[612] The numbers are not comparable, as the testing strategy differs between 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.[613]

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.[614] In 18 countries, at least one death has been reported.

As of 18 March, more than 250 million people are in lockdown in Europe.[615]

Italy

Civil Protection volunteers carrying out health checks at the Guglielmo Marconi Airport in Bologna, Italy on 5 February 2020.

The outbreak was confirmed to have spread to Italy on 31 January, when two Chinese tourists tested positive for SARS-CoV-2 in Rome.[616] Cases began to rise sharply, which prompted the Italian government to suspend all flights to and from China and declare a state of emergency.[617] An unassociated cluster of COVID-19 cases was later detected, starting with 16 confirmed cases in Lombardy on 21 February.[618]

On 22 February, the Council of Ministers announced a new decree-law to contain the outbreak, including quarantining more than 50,000 people from 11 different municipalities in northern Italy.[619] 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."[620][621]

On 4 March, the Italian government ordered the full closure of all schools and universities nationwide as Italy reached 100 deaths. All major sporting events, including Serie A football matches, were to be held behind closed doors until April,[622] but on 9 March, all sport was suspended completely for at least one month.[623] On 11 March, Prime Minister Conte ordered stoppage of nearly all commercial activity except supermarkets and pharmacies.[624][625]

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.[626][627][628] 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.[629][630] On 22 March, it was reported that Russia had sent nine military planes with medical equipment to Italy.[631] As of 5 April, there were 128,948 confirmed cases, 15,887 deaths, and 21,815 recoveries in Italy, with the majority of those cases occurring in the Lombardy region.[632] 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.[633]

Spain

Residents of Valencia, Spain, maintain social distance 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.[634] By 24 February, Spain confirmed multiple cases related to the Italian cluster, originating from a medical doctor from Lombardy, Italy, who was on holiday in Tenerife.[635] Other cases involving individuals who visited Italy were also discovered in Peninsular Spain.[636][637][638]

By 13 March, cases had been registered in all 50 provinces of the country. A state of alarm and national lockdown was imposed on 14 March.[639] On 29 March it was announced that, beginning the following day, all non-essential workers were to stay home for the next 14 days.[640]

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.[641] On 25 March 2020, the death toll in Spain surpassed that reported in mainland China and only Italy had a higher death toll globally.[642] 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.[643] The next day Spain surpassed Italy in total cases and is now second only to the United States.[644] As of 7 April, Spain has the third largest number of confirmed cases per capita, behind Iceland and Luxembourg, not counting microstates.[645]

As of 11 April 2020, there have been 163,027 confirmed cases with 59,109 recoveries and 16,606 deaths in Spain.[646][647] 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.[648][649] 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.[650]

United Kingdom

People in London buying canned foods and toilet paper on 18 March 2020.

The United Kingdom's response to the virus first emerged as one of the most relaxed of the affected countries, and until 18 March 2020, the British government did not impose any form of social distancing or mass quarantine measures on its citizens.[651][652] As a result, the government received criticism for the perceived lack of pace and intensity in its response to concerns faced by the public.[653][654][655]

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.[656][657] On 20 March, the government announced that all leisure establishments such as pubs and gyms were to close as soon as possible,[658] and promised to pay up to 80% of workers' wages to a limit of £2,500 per month to prevent unemployment in the crisis.[659]

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.[660]

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.
The pandemic reached France on 24 January 2020, when the first COVID-19 case in Europe and France was confirmed in Bordeaux. The first five cases were all individuals who had recently arrived or returned from China.[661][662] On 28 January, a Chinese tourist carrying the virus was admitted to hospital in Paris and died on 14 February, making it the first death in France.[663][664][665][666]

One key event in the spread of the disease across Metropolitan France as well as its overseas territories 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.[667][668]

On 12 March, French President Emmanuel Macron announced on public television that all schools and all universities would close from Monday 16 March until further notice. The next day, the prime minister Édouard Philippe banned gatherings of more than 100 people, not including public transport. The following day, the prime minister ordered the closure of all non-essential public places, including restaurants, cafés, cinemas and nightclubs, effective at midnight.[669] On 16 March, President Macron announced mandatory home confinement for 15 days starting at noon on 17 March.[670] On 27 March, Prime Minister Édouard Philippe extended the lockdown until 15 April.[670] On 8 April 2020, President Macron announced the lockdown would be extended once more.[671]

As of 11 April, France has reported 93,790 confirmed cases, 13,832 deaths, and 26,391 recoveries,[672] making it the fifth highest country by number of confirmed cases, now overtaking China where the outbreak first began.[673] France also counts nursing home deaths since 2 April 2020.[674] As of 8 April France has reported 30,902 confirmed or suspected cases in retirement homes. (These figures are now included in the national tally)[675]<ref>{{cite weburl=https://www.liberation.fr/france/2020/04/02/au-moins-884-morts-dans-les-maisons-de-retraite-et-ehpad_1784033%7Ctitle=Covid-19 : au moins 884 morts dans les maisons de retraite et Ehpad website=[Libération

Germany

Public venues like this playground in Hannover, Germany have closed throughout the country.
The pandemic was confirmed to have reached Germany on 27 January 2020, when the first COVID-19 case was confirmed and contained near Munich, Bavaria.[676] The majority of the cases in January and early February originated from the headquarters of a car parts manufacturer there. On 25 and 26 February, multiple cases related to the Italian outbreak were detected in Baden-Württemberg. A large cluster linked to a Carnival event was formed in Heinsberg, North Rhine-Westphalia, with the first death reported on 9 March 2020.[677][678] New clusters were introduced in other regions via Heinsberg as well as via people coming from Italy, Iran and China,[679] from where non-Germans could arrive by plane until 17-18 March.

German disease and epidemic control is advised by the Robert Koch Institute (RKI) according to a national pandemic plan. The outbreaks were first managed in a containment stage,[680] which attempted to minimise the expansion of clusters. The German government and several health officials stated that the country was well prepared and at first saw no need to take special measures to stock up or limit public freedom. Since 13 March, the pandemic has been managed in the protection stage as per the RKI plan, with German states mandating school and kindergarten closures, postponing academic semesters and prohibiting visits to nursing homes to protect the elderly. Two days later, borders to five neighbouring countries were closed. On 22 March, the government announced a national curfew. Individuals are only allowed to leave their living quarters for certain activities e.g. commuting to work, engaging in sports or purchasing groceries, and not in groups of more than two people if they do not share the same household.

As of 11 April 2020, 124,618 cases have been reported with 2,790 deaths and approximately 46,300 recoveries.[681][682][683][684] The preliminary fatality rate in Germany was much lower than in Italy or Spain, leading to a discussion and explanations including having a higher amount of tests conducted, a higher amount of intensive care beds with respiratory support available, no post-mortem tests conducted and more cases of younger people testing positive. The head of the Robert Koch Institute warned that the German death rate would increase over time.

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 except Bonaire and Saba (as of 5 April).

United States

Confirmed cases of COVID-19 per million inhabitants by state, as of 6 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.[685] The White House Coronavirus Task Force was established on 29 January.[686] On 31 January, the Trump administration declared a public health emergency,[687] and placed restrictions on entry for travellers from China.[688]

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

On 28 January 2020, the Center for Disease Control—the leading public health institute of the U.S. government—announced they had developed their own testing kit.[689] Despite doing so, the United States had a slow start in testing, which obscured the true extent of the outbreak at the time.[690][691] 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).[690][691] By 27 February, The Washington Post reported fewer than 4,000 tests had been conducted in the United States.[690] By 13 March, The Atlantic reported that less than 14,000 tests had been conducted.[692] On 22 March, the Associated Press reported: "Many people who have symptoms and a doctor's order have waited hours or days for a test."[693]

After the first death in the United States was reported in Washington state on 29 February,[694] Governor Jay Inslee declared a state of emergency,[695] an action that was soon followed by other states.[696][697][698] Schools in the Seattle area cancelled classes on 3 March,[699] and by mid-March, schools across the country were shutting down.[700]

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 epidemiologists at Imperial College London.[701] 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.[702] Corporations imposed employee travel restrictions, cancelled conferences,[703] and encouraged employees to work from home.[704] Sports events and seasons were cancelled.[30][705]

On 11 March, Trump announced travel restrictions for most of Europe, excluding the United Kingdom, for 30 days, effective 13 March.[706] The following day, he expanded the restrictions to include the United Kingdom and Ireland.[707] On 13 March, he declared a national emergency, which made federal funds available to respond to the crisis.[708] Beginning on 15 March, many businesses closed or reduced hours throughout the U.S. to try to reduce the spread of the virus.[709] By 17 March, the epidemic had been confirmed in all 50 states and in the District of Columbia.[710]

On 23 March, it was reported that New York City had 10,700 cases of the coronavirus, more than the total number of cases in South Korea.[711] On 25 March, the governor said that social distancing seemed to be working, as estimates of case doubling slowed from 2.0 days to 4.7 days.[712] As of 28 March, there were 32,308 confirmed cases in New York City, and 672 people had died from the virus.[713]

On 26 March, the United States was reported to have more confirmed coronavirus infection cases than any other country in the world, including China and Italy.[525]

As of 8 April, 400,335 cases have been confirmed in the United States, and 12,841 people have died.[6] Per media reports on 30 March, U.S. President Trump has decided to extend social distancing guidelines until 30 April.[714] On the same day, the USNS Comfort, a hospital ship with about 1000 beds, made anchor in New York.[715][716] On 3 April, the U.S. had a record 884 deaths due to the coronavirus in a 24-hour period.[717] In the state of New York the cases have exceeded 100,000 people on 3 April.[718]

The White House has been criticized 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.[719][720][721] Overall approval of Trump's management of the crisis has been polarized along partisan lines.[722] Some U.S. officials and commentators criticized the U.S. reliance on importation of critical materials, including essential medical supplies, from China.[723][724]

South America

Workers are trained to disinfect buses in Olinda, Pernambuco, Brazil, 16 March 2020.
As of 19 March, cases have been confirmed in all South American countries: Argentina, Brazil, Bolivia, Chile, Colombia, Ecuador, Guyana, Paraguay, Peru, Suriname, Uruguay, Venezuela and the French overseas department of French Guiana. Cases were confirmed in all South American territories, as cases were confirmed in the Falkland Islands on 3 April. The coronavirus was first reported in South America on 26 February when Brazil confirmed a case in São Paulo. Since then, governments across the region have taken an array of actions to protect their citizens and contain the spread of COVID-19.[725]

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".[726][727] As of 5 April, cases have been confirmed in all African nations except for Comoros and Lesotho, and the disputed state of the Sahrawi Arab Democratic Republic. There have been no reported cases in the territory of Saint Helena, Ascension and Tristan da Cunha.

Oceania

Barricades block entry from New South Wales into Queensland in Australia on 4 April.
Cases have been confirmed in Australia, Easter Island, Fiji, French Polynesia, Guam, Hawaii, New Caledonia, New Zealand, and Papua New Guinea. The first confirmed case was in Melbourne, Victoria on 25 January.[728] Many small Pacific island nations have thus far avoided the outbreak by closing their borders. Cases have been reported in all Oceanian sovereign states except Kiribati, Marshall Islands, Micronesia, Nauru, Palau, Samoa, Solomon Islands, Tonga, Tuvalu, and Vanuatu, and have not been reported in the associated states of Christmas Island, Cocos (Keeling) Islands, Cook Islands, and Niue. Additionally, no cases have been reported in American Samoa, the Autonomous Region of Bougainville, Norfolk Island, Pitcairn Islands, Tokelau, and Wallis and Futuna.

International responses

An analysis of air travel patterns was used to map and predict patterns of spread and was published in The Journal of Travel Medicine in mid-January 2020. Based on 2018 information from the International Air Transport Association, Bangkok, Hong Kong, Tokyo, and Taipei had the largest volume of travellers from Wuhan. Dubai, Sydney, and Melbourne were also reported as popular destinations for people travelling from Wuhan. Bali was reported as least able among the 20 most popular destination cities in terms of preparedness, while cities in Australia were considered most able.[729][730]

Australia released its Emergency Response Plan for Novel Coronavirus (COVID-19) on 7 February. It stated that much was yet to be discovered about COVID-19, and that Australia would emphasize border control and communication in its response to the pandemic.[731] On 21 March, a human biosecurity emergency was declared in Australia.[732]

Travel restrictions

Some of the countries that have imposed a global travel ban in response to the COVID-19 pandemic, as of April 5, 2020
  Current ban on foreign travellers
  Former ban on foreign travellers

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.[733] Other countries and regions have imposed global restrictions that apply to all foreign countries and territories, or prevent their own citizens from travelling overseas.[734]

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.[735] Concerns have been raised over the effectiveness of travel restrictions to contain the spread of COVID-19.[736]

The European Union rejected the idea of suspending the Schengen free travel zone and introducing border controls with Italy,[737][738][739] a decision which has been criticized by some European politicians.[740][741] After some EU member states announced complete closure of their national borders to foreign nationals,[742] 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."[743] The United States suspended travel from the Schengen Area and later the Common Travel Area,[744] a move that was criticised by EU leaders.[745]

Evacuation of foreign citizens

Ukraine evacuates Ukrainian and foreign citizens from Wuhan, China.

Owing to the effective quarantine of public transport in Wuhan and Hubei, several countries have planned to evacuate 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.[746] Pakistan has said that it will not be evacuating any citizens from China.[747] On 7 February, Brazil evacuated 34 Brazilians or family members in addition to four Poles, a Chinese person, and an Indian citizen. The citizens of Poland, China, and India deplaned in Poland, where the Brazilian plane made a stopover before following its route to Brazil. Brazilian citizens who went to Wuhan were quarantined at a military base near Brasília.[748][749][750] On the same day, 215 Canadians (176 from the first plane, and 39 from a second plane chartered by the U.S. government) were evacuated from Wuhan to CFB Trenton to be quarantined for two weeks.[751]

The United States sped up its withdrawal from Iraq due to the pandemic.[752]

On 11 February, another plane of 185 Canadians from Wuhan landed at CFB Trenton.[753] Australian authorities evacuated 277 citizens on 3 and 4 February to the Christmas Island Detention Centre, which had been repurposed as a quarantine facility, where they remained for 14 days.[754] A New Zealand evacuation flight arrived in Auckland on 5 February; its passengers (including some from Australia and the Pacific) were quarantined at a naval base in Whangaparoa, north of Auckland.[755] On 15 February, the United States announced that it would evacuate Americans aboard the cruise ship Diamond Princess.[756] On 21 February, a plane carrying 129 Canadian passengers who had been evacuated from Diamond Princess landed in Trenton, Ontario.[757] In early March, the Indian government began evacuating its citizens from Iran.[758][759]

On 14 March a South African Airways aircraft chartered by the South African Government repatriated 112[760][761] South African citizens. Medical screening was performed prior to departure, and four South Africans who were showing signs of coronavirus were left behind to mitigate risk. Only South Africans who tested negative were repatriated. Test results cleared all the South Africans, including the flight crew, pilots, hotel staff, police and soldiers involved in the humanitarian mission who, as a precautionary measure, all remained under observation and in quarantine for a 14-day period[760][761] at The Ranch Resort.[762][763] On 20 March, the United States began to partially withdrawal its troops from Iraq due to the pandemic.[752]

International aid

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

On 5 February, the Chinese foreign ministry stated that 21 countries (including Belarus, Pakistan, Trinidad and Tobago, Egypt, and Iran) had sent aid to China.[764] 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.[765] On 7 February, US Secretary of State Pompeo announced a $100 million pledge to China and other countries to assist with their fights against the virus,[766] and on 1 April, Apple announced a donation of 50 million yuan ($7 million) to China to support long-term public health recovery efforts.[767]

Other corporate donations to China include:[768]

  • 3M has donated respirators, surgical masks and hand sanitizer to specific areas in China.
  • Bayer is making a donation of €1.5 million in medicine and money.
  • BD has donated $300,000 worth of products that include catheters, blood collection tubes, syringes and sharps to the Red Cross in Wuhan. The company has also donated $50,000 for to supply frontline healthcare workers with personal protective equipment.
  • J&J has donated 1 million surgical masks to China and $1 million RMB to the Chinese Red Cross Foundation. Other donations include thermometers, respirators, goggles and protective suits.
  • Medtronic and its foundation has committed $1.5 million to COVID-19 relief efforts worldwide. It has donated ventilators, respiratory filters, pulse oximeters, sensors and centrifugal blood pumps to Wuhan Huoshenshan Hospital.
  • Qiagen is in the process of sending 200 QIAstat-Dx cartridges for the detection of respiratory pathogens that includes COVID-19 to China. The technology is being validated at four hospitals.Other medtech companies that have made significant donations include Varian, Roche, ResMed, GE Healthcare, Danaher Corp. and Cepheid.

The humanitarian aid organization 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.[769] 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".[770] Interaksyon reported that the Chinese government donated 200,000 masks to the Philippines on 6 February, after Senator Richard Gordon shipped 3.16 million masks to Wuhan.[771] On 19 February, the Singapore Red Cross announced that it would send $2.26 million worth of aid to China.[772]

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

Japan donated one million face masks to Wuhan,[773] Turkey dispatched medical equipment,[774] Russia sent more than 13 tonnes of medical supplies to Wuhan,[775] Malaysia announced a donation of 18 million medical gloves to China,[776] Germany delivered various medical supplies including 10,000 Hazmat suits,[777] Canada donated 16 tons of medical supplies,[778] and the United States donated 17.8 tons of medical supplies to China and promised an additional $100 million in financial support to affected countries.[779]

After cases in China seemed to stabilize, the country has been sending aid to various nations hit by the pandemic.[780][781] In March, China, Cuba and Russia sent medical supplies and experts to help Italy deal with its coronavirus outbreak.[782][783] 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.[784] He later sent 5,000 testing kits, 100,000 face masks and 5 ventilators to Panama.[785] Ma also donated medical supplies to Canada.[786]

Netherlands, Spain, Turkey, Georgia, and Czech Republic expressed their concerns over Chinese-made masks and test kits.[787] For instance, Spain withdrew 58,000 Chinese-made coronavirus testing kits with an accuracy rate of just 30%, meanwhile, Netherlands recalled 600,000 Chinese face masks which were defective.[788] Belgium recalled 100,000 unusable masks, thought to be from China, but were in fact from Colombia.[789] Chinese government have conducted investigations and official responses to these concerns, it's said many issues might caused by misusing or not following product instructions, and some products are found not purchased directly from qualified companies certified by Chinese government which might also cause problems,[790][791] such as the testing kits withdrew by Spain were not purchased from authorized Chinese company but through local Spanish agent, and the accuracy issue might caused by not following test instructions properly; the so-called "defective masks" rejected by Netherlands actually are not meant to be medical masks but still were issued to medical workers by Netherlands government, which results in disqualified upon inspection.[792][793] On the other hand, Chinese aid has been well-received in parts of Latin America and Africa.[794][795]

On 2 April, the World Bank launched emergency support operations for developing countries.[796]

WHO response measures

The WHO has commended the efforts of Chinese authorities in managing and containing the epidemic.[797] 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".[798]

Taiwan is excluded from the WHO due to diplomatic pressure from the People's Republic of China.[799]

January 2020

WHO Director-General Tedros Adhanom

On 23 January, in reaction to the central authorities' decision to implement a transportation ban in Wuhan, WHO representative Gauden Galea remarked that while it was "certainly not a recommendation the WHO has made", it was also "a very important indication of the commitment to contain the epidemic in the place where it is most concentrated" and called it "unprecedented in public health history".[798]

On 30 January, following confirmation of human-to-human transmission outside China and the increase in the number of cases in other countries, the WHO declared the outbreak a Public Health Emergency of International Concern (PHEIC), the sixth PHEIC since the measure was first invoked during the 2009 swine flu pandemic. WHO Director-General Tedros Adhanom said that the PHEIC was due to "the risk of global spread, especially to low- and middle-income countries without robust health systems.[9][800] In response to the implementations of travel restrictions, Tedros stated that "there is no reason for measures that unnecessarily interfere with international travel and trade" and that the "WHO doesn't recommend limiting trade and movement."[801]

February 2020

On 5 February, the WHO appealed to the global community for a $675 million contribution to fund strategic preparedness in low-income countries, citing the urgency to support those countries which "do not have the systems in place to detect people who have contracted the virus, even if it were to emerge". Tedros further made statements declaring that "we are only as strong as our weakest link" and urged the international community to "invest today or pay more later".[802][803]

On 11 February, the WHO in a press conference established COVID-19 as the name of the disease. On the same day, Tedros stated that 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".[804]

WHO representatives holding a joint meeting with Tehran city managers.

On 14 February, a WHO-led Joint Mission Team with China was activated to provide international and WHO experts on the ground in China to assist in the domestic management and evaluate "the severity and the transmissibility of the disease" by hosting workshops and meetings with key national-level institutions and to conduct field visits to assess the "impact of response activities at provincial and county levels, including urban and rural settings".[805]

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".[806] In response to a developing outbreak in Iran, the WHO sent a Joint Mission Team there to assess the situation.[807]

On 28 February, WHO officials said that 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 in a statement 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 that such a declaration would mean "we're essentially accepting that every human on the planet will be exposed to that virus."[808]

March 2020

On 11 March, the WHO declared the coronavirus outbreak a pandemic.[809] The Director-General said that the WHO was "deeply concerned both by the alarming levels of spread and severity, and by the alarming levels of inaction".[810]

The WHO has faced significant criticism for what is seen as inadequate handling of the pandemic, including the late declaration of a public health emergency and the classification of the virus as a pandemic.[811] The backlash included a petition for the WHO Director-General Tedros Adhanom to tender his resignation, signed by 733,000 people as of 6 April.[812]

Economic and social policy responses

International governmental organizations 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 lockdown 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.[813]

Impact

Politics

China

Chinese Communist Party general secretary Xi Jinping (left) and State Council Premier Li Keqiang (right), who are in charge of prevention and control of the epidemic in China.

The Chinese government has been criticized by the United States,[814] UK Minister for the Cabinet Office Michael Gove,[815] and Brazil President Jair Bolsonaro's son Eduardo Bolsonaro[816] for its handling of the pandemic, which began in the Chinese province of Hubei. A number of provincial-level administrators of the Communist Party of China (CPC) were dismissed over their handling of the quarantine efforts in Central China, a sign of discontent with the political establishment's response to the outbreak in those regions. Some commentators believe that this move was intended to protect Chinese Communist Party general secretary Xi Jinping from the public's anger over the coronavirus outbreak.[817] Some Chinese officials, e.g. Zhao Lijian rejected an earlier acknowledgement of the coronavirus outbreak starting in Wuhan, in favour of conspiracy theories about the COVID-19 originating from the U.S. or Italy.[818][819][820] The U.S. administration of Donald Trump has referred to the coronavirus as "Chinese virus" or "Wuhan virus" saying that China's "censorship supercharged a virus that has now turned into a global pandemic", which has in turn been criticized by some critics as racism[821][822] and "distract[ing] from his administration's failure to contain the disease".[823] The Daily Beast obtained a U.S. government cable outlining a communications stratagem with apparent origins in the National Security Council, with the strategy being quoted as "Everything is about China. We're being told to try and get this messaging out in any way possible, including press conferences and television appearances."[824]

Outlets such as Politico, Foreign Policy, and Bloomberg have claimed that China's efforts to send aid to virus-stricken countries is part of a propaganda push for global influence.[825][826][827] EU foreign policy chief Josep Borrell warned that there is "a geo-political component including a struggle for influence through spinning and the 'politics of generosity'".[828] Borrell also said that "China is aggressively pushing the message that, unlike the US, it is a responsible and reliable partner."[829] China has also called for the US to lift its sanctions off of Syria,[830] Venezuela[831] and Iran,[832][833] while reportedly sending aid to the latter two countries.[834][835] Jack Ma's donation of 100,000 masks to Cuba was blocked by US sanctions on 3 April.[836] US authorities have also been accused of diverting aid meant for other nations to their own country.[837][838] And there have been mask-related disputes reported between other countries, such as Germany, Austria and Switzerland;[839] and the Czech Republic and Italy.[840] In addition, Turkey seized hundreds of ventilators destined for Spain.[841]

Italy

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.

In early March, the Italian government criticized the European Union's lack of solidarity with coronavirus-affected Italy.[842][843] Maurizio Massari, Italy's ambassador to the EU, said that "Only China responded bilaterally. Certainly, this is not a good sign of European solidarity."[825] On 22 March, after a phone call with Italian Prime Minister Giuseppe Conte, Russian president Vladimir Putin arranged the Russian army to send military medics, special disinfection vehicles, and other medical equipment to Italy.[844] Italy's La Stampa newspaper cited an anonymous "high-level political source" that 80 percent of Russia's aid was "useless or of little use to Italy". The source accused Russia of embarking on a "geopolitical and diplomatic" charm offensive.[845] The President of Lombardy, Attilio Fontana, and Italian Foreign Minister Luigi Di Maio dismissed the media reports and expressed their gratitude.[846] Russia also sent a cargo plane with medical aid to the United States.[847] Kremlin spokesman Dmitry Peskov said that "when offering assistance to US colleagues, [Putin] assumes that when US manufacturers of medical equipment and materials gain momentum, they will also be able to reciprocate if necessary."[848]

Other countries

The planned NATO "Defender 2020" military exercise in Germany, Poland, and the Baltic states,[849] the largest NATO war exercise since the end of the Cold War, will be held on a reduced scale.[850] The Campaign for Nuclear Disarmament's general secretary Kate Hudson criticized the Defender 2020 exercise: "In the current public-health crisis, it jeopardizes the lives not only of the troops from the US and the many European countries participating but the inhabitants of the countries in which they are operating."[851]

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.[852][853] Iran's President Hassan Rouhani wrote a public letter to world leaders asking for help on 14 March 2020, saying that his country is struggling to fight the outbreak due to lack of access to international markets as a result of the United States sanctions against Iran.[854] Saudi Arabia, which launched its military intervention in Yemen in March 2015, declared ceasefire.[855]

The outbreak has prompted calls for the United States to adopt social policies common in other wealthy countries, including universal health care, universal child care, paid family leave, and higher levels of funding for public health.[856] Political analysts anticipated it may negatively affect Donald Trump's chances of re-election in the 2020 presidential election.[857]

Diplomatic relations between Japan and South Korea worsened due to the pandemic.[858] South Korea criticized Japan's "ambiguous and passive quarantine efforts" after Japan announced anybody coming from South Korea will be placed in two weeks' quarantine at government-designated sites.[859] The South Korean society was initially polarized on President Moon Jae-in's response to the crisis. Many Koreans signed petitions either calling for the impeachment of Moon over what they claimed to be government mishandling of the outbreak, or praising his response.[586]

The pandemic has allowed countries to pass emergency legislation in response. Some commentators have expressed concerns that it could allow governments to strengthen their grip on power.[860][861] In Hungary, its 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.[862]

Education

Learners affected by school closures caused by COVID-19 as of 4 April 2020
  Country-wide school closures
  Localized school closures
  No school closures
  No data

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

As of 11 April 2020, approximately 1.716 billion learners have been affected due to school closures in response to COVID-19. According to UNESCO monitoring, 188 countries have implemented nationwide closures and 5 have implemented local closures, impacting about 99.4 percent of the world's student population.[863] 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.[864] International Baccalaureate exams have also been cancelled.[865]

School closures impact not only students, teachers, and families, but have far-reaching economic and societal consequences.[866][867] School closures in response to COVID-19 have shed light on various social and economic issues, including student debt,[868] digital learning,[869][870] food insecurity,[871] and homelessness,[872][873] as well as access to childcare,[874] health care,[875] housing,[876] internet,[877] and disability services.[878] 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.[33][879]

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.[880]

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.

The coronavirus outbreak has been blamed for several instances of supply shortages, stemming from globally increased usage of equipment to fight the outbreaks, panic buying, and disruption to factory and logistic operations. The United States Food and Drug Administration has issued warnings about shortages of drugs and medical equipment due to increased consumer demand and supplier disruption.[881] Several localities also witnessed panic buying that led to shelves being cleared of grocery essentials such as food, toilet paper, and bottled water, inducing supply shortages.[882] The technology industry in particular has been warning about delays to shipments of electronic goods.[883] According to WHO director-general Tedros Adhanom, the demand for personal protection equipment has risen 100-fold. This demand has led to the increase in prices of up to twenty times the normal price and also induced delays on the supply of medical items for four to six months.[884][885] It has also caused a shortage of personal protective equipment worldwide, with the WHO warning that this will endanger health workers.[886] In Australia, the pandemic provided a new opportunity for daigou shoppers to sell Australian products into China.[887] The activity has created a shortage of baby formula in some supermarkets[888] and was subsequently banned by the Australian government.[889]

Despite the high prevalence of COVID-19 cases in Northern Italy and the Wuhan region, and the ensuing high demand for food products, both areas have been spared from acute food shortages. Measures by China and Italy against the hoarding and illicit trade of critical products have been successful, avoiding acute food shortages that were anticipated in Europe as well as in North America. Northern Italy with its significant agricultural production has not seen a large reduction, but prices may increase according to industry representatives. Empty food shelves were only encountered temporarily, even in Wuhan city, while Chinese government officials released pork reserves to assure sufficient nourishment of the population. Similar laws exist in Italy requiring food producers to keep reserves for such emergencies.[890][891] Damage to the global economy has been felt in China: according to a media report on 16 March, the economy in China was very hard hit in the first two months of 2020 due to the measures taken by the government to curtail virus spread, and retail sales plunged 20.5%.[892]

Economic impacts

The near-empty arrival hall of Seoul–Incheon International Airport in South Korea on 6 March 2020.

As mainland China is a major economy and manufacturing hub, the viral outbreak has been seen to pose a major destabilizing 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 that the economic fallout of the epidemic on global growth could surpass that of the 2002–2004 SARS outbreak.[893] 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.[894] The Organization of the Petroleum Exporting Countries (OPEC) reportedly "scrambled" after a steep decline in oil prices due to lower demand from China.[895] Global stock markets fell on 24 February due to a significant rise in the number of COVID-19 cases outside mainland China.[896][897] On 27 February, due to mounting worries about the coronavirus outbreak, various U.S. stock indexes including the NASDAQ-100, the S&P 500 Index, and the Dow Jones Industrial Average 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.[898] All three indexes ended the week down more than 10%.[899] On 28 February, Scope Ratings GmbH affirmed China's sovereign credit rating, but maintained a Negative Outlook.[900] Stocks plunged again based on coronavirus fears, the largest fall being on 16 March.[901] Many consider an economic recession to be likely.[902][903][904] Economist Mohamed El-Erian praised central banks' and states' timely emergency measures. Central banks are reacting more quickly than they did to the 2008 financial crash.[905]

Tourism is one of the worst affected sectors due to travel bans, closing of public places including travel attractions, and advice of governments against any travel all over the world. As a consequence, numerous airlines have cancelled flights due to lower demand, including British Airways, China Eastern Airlines, and Qantas, while British regional airline Flybe collapsed.[906] The impact on the cruise line industry was at a level never seen before.[907] Several train stations and ferry ports have also been closed.[908] The epidemic coincided with the Chunyun, a major travel season associated with the Chinese New Year holiday. A number of events involving large crowds were cancelled by national and regional governments, including annual New Year festivals, with private companies also independently closing their shops and tourist attractions such as Hong Kong Disneyland and Shanghai Disneyland.[909][910] Many Lunar New Year events and tourist attractions have been closed to prevent mass gatherings, including the Forbidden City in Beijing and traditional temple fairs.[911] In 24 of China's 31 provinces, municipalities and regions, authorities extended the New Year's holiday to 10 February, instructing most workplaces not to re-open until that date.[912][913] These regions represented 80% of the country's GDP and 90% of exports.[913] Hong Kong raised its infectious disease response level to the highest and declared an emergency, closing schools until March and cancelling its New Year celebrations.[914][915]

The retail sector has been impacted globally, with reductions in store hours or temporary closures.[916] Visits to retailers in Europe and Latin America declined by 40%. North America and Middle East retailers saw a 50–60% drop.[917] This also resulted in a 33–43% drop in foot traffic to shopping centres in March compared to February. Shopping mall operators around the world imposed additional measures, such increased sanitation, installation of thermal scanners to check the temperature of shoppers, and cancellation of events.[918]

According to a United Nations Economic Commission for Latin America estimate, the pandemic-induced recession could leave between 14 and 22 million more people in extreme poverty in Latin America than would have been in that situation without the pandemic.[919]

Unemployment

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

In January and February 2020, during the height of the epidemic in Wuhan, about 5 million people in China lost their jobs.[920] Many of China's nearly 300 million rural migrant workers have been stranded at home in inland provinces or trapped in Hubei province.[921][922]

Nearly 17 million Americans lost their jobs and applied for government aid,[923] including 2.4 million people in California.[924] The coronavirus outbreak could cost 47 million jobs in the United States and unemployment rate may hit 32%, according to estimates by the Federal Reserve Bank of St. Louis.[925]

The lockdown in India has left tens of millions of Indian migrant workers (who are paid through daily wages) unemployed.[926][927]

The survey from the Angus Reid Institute found that 44% of Canadian households have experienced some type of unemployment.[928][929]

Nearly 900,000 workers lost their jobs in Spain since it went into lockdown in mid-March 2020.[930] During the second half of March, 4 million French workers applied for temporary unemployment benefits and 1 million British workers applied for a universal credit scheme.[931]

Almost half a million companies in Germany have sent their workers on a government-subsidized short-time working schemes known as Kurzarbeit.[932][933] The German short-time work compensation scheme has been adopted by France and Britain.[934]

Culture

The closed entrance to the Shah Abdol-Azim Shrine in Ray, Iran. Cultural sites and other public spaces throughout the world were closed to slow the spread of the pandemic.

The performing arts and cultural heritage sectors have been profoundly affected by the pandemic, impacting organizations' operations as well as individuals—both employed and independent—globally. Arts and culture sector organizations 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.[935] In response there were intensive efforts to provide alternative services through digital platforms.[936]

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.[937][938]

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.[937] 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.[939][940][937] With the Roman Catholic Diocese of Rome closing its churches and chapels and St. Peter's Square emptied of Christian pilgrims,[937] other religious bodies also cancelled services and limited public gatherings in churches, mosques, synagogues, temples and gurdwaras.[937] Iran's Health Ministry announced the cancellation of Friday prayers in areas affected by the outbreak and shrines were later closed,[941][600] while Saudi Arabia banned the entry of foreign pilgrims as well as its residents to holy sites in Mecca and Medina.[942][943]

Announcement posted in the door of a public library in Island Bay, New Zealand that it is closed due to the pandemic, and will waive all late return fees.

The pandemic has caused the most significant disruption to the worldwide sporting calendar since the Second World War. Most major sporting events have been either cancelled or postponed, including the 2019–20 UEFA Champions League,[944] 2019–20 Premier League,[945] UEFA Euro 2020, 2019–20 NBA season,[946] and 2019–20 NHL season.[947] 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 the event will be "rescheduled to a date beyond 2020 but not later than summer 2021".[948][949]

Casinos and other gaming venues worldwide have closed and live poker tournaments have been either postponed or cancelled. This has led many gamblers to move online, with many online gambling sites reporting significant increases in their rates of new sign-ups.[950]

The entertainment industry has also been affected, with various music groups suspending or cancelling concert tours.[951][952] Many large theatres such as those on Broadway also suspended all performances.[953] 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[954] or creating web-based "festivals" for artists to perform, distribute, and publicize their work.[955] Online, numerous coronavirus-themed Internet memes have spread as many turn to humour and distraction amid uncertainty.[956]

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).[957]
The worldwide disruption caused by the coronavirus pandemic has resulted in numerous impacts on the environment and the climate. The severe decline in planned travel[958] 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,[959] which one Earth systems scientist estimated may have saved at least 77,000 lives over two months.[960] However, the outbreak has also disrupted environmental diplomacy efforts, including causing the postponement of the 2020 United Nations Climate Change Conference,[961] and the economic fallout from it is predicted to slow investment in green energy technologies.[962][963][964]

Xenophobia and racism

Chinatown, Houston experienced a reduction in business early during the outbreak when there were still few cases.[965]

Since the outbreak of COVID-19, heightened prejudice, xenophobia, and racism have been noted toward people of Chinese and East Asian descent, and against people from hotspots in Europe, the United States and other countries. Incidents of fear, suspicion, and hostility have been observed in many countries, particularly in Europe, East Asia, North America, and the Asia-Pacific region.[966][967][968] Reports from February (when the majority of the cases had still been confined to China) have documented racist sentiments expressed in various groups worldwide of Chinese people deserving the virus[969] or receiving what has been claimed as justified retribution.[970][971][972] Some countries in Africa have also seen a rise in anti-Chinese sentiment.[973][974] Many residents of Wuhan and Hubei have reported discrimination based on their regional origin.[975][976][977] There has been support for the Chinese, both on and offline, and towards those in virus-stricken areas.[978][979][980] 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, could also be subjected to suspicion and xenophobia.[981][982]

Citizens in countries including Malaysia,[983] New Zealand,[984] Singapore,[985] and South Korea initially signed petitions lobbying to ban Chinese people from entering their countries in an effort to stop the disease.[986] In Japan, the hashtag #ChineseDontComeToJapan trended on Twitter.[987] Chinese people as well as other Asians in the United Kingdom and the United States have reported increasing levels of racist abuse, as well as assaults.[988][36][989] U.S. president Donald Trump has faced criticism for referring to the coronavirus as the "Chinese Virus", a term considered by critics to be racist and anti-Chinese.[821][990] Protesters in Ukraine attacked buses carrying Ukrainian and foreign evacuees from Wuhan to Novi Sanzhary.[991] Students who come from Northeast India, which shares a border with China, and study in major Indian cities have reportedly experienced harassment related to the coronavirus outbreak.[992] The Bharatiya Janata Party's State unit president in West Bengal Dilip Ghosh stated that the Chinese had destroyed nature and "that's why the God took revenge against them." The remarks were later condemned by the Chinese consulate in Kolkata, calling it "erroneous".[993] Discrimination and violence against Muslims in India has escalated after public health authorities identified an Islamic missionary group's large gathering in New Delhi in early March 2020 as a source of coronavirus contagion.[994][995]

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".[996]

Information dissemination

Many newspapers with paywalls have removed them for some or all of their coronavirus coverage.[997] Many scientific publishers made scientific papers related to the outbreak available with open access.[998] Some scientists chose to share their results quickly on preprint servers such as bioRxiv.[999]

Misinformation

After the initial outbreak of coronavirus disease 2019 (COVID-19), conspiracy theories, misinformation, and disinformation emerged regarding the origin, scale, prevention, treatment, and other aspects of the disease.[1,000][1,001][1,002][1,003] Disinformation and misinformation can be spread through social media,[1,002][1,004] text messages,[1,005][1,006] as well as the state media of countries such as China, Iran and Turkmenistan,[1,002][1,007][1,008] and they may be propagated by celebrities, politicians, or other prominent public figures.[1,009][1,010] Medical misinformation about ways to prevent, treat, and self-diagnose coronavirus disease has circulated on social media.[1,011] Some false claims may be commercial scams offering at-home tests, supposed preventives, and "miracle" cures.[1,012][1,013] The World Health Organization has declared an "infodemic" of incorrect information about the virus, which poses risks to global health.[1,002] Some misinformation and disinformation claimed the virus was a bio-weapon with a patented vaccine, a population control scheme, or the result of a spy operation.[1,004][1,003][1,014] Some of these misinformation and conspiracy theories may have state involvement.[1,007][1,015][1,016] Some world leaders have also downplayed the threat of the virus and disseminated misinformation.[1,017][1,018][1,019]

See also

Notes

  1. ^ 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.[42]
    The total number of cases may not necessarily add up due to the frequency of values being updated for each location.
  2. ^ 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.[8]
  3. ^ Close contact is defined as one metre (three feet) by the WHO[16] and two metres (six feet) by the CDC.[17]
  4. ^ An uncovered cough can travel up to 8.2 metres (27 feet).[18]
  5. ^ Countries, territories, and five international conveyances where cases were diagnosed. The nationality of the infected and the origin of infection may vary. In some countries, cases are split into several territories and are noted accordingly.
  6. ^ Total deaths may not necessarily add up due to the frequency of values updating for each location.
  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. There are no standard requirements to receive a COVID-19 test across the entire United States. The official Centers for Disease Control (CDC) notes that "decisions about testing are at the discretion of state and local health departments and/or individual clinicians."[43] People often have to show symptoms consistent with COVID-19 to be tested,[44][45] although some locations will test asymptomatic people under certain circumstances.[46][47]
    2. Figures include cases identified on the Grand Princess.
    3. Not all states or overseas territories report recovery data.
    4. Data is from unofficial trackers and not from the official Centers for Disease Control and Prevention (CDC).
    5. 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.[48]
    6. Figures from the Department of Defense (DoD) are as follows:
      • The DoD reports a total of 3,366 cases, 13 deaths, and 299 recovered.[49]
      • The Navy reports 976 cases, 4 deaths, and 125 recovered.[50]
      • The Air Force reports 549 cases, 1 death, and 109 recovered.[49]
    7. Cases for the USS Theodore Roosevelt, currently docked at Guam, are reported separate from national figures but included in the Navy's totals.
  9. ^ Spain
    1. Including the autonomous cities of Ceuta and Melilla.
    2. Testing has been restricted to at-risk people showing symptoms.[52] The Ministry of Health estimates that there are at least 15 times as many cases as are confirmed.[53]
  10. ^ Italy
    1. Only at-risk people showing symptoms have been tested from 27 February 2020 and onwards.[55][56]
  11. ^ Germany
    1. Not all state authorities count recoveries.[58]
    2. Recoveries include estimations by the Robert Koch Institute.[58][59]
  12. ^ France
    1. Testing has been restricted to at-risk people showing severe symptoms.[60]
    2. Excluding all Overseas departments and regions and Overseas collectivities.
    3. Recoveries only include hospitalized cases.[61][62]
  13. ^ China
    1. Excluding 1,430 asymptomatic cases under medical observation as of 10 April 2020
    2. Asymptomatic cases were not reported before 31 March 2020.
  14. ^ United Kingdom
    1. Excluding all British Overseas Territories and Crown dependencies.
    2. As of 23 March 2020, the United Kingdom government does not publish the number of recoveries. The last update on 22 March reported 135 recovered patients.[64]
  15. ^ Iran
    1. Due to a shortage of resources, testing is restricted to only severe cases.[67]
    2. Non-official sources inside and outside Iran report significantly higher numbers of infected and dead.[68][69][70][71]
  16. ^ 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) are listed separately.
    2. The special municipalities of the Caribbean Netherlands are listed separately.
    3. The Dutch Government agency RIVM, responsible for the constituent country the Netherlands, does not count its number of recoveries.[77]
  17. ^ Brazil
    1. Since 13 March 2020, the Brazilian government does not publish the number of recoveries.[80][81]
  18. ^ Russia
    1. Including cases from the disputed Crimea and Sevastopol, which was annexed by Russia in 2014 but remains internationally recognized as being under Ukrainian sovereignty.
    2. Excluding the cases from Diamond Princess cruise ship which are classified as "on an international conveyance".
  19. ^ Israel
    1. Excluding cases from the West Bank, which has been occupied by Israel since 1967.
    2. Including cases from the disputed Golan Heights, which was occupied and annexed by Israel in 1981 but remains internationally recognized as being under Syrian sovereignty.
  20. ^ Sweden
    1. Testing of suspected infections has been cut back in the whole country in the period around 12 March 2020, to focus efforts on people with increased risk of serious illness and complications.
  21. ^ Norway
    1. From 13 March 2020, testing of the normal population was discontinued and is now only reserved for health professionals and acutely ill people in vulnerable groups.
    2. The Norwegian Institute of Public Health states that there are more infected people in Norway than the figures show. The dark figures are presumed to be higher because of limited testing.[97]
    3. Estimation of the number of infected:
      • As of 23 March 2020, according to figures from just over 40% 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.[98]
      • 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.[99]
  22. ^ 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.
  23. ^ 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 neither included in neither the Japanese or British official counts. The World Health Organization classifies the cases as being located "on an international conveyance".
  24. ^ Denmark
    1. The autonomous territories of the Faroe Islands and Greenland are listed separately.
    2. From 12 March to 1 April 2020, testing primarily focused on people with more serious symptoms, vulnerable people, and health professionals. Before and after this period testing was done more broadly, among others including people with mild symptoms and people that have been in close contact with an infected person.[103]
  25. ^ Serbia
    1. Excluding cases from the disputed Kosovo, which unilaterally declared independence from Serbia in 2008.[117]
  26. ^ Finland
    1. Excluding the autonomous region of the Åland Islands.
    2. From 1 March 2020, testing has primarily focused on patients with severe symptoms of respiratory tract infection, as well as healthcare and social welfare personnel.[122] Testing is also recommended for people in vulnerable groups, including the elderly and those with an underlying condition. Where testing capacity allows, specimens may also be taken from patients with mild symptoms, close contacts with a confirmed case, returning travellers, and other patient groups.[123]
    3. There is no reliable or frequently published national data source that provides counts of recoveries. However, as of 1 April 2020, there were reported to be hundreds of recoveries. The exact number is not known, as only a small proportion of patients have been hospitalized.[124]
  27. ^ Ukraine
    1. Excluding cases from the disputed Crimea and Sevastopol, which was annexed by Russia in 2014 but remains internationally recognized as being under Ukrainian sovereignty. Because the Russian authorities are tabulating cases from Crimea, they are included in the Russian total.
    2. Excluding cases from the unrecognized Donetsk and Lugansk People's Republics.
  28. ^ Egypt
    1. Includes cases identified on the MS River Anuket.
  29. ^ Moldova
    1. Including the disputed territory of Transnistria.
  30. ^ Morocco
    1. Including cases in the disputed Western Sahara territory controlled by Morocco. There are no confirmed cases in the rest of Western Sahara.[146]
  31. ^ Azerbaijan
    1. Excluding the self-declared state of Artsakh.
  32. ^ Cuba
    1. Includes cases on the MS Braemar.
    2. Excluding cases from Guantanamo Bay, which is governed by the United States.
  33. ^ Cyprus
  34. ^ a b Guam and Theodore Roosevelt
    1. Cases for the USS Theodore Roosevelt, currently docked at Guam, are reported separately.
  35. ^ 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 hopitalization.
  36. ^ Réunion
    1. Recoveries only include hospitalized cases.
  37. ^ Kosovo
    1. Excluding Serbia.
    2. Kosovo is the subject of a territorial dispute between the Republic of Kosovo and the Republic of Serbia.
  38. ^ Georgia
    1. Excluding the de facto state of Abkhazia.
  39. ^ 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."[209]
  40. ^ Greg Mortimer
    1. Although currently anchored off the coast of Uruguay, cases for the Greg Mortimer are currently reported separately.
  41. ^ Northern Cyprus
    1. Cases from this de facto state are not counted by Cyprus.
  42. ^ French Guiana
    1. Recoveries only include hospitalized cases.
  43. ^ Somalia
    1. Excluding the de facto state of Somaliland.
  44. ^ a b Donetsk and Luhansk People's Republic
    1. Cases from these unrecognized territories are not counted by Ukraine.[279]
    2. Note that these territories are distinct from the Ukraine-administered regions of the Donetsk and Luhansk Oblasts.
  45. ^ 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.[296][297]
    3. MS Zaandam and Rotterdam's numbers are currently not counted in any national figures.
  46. ^ Coral Princess
    1. The cruise ship Coral Princess has tested positive cases since early April 2020 and has since docked in Miami.[301]
    2. Coral Princess's numbers are currently not counted in any national figures.
  47. ^ St. Vincent
    1. The sovereign state of Saint Vincent and the Grenadines.
  48. ^ Guantanamo Bay
    1. Since April 2020, the United States Department of Defense has directed bases to not publicize case statistics.[48]

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