2019–20 coronavirus pandemic

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2019–20 coronavirus pandemic
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2019-20 coronavirus pandemic
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Disease Coronavirus disease 2019 (COVID-19)
Virus strain Severe acute respiratory syndrome
coronavirus 2
(SARS-CoV-2)
Source Bats or possibly pangolins [1] [2] [3]
LocationWorldwide (list of locations)
First outbreak Huanan Seafood Wholesale Market
Index case Wuhan, Hubei, China
30°37′11″N114°15′28″E / 30.61972°N 114.25778°E / 30.61972; 114.25778
Date1 December 2019 – ongoing
(3 months and 4 weeks)
Confirmed cases721,000+ [4] [lower-alpha 1]
Recovered151,000+ [4]
Deaths
33,900+ [4]
Territories
190+ [4]

The 2019–20 coronavirus pandemic is an ongoing pandemic of coronavirus disease 2019 (COVID-19), caused bysevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2). [5] The outbreak was first identified in Wuhan, Hubei, China, in December 2019. The World Health Organization (WHO) declared the outbreak to be a Public Health Emergency of International Concern on 30 January 2020. [6] The WHO later recognized the outbreak as a pandemic on 11 March. [7] As of 29 March 2020, more than 721,000 cases of COVID-19 have been reported in over 190 countries and territories, resulting in approximately 33,900 deaths. [4] More than 151,000 people have since recovered. [8] [4]

Contents

The virus is mainly spread during close contact and by respiratory droplets produced when people cough or sneeze. [9] [10] [11] Respiratory droplets may be produced during breathing but the virus is not generally airborne. [10] [9] [12] People may also catch COVID-19 by touching a contaminated surface and then their face. [9] [11] It is most contagious when people are symptomatic, although spread may be possible before symptoms appear. [11] The time between exposure and symptom onset is typically around five days, but may range from 2 to 14 days. [13] [14] Common symptoms include fever, cough, and shortness of breath. [13] Complications may include pneumonia and acute respiratory distress syndrome. [15] There is no known vaccine or specific antiviral treatment. [9] Primary treatment is symptomatic and supportive therapy. [16] 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. [9] [17]

Efforts to prevent the virus spreading include travel restrictions, quarantines, curfews, workplace hazard controls, event postponements and cancellations, and facility closures. These include the quarantine of Hubei, [18] national or regional quarantines elsewhere in the world, curfew measures in China and South Korea, [19] [20] [21] various border closures or incoming passenger restrictions, [22] [23] screening at airports and train stations, [24] and outgoing passenger travel bans. [25] [26] [27] [28]

The pandemic has led to severe global socioeconomic disruption, [29] the postponement or cancellation of sporting, religious, and cultural events, [30] and widespread fears of supply shortages which have spurred panic buying. [31] [32] Schools and universities have closed either on a nationwide or local basis in more than 160 countries, affecting more than 1.5 billion students. [33] Misinformation and conspiracy theories about the virus have spread online [34] [35] and there have been incidents of xenophobia and racism against Chinese, and other East and Southeast Asian people. [36] [37]

Epidemiology

Signs and symptoms

Symptoms of COVID-19. Symptoms of coronavirus disease 2019 3.0.png
Symptoms of COVID-19.

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 smell, shortness of breath, muscle and joint pain, sore throat, headache, or chills. [2] [279]

The WHO states that approximately 1 person in 6 becomes seriously ill and has difficulty breathing. [280] The US Centres 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. [281]

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 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. [244] [282] [283] [284] Chinese estimates of the asymptomatic ratio range from few to 44%. [285] The usual incubation period (the time between infection and symptom onset) ranges from one to 14 days; it is most commonly five days. [286] [287]

Cause

Transmission

Respiratory droplets, produced when a man is sneezing Sneeze.JPG
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 unknown and is being determined. [10] [11] The WHO and CDC state that it is primarily spread during close contact and by respiratory droplets produced when people cough or sneeze; [9] [11] with close contact being within 1 to 2 meters (3 to 6 feet). [9] A study in Singapore found that an uncovered coughing can lead to droplets travelling up to 4.5 metres (15 feet). [288]

Respiratory droplets may also be produced during breathing out, including when talking, though the virus is not generally airborne. [9] [289] These droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into the lungs. [290] Some medical procedures such as intubation and cardiopulmonary resuscitation (CPR) may cause respiratory secretions to be aerosolized and thus result in airborne spread. [289] It may also spread when one touches a contaminated surface and then touches their eyes, nose, or mouth. [9] While there are concerns it may spread by feces, this risk is believed to be low. [9] [11]

The virus is most contagious when people are symptomatic; while spread may be possible before symptoms appear, this risk is low. [11] [9] 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. [10]

The virus survives for hours to days on surfaces. [10] [291] Specifically the virus was found to be detectable for up to three days on plastic and stainless steel, for one day on cardboard, and for up to four hours on copper. [292] This however varies based on the humidity and temperature. [293] 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 chlorhexidine gluconate are less effective. [294]

Virology

Illustration of SARSr-CoV virion Coronavirus virion structure.svg
Illustration of SARSr-CoV virion

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel severe acute respiratory syndrome coronavirus, first isolated from three people with pneumonia connected to the cluster of acute respiratory illness cases in Wuhan. [241] All features of the novel SARS-CoV-2 virus occur in related coronaviruses in nature. [295]

Outside the human body, the virus is killed by soap, which bursts its protective bubble. [17]

SARS-CoV-2 is closely related to the original SARS-CoV. [296] 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] [297] 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, however, whole-genome comparison to date 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

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 (71% sensitivity) or CT imaging (98% sensitivity). [298] [299]

Viral testing

The WHO has published several RNA testing protocols for SARS-CoV-2, with the first issued on 17 January. [300] [301] [302] Testing uses real-time reverse transcription polymerase chain reaction (rRT-PCR). [303] The test can be done on respiratory or blood samples. [304] Results are generally available within a few hours to days. [305] [306]

A person is considered at risk if they have travelled to an area with ongoing community transmission within the previous 14 days, or have had close contact with an infected person. Common key indicators include fever, coughing, and shortness of breath. Other possible indicators include fatigue, myalgia, anorexia, sputum production, and sore throat. [307]

Imaging

Characteristic imaging features on radiographs and computed tomography (CT) of symptomatic patients include asymmetric peripheral ground glass opacities and absent pleural effusions. [308] The Italian Radiological Society is compiling an international online database of imaging findings for confirmed cases. [309] Due to overlap with other infections such as adenovirus, imaging without confirmation by PCR is of limited specificity in identifying COVID-19. [308] However, 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. [310] Artificial intelligence-based convolutional neural networks have been developed to detect imaging features of the virus with both radiographs [311] and CT. [312]

Mitigation

Infographic by the United States CDC, describing how to stop the spread of germs Stop the Spread of Germs (COVID-19).jpg
Infographic by the United States CDC, describing how to stop the spread of germs

Strategies for preventing transmission of the disease include maintaining overall good personal hygiene, washing hands, avoiding touching the eyes, nose, or mouth with unwashed hands, and coughing or sneezing into a tissue and putting the tissue directly into a waste container. Those who may already have the infection have been advised to wear a surgical mask in public. [313] [314] [315] Physical distancing measures are also recommended to prevent transmission. [316] [317]

Many governments have restricted or advised against all non-essential travel to and from countries and areas affected by the outbreak. [318] 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. [319]

Health care providers taking care of someone who may be infected are recommended to use standard precautions, contact precautions, and eye protection. [320]

Contact tracing is an important method for health authorities to determine the source of an infection and to prevent further transmission. [321] Misconceptions are circulating about how to prevent infection; for example, rinsing the nose and gargling with mouthwash are not effective. [322] As of 29 March 2020, there is no COVID-19 vaccine, though many organizations are working to develop one. [323]

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 20 seconds, especially after going to the toilet or when hands are visibly dirty; before eating; and after blowing one's nose, coughing, or sneezing. The CDC further recommended using an alcohol-based hand sanitizer with at least 60% alcohol by volume when soap and water are not readily available. [313] The WHO advises people to avoid touching the eyes, nose, or mouth with unwashed hands. [314] [324]

Respiratory hygiene

People in Hong Kong wearing face masks Street in Hong Kong during the COVID-19 pandemic.jpg
People in Hong Kong wearing face masks

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. [314] [326] Surgical masks are recommended for those who may be infected, [327] [328] [329] as wearing a mask can limit the volume and travel distance of expiratory droplets dispersed when talking, sneezing, and coughing. [330] The WHO has issued instructions on when and how to use masks. [331] According to Stephen Griffin, a virologist at the University of Leeds, "Wearing a mask can reduce the propensity for people to touch their faces, which is a major source of infection without proper hand hygiene." [332]

Masks have also been recommended for use by those taking care of someone who may have the disease. [329] 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. [329]

China has specifically recommended the use of disposable medical masks by healthy members of the public. [333] [334] Hong Kong recommends wearing a surgical mask when taking public transport or staying in crowded places. [335] Thailand's health officials are encouraging people to make face masks at home out of cloth and wash them daily. [336] The Czech Republic banned going out in public without wearing a mask or covering one's nose and mouth. [337] Face masks have also been widely used in Taiwan, [338] Japan, [339] South Korea, [340] Malaysia, [341] Singapore, [342] and Hong Kong. [343]

Social distancing

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. [344] [345] Many governments are now mandating or recommending social distancing in regions affected by the outbreak. [346] [347] The maximum gathering size recommended by 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. [348] On 22 March 2020, Germany banned public gatherings of more than two people. [349]

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. [350] [351]

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. [352] [353] [354]

Self-isolation

Transmission of COVID-19 depends on many factors, and the basic reproduction number can be lowered by engaging in outbreak prevention measures such as physical distancing and self-isolation upon experiencing symptoms. Covid-19-Transmission-graphic-01.gif
Transmission of COVID-19 depends on many factors, and the basic reproduction number can be lowered by engaging in outbreak prevention measures such as physical distancing and self-isolation upon experiencing symptoms.

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. [355] [356]

Many governments have mandated or recommended self-quarantine for entire populations living in affected areas. [357] [358] 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. [9] [13] [359] [360]

Containment

The goal of community mitigation: (1) delay outbreak peak; (2) decompress peak burden on healthcare, known as "flattening the curve"; (3) diminish overall cases and health impact FlattenTheCurveCDC.gif
The goal of community mitigation: (1) delay outbreak peak; (2) decompress peak burden on healthcare, known as "flattening the curve"; (3) diminish overall cases and health impact

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. [363] Suppression requires more extreme measures so as to reverse the pandemic by reducing the basic reproduction number to less than 1. [364]

Part of managing an infectious disease outbreak is trying to decrease the epidemic peak, known as flattening the epidemic curve. [361] This decreases the risk of health services being overwhelmed and provides more time for vaccines and treatments to be developed. [361] 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. [365]

Suppression

More drastic actions aimed at suppressing the outbreak were taken in China once the severity of the outbreak became apparent, such as quarantining entire cities and imposing strict travel bans. [366] 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. [367]

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. [364]

Management

Treatment

There are no specific antiviral medications approved for COVID-19, but development efforts are underway, including testing of existing medications. Attempts to relieve the symptoms may include taking regular (over-the-counter) cold medications, [368] drinking fluids, and resting. [313] Depending on the severity, oxygen therapy, intravenous fluids, and breathing support may be required. [369] The use of steroids may worsen outcomes. [370] Several compounds which were previously approved for treatment of other viral diseases are being investigated for use in treating COVID-19. [371]

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 in the face of the coronavirus disease pandemic. [372] 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. [372] [373]

History

Cases by country plotted on a logarithmic scale Trakectproes-Covid-confirmed-cases-since-100th-case.png
Cases by country plotted on a logarithmic scale

There have been various theories as to where the first-ever case, or patient zero, may have originated. [374] The first known case of the novel coronavirus was traced back to 1 December 2019 in Wuhan, Hubei, China. [242] A later unconfirmed claim, citing Chinese government documents, suggests that the first victim was a 55-year-old man who fell ill on 17 November 2019. [375]

On 30 December, a group of doctors from Wuhan Central Hospital, led by Dr. Ai Fen, launched an alert on a "SARS-like coronavirus". Eight of these doctors were arrested by Chinese government on charges of spreading false rumours, including doctor Li Wenliang. In an interview with Renwu magazine, Ai Fen said she was reprimanded after alerting her superiors and colleagues of a SARS-like virus seen in patients in December.[ citation needed ]

Within the next month, the number of coronavirus cases in Hubei gradually increased to a couple of hundred, before rapidly increasing in January 2020. On 31 December 2019, enough cases of unknown pneumonia had been reported to health authorities in Wuhan, the capital of Hubei province, [236] to trigger an investigation. [237] These were mostly linked to the Huanan Seafood Wholesale Market, which also sold live animals; thus the virus is thought to have a zoonotic origin. [238]

During the early stages of the outbreak, the number of cases doubled approximately every seven and a half days. [376] 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. [377] Later official data shows that 6,174 people had already developed symptoms by 20 January 2020. [378]

On 10 January, based on reports from Chinese authorities, the WHO issued a travel advisory asking travellers to follow guidelines "to reduce the general risk of acute respiratory infections while travelling in or from affected areas (currently Wuhan City)". [379] While noting that the mode of transmission of the virus was unclear, it advised against "the application of any travel or trade restrictions on China". On 12 January, based on additional information from the Chinese National Health Commission, the WHO stated that "at this stage, there is no infection among healthcare workers, and no clear evidence of human to human transmission." [380] On 24 January, the WHO updated its travel advisory by recommending entry and exit screenings while continuing to advise against travel restrictions. [381]

On 30 January, the WHO declared the outbreak to be a Public Health Emergency of International Concern. [6] On 24 February, WHO director Tedros Adhanom warned that the virus could become a global pandemic because of the increasing number of cases outside China. [382]

On 11 March, the WHO officially declared the coronavirus outbreak to be a pandemic, following a period of sustained community-level transmission in many regions of the world. [7] On 13 March, the WHO declared Europe to be the new centre of the pandemic after the rate of new European cases surpassed that of regions of the world apart from China. [383] By 16 March 2020, the total number of cases reported around the world outside China had exceeded that of mainland China. [384] On 19 March 2020, China reported no new domestic cases (excluding cases re-imported from abroad) for the first time since the outbreak, while the total number of reported deaths in Italy surpassed that of China. [385]

On 27 March 2020, Chinese scientists reported that as many as 10% of those who have recovered from COVID-19 and tested negative, tested positive again. [386]

As of 29 March 2020, more than 713,000 cases have been reported worldwide; more than 33,600 people have died and more than 150,000 have recovered. The United States has overtaken China and Italy to have the highest number of confirmed cases in the world. [8] [4] [387] [388]

Domestic responses

Around 200 countries and territories have had at least one case. [4] Due to the pandemic in Europe, many countries in the Schengen Area have restricted free movement and set up border controls. [389] National reactions have included containment measures such as quarantines (known as stay-at-home orders, shelter-in-place orders, or lockdown) and curfews. [390]

As of 24 March, more than 158 million people are in lockdown in the United States, [391] more than 50 million people are in lockdown in the Philippines, [392] and 1.3 billion people are in lockdown in India. [393] On 26 March, 1.7 billion people worldwide were under some form of lockdown, [394] which increased to 2.6 billion people two days later—around a third of the world's population. [395] [396]

China

Aerial video from China News Service shows mostly empty roads after motor vehicles were banned in central urban areas of Wuhan

The first confirmed case of COVID-19 has been traced back to 1 December 2019 in Wuhan; [242] one unconfirmed report suggests the earliest case was on 17 November. [247] Doctor Zhang Jixian observed a pneumonia-cluster of unknown cause on 26 December, upon which her hospital informed Wuhan Jianghan CDC on 27 December. [397] A public notice was released by Wuhan Municipal Health Commission on 31 December. [398] The WHO was informed on the same day. [236] As these notifications occurred, doctors in Wuhan were simultaneously threatened by police for sharing information about the outbreak. [399] The Chinese National Health Commission initially claimed that there was no "clear evidence" of human-to-human transmission. [400]

A temporary hospital for treating mild cases of COVID-19 in Wuhan, one of more than 10 such hospitals in the city Ta Zi Hu Ti Yu Zhong Xin Gai Zao De Fang Cang Yi Yuan 07.jpg
A temporary hospital for treating mild cases of COVID-19 in Wuhan, one of more than 10 such hospitals in the city

The Chinese Communist Party launched a radical campaign later described by the Party general secretary Xi Jinping as a "people's war" to contain the spread of the virus. [402] In what has been described as "the largest quarantine in human history", [403] a quarantine was announced on 23 January stopping travel in and out of Wuhan, [404] which was extended to a total of 15 cities in Hubei, affecting a total of about 57 million people. [405] Private vehicle use was banned in the city. [406] Chinese New Year (25 January) celebrations were cancelled in many places. [407] The authorities also announced the construction of a temporary hospital, Huoshenshan Hospital, which was completed in 10 days, and 14 temporary hospitals were constructed in China in total. [408]

On 26 January, the Communist Party and the government instituted further measures to contain the COVID-19 outbreak, including issuing health declarations for travellers [409] and extending the Spring Festival holiday. [410] Universities and schools around the country were also closed. [411] [412] [413] The regions of Hong Kong and Macau instituted several measures, particularly in regard to schools and universities. [414] Remote working measures were instituted in several Chinese regions. [415] Travel restrictions were enacted in and outside of Hubei. [415] [416] Public transport was modified, [417] and museums throughout China were temporarily closed. [415] [418] [419] 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. [420]

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. [421]

Early responses by Wuhan authorities were criticized as prioritizing control of information that might be unfavourable for local officials over public safety, and the Chinese government was criticized for cover-ups and downplaying the discovery and severity of the outbreak. [422] In early January 2020, Wuhan police summoned and "admonished" several doctors—including Li Wenliang, an ophthalmologist at Wuhan Central Hospital—for "spreading rumours" likening the disease to SARS. [423] Li later died from the virus. [424] Observers have blamed institutional censorship which left the citizens and senior officials with incomplete information on the outbreak and "contributed to a prolonged period of inaction that allowed the virus to spread". [425] Experts have questioned the accuracy of the number of cases reported by the Chinese government, [426] [427] and the Chinese government has been accused of rejecting help from the US CDC and the WHO. [428]

Body temperature screening at the entrance of the Beijing Subway Check for 2019-nCoV in Beijing railway station metro station.jpg
Body temperature screening at the entrance of the Beijing Subway

Later criticisms have targeted China's aggressive response aimed at controlling the outbreak, [429] though some foreign leaders such as US President Donald Trump, [430] Philippine President Rodrigo Duterte, [431] and Russian president Vladimir Putin have praised them. [432] Trump later reversed his stance, stating that he "wish[ed] they could have told us earlier about what was going on inside," and that China "was very secretive, and that's unfortunate". [433] The director of the WHO Tedros Adhanom Ghebreyesus congratulated the Chinese government "for the extraordinary measures it has taken to contain the outbreak", [434] and a later WHO report described China's response as "perhaps the most ambitious, agile and aggressive disease containment effort in history". [435] Damage to the global economy has been felt in China as well: 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%. [436]

On 23 March, mainland China had gone five days with only one case transmitted domestically, in this instance via a traveller returning to Guangzhou from Istanbul. [437] [438] 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. [439] The same day travel restrictions were eased in Hubei, apart from Wuhan, two months after the lockdown was imposed. [440]

The Chinese Ministry of Foreign Affairs announced on 26 March 2020 that entry for visa or residence permit holders will be suspended from 28 March onwards, with no specific details on when this policy will end. Those wishing to enter China will have to apply for visas in Chinese embassies or consulates. [441] [442]

South Korea

Coronavirus infection prevention tips banner in Seoul Coronavirus Jongno 1.jpg
Coronavirus infection prevention tips banner in Seoul

COVID-19 was confirmed to have spread to South Korea on 20 January 2020 from China. There was a large increase in cases on 20 February, [443] potentially attributable to a gathering in Daegu of a new religious movement known as the Shincheonji Church of Jesus. [443] [444] Shincheonji devotees visiting Daegu from Wuhan were suspected to be the origin of the outbreak. [445] [446] As of 22 February, among 9,336 followers of the church, 1,261 or about 13% reported symptoms. [447]

South Korea declared the highest level of alert on 23 February 2020. [448] On 28 February, more than 2,000 confirmed cases were reported in Korea, [449] rising to 3,150 on 29 February. [450] All South Korean military bases were quarantined after tests confirmed that three soldiers were positive for the virus. [445] Airline schedules were also affected and therefore they were changed. [451] [452]

South Korea introduced what was considered the largest and best-organised program 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. [453] [454] Screening methods included drive-thru testing for the virus with the results available the next day, [455] and South Korea's approach to the outbreak includes having 20,000 people tested every day. [456] South Korea's program is considered to be a success in controlling the outbreak despite not quarantining entire cities. [453] [457]

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. [458] On 23 March, it was reported that South Korea had the lowest one-day case total in four weeks. [456] On 29 March it was reported that beginning April 1, all new overseas arrivals will be quarantined for two weeks. [459]

Iran

Disinfection of Tehran Metro trains against coronavirus Disinfection of Tehran subway wagons against coronavirus 2020-02-26 09.jpg
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. [460] [461] Early measures announced by the government included the cancellation of concerts and other cultural events, [462] sporting events, [463] and Friday prayers, [464] and closures of universities, higher education institutions, and schools. [465] Iran allocated five trillion rials to combat the virus. [466] 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. [467] Plans to limit travel between cities were announced in March, [468] although heavy traffic between cities ahead of the Persian New Year Nowruz continued. [469] Shia shrines in Qom remained open to pilgrims until 16 March 2020. [470] [471]

Iran became a centre of the spread of the virus after China. [472] [473] Amidst claims of a cover-up of the extent of the outbreak in Iran, [474] 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. [473] [475] The Iranian Parliament was shut down, with 23 of its 290 members reported to have had tested positive for the virus on 3 March. [476] 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. [477] On 15 March, the Iranian government reported 100 deaths in a single day, the most recorded in the country since the outbreak began. [478] At least 12 sitting or former Iranian politicians and government officials had died from the disease by 17 March. [479] Per media reports on 23 March, Iran has 50 new cases every hour and one new death every ten minutes due to coronavirus. Even so, some sources like Radio Farda, which is US-backed, say Iran may be underreporting. [480] According to media reports on 29 March, the WHO believes there are five times more cases in Iran than what is being reported. The same report indicates US sanctions on Iran may be affecting the country's financial ability to respond to the viral outbreak. [481]

Europe

Map of confirmed cases in Europe per million inhabitants Coronavirus infected persons per capita in Europe.svg
Map of confirmed cases in Europe per million inhabitants

As of 18 March, more than 250 million people are in lockdown in Europe. [482]

Italy

Civil Protection volunteers carrying out health checks at the Guglielmo Marconi Airport in Bologna Emergenza coronavirus (49496308758).jpg
Civil Protection volunteers carrying out health checks at the Guglielmo Marconi Airport in Bologna

The outbreak was confirmed to have spread to Italy on 31 January, when two Chinese tourists tested positive for SARS-CoV-2 in Rome. [483] Cases began to rise sharply, which prompted the Italian government to suspend all flights to and from China and declare a state of emergency. [484] An unassociated cluster of COVID-19 cases was later detected, starting with 16 confirmed cases in Lombardy on 21 February. [485]

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. [486] 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." [487] [488]

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, will be held behind closed doors until April. [489] On 9 March, all sport was suspended completely for at least one month. [490] On 11 March, Prime Minister Conte ordered stoppage of nearly all commercial activity except supermarkets and pharmacies. [491] [492]

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. [493] [494] [495] 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. [496] [497] On 22 March, it was reported that Russia had sent nine military planes with medical equipment to Italy. [498] As of 29 March, there were 97,689 confirmed cases, 10,779 deaths, and 13,030 recoveries in Italy, with the majority of those cases occurring in the Lombardy region. [499] 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 mortality rate. [500]

Spain

People maintain social distancing in Valencia, Spain 2020-03-Detalls i consequencies del COVID-19 al Pais Valencia 14.jpg
People maintain social distancing in Valencia, Spain

The 2019–20 coronavirus 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. [501]

On 24 February, following the COVID-19 outbreak in Italy, Spain confirmed multiple cases related to the Italian clusters, originating from a medical doctor from Lombardy, Italy, who was on holiday in Tenerife. [502]

By 3 March, Madrid had become the major focus of the pandemic in Spain, with a major outbreak linked to evangelical churches in eastern Madrid. [503] A state of alarm and national lockdown was imposed on 14 March. [504] More than 350,000 tests for COVID-19 had been conducted by 21 March. [505] The daily death toll surpassed 700 on 23 March, with 738 people dying in a single day, [506] [507] [508] and peaking at 838 dead over a 24-hour period on 28 March. [509] As of 29 March, at least 6,803 people have died [499] and 4,907 people were hospitalized in intensive care (1,429 in the Community of Madrid). [510] On 29 March it was announced that, beginning the following day, all non-essential workers were to stay home for the next 14 days. [511]

United Kingdom

People in London buying canned foods and toilet paper on 18 March 2020 DSC05532 (49675496857).jpg
People in London buying canned foods and toilet paper on 18 March 2020

The United Kingdom 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. [512] [513] As a result, the government received criticism for the perceived lack of pace and intensity in its response to concerns faced by the public. [514] [515] [516]

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. [517] [518] On 20 March, the government announced that all leisure establishments such as pubs and gyms were to close as soon as possible, [519] and promised to pay up to 80% of workers' wages to a limit of £2,500 per month to prevent unemployment in the crisis. [520]

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. [521]

On 25 March, Prince Charles tested positive for coronavirus, [522] with Clarence House announcing that he was displaying mild symptoms. [523]

On 27 March, Prime Minister Boris Johnson and Health Secretary Matt Hancock tested positive for COVID-19. [524] They are in isolation but Johnson said he will continue to lead the government's response via videoconference. [525] On the same day, the government's Chief Medical Adviser Chris Whitty announced that he was self-isolating after experiencing symptoms of the virus. [526] On 29 March, the number of confirmed deaths passed 1,000 individuals, and the Prime Minister indicated that stricter lockdown measures could be put in place. [527]

France

The virus was confirmed to have spread to France on 24 January 2020, when the first COVID-19 case in Europe and France was confirmed in Bordeaux. It involved a 48-year-old French citizen who arrived in France from China. Two more cases were confirmed by the end of the day, all among individuals who had recently returned from China. [528] A Chinese tourist was admitted to a hospital in Paris on 28 January and died on 14 February, marking the first death from COVID-19 in Europe and France. It was also the first death outside of Asia. [529] [530] A national lockdown was put in place on 17 March. [531] As of 29 March, there have been 40,174 confirmed cases, 2,606 deaths, and at least 7,202 recoveries in France. [532] [533] [4]

Germany

The virus was confirmed to have been transmitted to Germany on 27 January 2020, when the first COVID-19 case was confirmed in Bavaria. The majority of the COVID-19 cases in January and early February originated from the headquarters of a car parts manufacturer in Bavaria. Later, new clusters were introduced by travellers from Italy, China, and Iran. As of 29 March, Germany has reported 62,440 cases, 541 deaths, and 5,024 recoveries. [534] [535] According to a media report on 29 March, the mortality rate in Germany is 0.5%, which is much lower than other European countries such as Spain. The report speculates this could be due to the country starting widespread testing early, having a better-equipped healthcare system, differences in population age distribution, or Germany not testing as many people postmortem compared to other countries. [536] [537]

United States

Confirmed cases of COVID-19 per million inhabitants by state COVID-19 outbreak USA per capita cases map.svg
Confirmed cases of COVID-19 per million inhabitants by state

The first known case in the United States of COVID-19 was confirmed in the Pacific Northwest state of Washington on 20 January 2020, in a man who had returned from Wuhan on 15 January. [538] The White House Coronavirus Task Force was established on 29 January. [539] On 31 January, the Trump administration declared a public health emergency, [540] and placed travel restrictions on entry for travellers from China. [541]

President Trump signs the Coronavirus Preparedness and Response Supplemental Appropriations Act into law on 6 March 2020 President Trump Signs the Congressional Funding Bill for Coronavirus Response (49627907646).jpg
President Trump signs the Coronavirus Preparedness and Response Supplemental Appropriations Act into law on 6 March 2020

After the first death in the United States was reported in Washington state on 29 February, [542] Governor Jay Inslee declared a state of emergency, [543] an action that was soon followed by other states. [544] [545] [546] Schools in the Seattle area cancelled classes on 3 March, [547] and by mid-March, schools across the country were closing and most of the country's students were out of school. [548]

On 6 March, President Trump signed the Coronavirus Preparedness and Response Supplemental Appropriations Act, which provided $8.3 billion in emergency funding for federal agencies to respond to the outbreak. [549] Corporations imposed employee travel restrictions, cancelled conferences, [550] and encouraged employees to work from home. [551] Sports events and seasons were cancelled. [30] [552]

On 11 March, Trump announced travel restrictions for most of Europe, excluding the United Kingdom, for 30 days, effective 13 March. [553] The following day, he expanded the restrictions to include the United Kingdom and Ireland. [554] On 13 March, he declared a national emergency, which made federal funds available to respond to the crisis. [555] Beginning on 15 March, many businesses closed or reduced hours throughout the US to try to reduce the spread of the virus. [556] By 17 March, the epidemic had been confirmed in all 50 states and in the District of Columbia. [557]

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. [558] However, the governor said on 25 March that social distancing seemed to be working, as estimates of case doubling slowed from 2.0 days to 4.7 days. [559] As of 28 March, there were 32,308 confirmed cases in New York City, and 672 people had died from the virus. [560]

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. [388] 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. [561] [562] [563] Overall approval of Trump's management of the crisis has been polarized along partisan lines. [564]

As of 29 March, 142,226 cases have been confirmed in the United States, and 2,493 people have died. [4]

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. [565] [566]

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 emphasise border control and communication in its response to the pandemic. [567] On 21 March, a human biosecurity emergency was declared in Australia. [568]

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A worker disinfects an ambulance in Daegu, South Korea
Announcement on a television screen at Delft University of Technology in the Netherlands, advising students not to travel to China (19 February 2020) TUDelftCorona 02.jpg
Announcement on a television screen at Delft University of Technology in the Netherlands, advising students not to travel to China (19 February 2020)

Travel restrictions

Countries that have implemented a global travel ban in response to the COVID-19 pandemic (red) COVID-19 Outbreak World Map-GlobalTravelBan.svg
Countries that have implemented a global travel ban in response to the COVID-19 pandemic (red)

As a result of the outbreak, many countries and regions have imposed quarantines or entry bans for citizens or visitors of the most affected areas of the pandemic. [569]

The European Union rejected the idea of suspending the Schengen free travel zone and introducing border controls with Italy, [570] [571] [572] a decision which has been criticized by some European politicians. [573] [574] After some EU member states announced complete closure of their national borders to foreign nationals, [575] 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." [576] The United States suspended travel from the Schengen Area and later the Common Travel Area. [577]

Evacuation of foreign citizens

Ukraine evacuates Ukrainian and foreign citizens from Wuhan Ukraine evacuates Ukrainian and foreign citizens from Wuhan 16.jpg
Ukraine evacuates Ukrainian and foreign citizens from Wuhan

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, France, Australia, Sri Lanka, Germany, and Thailand were among the first to plan the evacuation of their citizens. [578] Pakistan has said that it will not be evacuating any citizens from China. [579] 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. [580] [581] [582] On the same day, 215 Canadians (176 from the first plane, and 39 from a second plane chartered by the US government) were evacuated from Wuhan to CFB Trenton to be quarantined for two weeks. [583]

On 11 February, another plane of 185 Canadians from Wuhan landed at CFB Trenton. [584] 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. [585] 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. [586] On 15 February, the United States announced that it would evacuate Americans aboard the cruise ship Diamond Princess . [587] On 21 February, a plane carrying 129 Canadian passengers who had been evacuated from Diamond Princess landed in Trenton, Ontario. [588] In early March, the Indian government began evacuating its citizens from Iran. [589] [590]

On 14 March a South African Airways aircraft chartered by the South African Government repatriated 114 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 the 21 day period at The Ranch Resort. [591] [592]

International aid

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

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. [593] 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. [594]

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. [595] On 5 February, Bill and Melinda Gates announced a US$100 million donation to the WHO to fund vaccine research and treatment efforts along with protecting "at-risk populations in Africa and South Asia". [596]

Tehran's Azadi Tower lights in the colours of the Flag of China to show support Azadi Tower lights in support of China against coronavirus 2.jpg
Tehran's Azadi Tower lights in the colours of the Flag of China to show support

Japan donated one million face masks to Wuhan, [597] Turkey dispatched medical equipment, [598] Russia sent more than 13 tonnes of medical supplies to Wuhan, [599] Malaysia announced a donation of 18 million medical gloves to China, [600] and Germany delivered various medical supplies including 10,000 Hazmat suits. [601] On 19 February, the  Singapore Red Cross announced that it would send $2.26 million worth of aid to China. [602]

In March 2020, China, Cuba and Russia sent medical supplies and experts to help Italy deal with its coronavirus outbreak. [603] [604] 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. [605] He later sent 5,000 testing kits, 100,000 face masks and 5 ventilators to Panama. [606] Ma also donated medical supplies to Canada. [607]

WHO response measures

The WHO has commended the efforts of Chinese authorities in managing and containing the epidemic. [608] 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". [609]

WHO Director-General Tedros Adhanom Tedros Adhanom Ghebreyesus (44834995345).jpg
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". [609]

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. [6] [610] 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." [611]

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". [612] [613]

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". [614]

WHO representatives holding joint meeting with Tehran administrators 13981214000744637189356214810969 nshst mdyrn shhry b nmyndgn szmn bhdsht jhny.jpg
WHO representatives holding joint meeting with Tehran administrators

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". [615]

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". [616] In response to a developing outbreak in Iran, the WHO sent a Joint Mission Team there to assess the situation. [617]

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." [618]

On 11 March, the WHO declared the coronavirus outbreak a pandemic. [619] 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". [620]

Ease of sanctions

With a rapid increase observed in the number of active COVID-19 cases, the UN High Commissioner for Human Rights, Michelle Bachelet, demanded economic sanctions to be eased for nations most affected by the pandemic. The ease is demanded to provide the countries a chance to counter the disease and limit its global impact. [621] Iran is one of the nations named in the appeal, which has over 35,000 COVID-19 cases and more than 2,500 deaths. [4]

Impact

Politics

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

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 experts believe this is likely in a move to protect Communist Party general secretary Xi Jinping from people's anger over the coronavirus outbreak. [622]

In early March, the Italian government criticized the European Union's lack of solidarity with coronavirus-affected Italy. [623] [624] 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. [625]

The planned NATO "Defender 2020" military exercise in Germany, Poland, and the Baltic states, [626] the largest NATO war exercise since the end of the Cold War, will be held on a reduced scale. [627]

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. [628] [629] 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. [630]

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. [631] Political analysts anticipated it may negatively affect Donald Trump's chances of re-election in the 2020 presidential election. [632]

Diplomatic relations between Japan and South Korea worsened due to the pandemic. [633] 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. [634]

Education

Learners affected by school closures caused by COVID-19
Country-wide school closures
Localized school closures
No school closures COVID-19 school closures.svg
Learners affected by school closures caused by COVID-19
  Country-wide school closures
  Localized school closures
  No school closures

As of 29 March 2020, more than 1.5 billion children and other students were affected by nationwide school closures. Others have been disrupted by localized closures. [33]

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. [635] International Baccalaureate exams have also been cancelled. [636]

Even when school closures were temporary, the measures carried high social and economic costs, affecting people across communities. 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] [637]

In response to school closures, UNESCO recommended the use of distance learning programs and open educational applications and platforms that schools and teachers can use to reach learners remotely and limit the disruption of education. [638]

Socioeconomics

Coronavirus fears have led to panic buying of essentials in Singapore and elsewhere, including toilet paper, dried and/or instant noodles, bread, rice, vegetables, disinfectant, and rubbing alcohol Ntuc super store, Singapore (49505410793).jpg
Coronavirus fears have led to panic buying of essentials in Singapore and elsewhere, 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 to drugs and medical equipment due to increased consumer demand and supplier disruption. [639] 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. [640] [641] [642] [643] The technology industry in particular has been warning about delays to shipments of electronic goods. [644] 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. [645] [646] It has also caused a shortage of personal protective equipment worldwide, with the WHO warning that this will endanger health workers. [647] In Australia, the pandemic has provided a new opportunity for daigou shoppers to sell Australian product into China. [648] This activity has left locals without essential supplies. [649]

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. [650] 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. [651] Organization of the Petroleum Exporting Countries (OPEC) reportedly "scrambled" after a steep decline in oil prices due to lower demand from China. [652] Global stock markets fell on 24 February due to a significant rise in the number of COVID-19 cases outside mainland China. [653] [654] On 27 February, due to mounting worries about the coronavirus outbreak, various US 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. [655] All three indexes ended the week down more than 10%. [656] On 28 February, Scope Ratings GmbH affirmed China's sovereign credit rating, but maintained a Negative Outlook. [657] Stocks plunged again based on coronavirus fears, the largest fall being on 16 March. [658] Many consider an economic recession to be likely. [659] [660] [661] 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. [662]

The near-empty arrival hall of Seoul-Incheon International Airport in South Korea on 6 March Incheon 2.jpg
The near-empty arrival hall of Seoul–Incheon International Airport in South Korea on 6 March

Tourism is one of the worst affected sectors due to travel bans, closing of public places including travel attractions, and advise 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. [663] Several train stations and ferry ports have also been closed. [664] 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. [665] [666] 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. [667] 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. [668] [669] These regions represented 80% of the country's GDP and 90% of exports. [669] 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. [670] [671]

The retail sector has been impacted globally, with reductions in store hours or temporary closures. [672] This 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. [673]

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. [674] [675]

Environment and climate

Empty A1 motorway in Slovenia Empty motorway due to 2019-20 coronavirus pandemic (A1 motorway, Slovenia).jpg
Empty A1 motorway in Slovenia

Due to the coronavirus outbreak's impact on travel and industry, many regions experienced a drop in air pollution. The Centre for Research on Energy and Clean Air reported that methods to contain the spread of coronavirus, such as quarantines and travel bans, resulted in a 25% reduction of carbon emission in China. [676] [677] In the first month of lockdowns, China produced approximately 200 million fewer metric tons of carbon dioxide than the same period in 2019, due to the reduction in air traffic, oil refining, and coal consumption. [677] One expert estimated that this reduction may have saved at least 77,000 lives. [677] Between 1 January and 11 March 2020, the European Space Agency observed a marked decline in nitrous oxide emissions from cars, power plants, and factories in the Po Valley region in northern Italy, coinciding with lockdowns in the region. [678] In Venice, the water in the canals cleared and experienced an increased presence of fish and waterfowl; the Venice mayor's office clarified that the increase in water clarity was due to the settling of sediment that is disturbed by boat traffic and mentioned the decrease in air pollution along the waterways. [679]

Despite a temporary decline in global carbon emissions, the International Energy Agency warned that the economic turmoil caused by the coronavirus outbreak may prevent or delay companies from investing in green energy. [680] [681] [682] However, extended quarantine periods have boosted adoption of remote work policies. [683] [684] As a consequence of the unprecedented use of disposable face masks, significant numbers are entering the natural environment, adding to the worldwide burden of plastic waste. [685]

The European Centre for Medium-Range Weather Forecasts (ECMWF) announced that a worldwide reduction in aircraft flights due to the pandemic could impact the accuracy of weather forecasts, citing commercial airlines' use of Aircraft Meteorological Data Relay (AMDAR) as an integral contribution to weather forecast accuracy. The ECMWF predicted that AMDAR coverage would decrease by 65% or more due to the drop in commercial flights. [686]

Culture

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. Closed library - Island Bay.jpg
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 performing arts and cultural heritage sectors have been profoundly affected by the pandemic, impacting organisations' operations as well as individuals – both employed and independent – globally. Arts and culture sector organisations attempted to uphold their (often publicly funded) mission to provide access to cultural heritage to the community, maintain the safety of their employees and the public, and support artists where possible. By March 2020, across the world and to varying degrees, museums, libraries, performance venues, and other cultural institutions had been indefinitely closed with their exhibitions, events and performances cancelled or postponed. [687] In response there were intensive efforts to provide alternative services through digital platforms. [688]

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. [689] [690]

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. 3404926 syh khrwn br zndgy shhry.jpg
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 Vatican announced that Holy Week observances in Rome, which occur during the last week of the Christian penitential season of Lent, have been cancelled. [689] 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 livestreaming or television while others are offering drive-in worship. [691] [692] [689] With the Roman Catholic Diocese of Rome closing its churches and chapels and St. Peter's Square emptied of Christian pilgrims, [689] other religious bodies also cancelled services and limited public gatherings in churches, mosques, synagogues, and gurdwaras. [689] Iran's Health Ministry announced the cancellation of Friday prayers in areas affected by the outbreak and shrines were later closed, [693] [471] while Saudi Arabia banned the entry of foreign pilgrims as well as its residents to holy sites in Mecca and Medina. [694] [695]

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, [696] 2019–20 Premier League, [697] UEFA Euro 2020, 2019–20 NBA season, [698] and 2019–20 NHL season. [699] 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". [700] [701]

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. [702]

The entertainment industry has also been affected, with various music groups suspending or cancelling concert tours. [703] [704] Many large theatres such as those on Broadway also suspended all performances. [705] 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 [706] or creating web-based "festivals" for artists to perform, distribute, and publicize their work. [707]

Potential long-term impacts

The political, cultural, and socio-economic impacts of the pandemic may together cause major changes in human society. [708] Commentators have suggested this could include an increase in remote work, [709] localization of global supply chains, [710] [711] and increased political polarization. [708]

Xenophobia and racism

Houston Chinatown experienced a reduction in business early during the outbreak when there were still few cases Chinatown2.JPG
Houston Chinatown experienced a reduction in business early during the outbreak when there were still few cases

Since the outbreak of COVID-19, heightened prejudice, xenophobia, and racism have been noted toward people of European, Chinese, and other East Asian descent. Incidents of fear, suspicion, and hostility have been observed in many countries, particularly in Europe, East Asia, North America, and the Asia-Pacific region. [713] [714] [715] Some countries in Africa have seen rising anti-Chinese sentiment. [716] [717] Many residents of Wuhan and Hubei have reported discrimination based on their regional origin. [718] [719] [720] There has been support for the Chinese, both on and offline, and towards those in virus-stricken areas. [721] [722] [723] Following the progression of the outbreak to new hotspot countries, people from Italy, the early epicentre of Europe's coronavirus pandemic, could also be subjected to suspicion and xenophobia. [724] [725]

Citizens in countries including Malaysia, [726] New Zealand, [727] Singapore, [728] and South Korea initially signed petitions lobbying to ban Chinese people from entering their countries in an effort to stop the disease. [729] In Japan, the hashtag #ChineseDontComeToJapan trended on Twitter. [730] 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. [731] [36] [732] US president Donald Trump has faced criticism for referring to the coronavirus as the "Chinese Virus", a term considered by detractors to be racist and anti-Chinese. [733] [734] In response to reports of Sinophobic incidents, Trump tweeted: "It is very important that we totally protect our Asian American community in the United States, and all around the world." [734] Protesters in Ukraine attacked buses carrying Ukrainian and foreign evacuees from Wuhan to Novi Sanzhary. [735] Students from Northeast India, which shares a border with China, who study in major Indian cities have reportedly experienced harassment related to the coronavirus outbreak. [736] 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". [737]

In the Russian cities of Moscow and Yekaterinburg, Chinese nationals were targeted by quarantine enforcing campaigns, as well as police raids, which were condemned by human rights advocates as racial profiling. [738] The Chinese Embassy in Germany has acknowledged a rise in hostility against its citizens since the outbreak. [739] Children of Asian descent were ostracized and mocked over their origins in middle schools near Paris. [740] [741] Many French-Vietnamese report also being subject to harassment since the coronavirus outbreak in Wuhan. [742] Local authorities in Bolivia quarantined Japanese nationals despite them having no coronavirus-related symptoms. [743]

As Covid-19 cases in China fell while those in the West and around the world rose, anti-Western sentiment has risen in Hong Kong as well as Mainland China, as expats are accused of introducing a "second wave" of the disease, and Chinese media published articles with titles like "Beware of a second outbreak started by foreign garbage." [744] [745] Westerners and other foreigners in China have reported increased incidences of xenophonia against them. [37]

Anti-Caucasian sentiment has also risen in Thailand, where Westerners are accused of spreading the disease. [746] As the pandemic has progressed, there have also been isolated instances of prejudice against Westerners, particularly Western tourists accused of importing the disease. A Twitter post reportedly by the Thai Health Minister, Anutin Charnvirakul, urged Thais to be "more careful of Westerners than Asians". [747] It claimed many Western tourists refused to wear masks and "dressed dirtily and never shower". [747] The post attracted negative reaction in Thailand [748] and the UK [749] and was quickly removed. Mr. Charnvirakul claimed he was not responsible for it. [750]

Islamists have exploited the disease to foster anti-Western sentiment. [751] There were also false rumours in India, amplified by bloggers and some social media channels, that some Muslims who returned from Dubai refused to undergo coronavirus testing for religious reasons. [752]

The Anti-Defamation League [753] and Life After Hate [754] observed that in addition to the wave of anti-Asian xenophobia online, there was a white nationalist and white supremacist [753] [755] -fueled wave of anti-Semitic and racist anti-Israeli agitation, including but not limited to claims that Jews and/or Israelis were spreading the virus, but also an online campaign to infect Jews with the virus as a means of murder. [753] The ADL was especially concerned with the prevalence of anti-Semitic messaging on Twitter, Instagram, [756] Steam, Discord and TikTok combined with the increased internet usage by children after school closings. [755] The FBI also warned that white supremacists groups were plotting to "expose Jewish people to coronavirus" by having members use themselves as bio-weapons" to infect areas Jewish people are deemed likely to visit. [757] [758] On 23 March, the FBI foiled a terrorist [759] plot by a white supremacist to use a car bomb to blow up a Missouri hospital overflowing with COVID-19 patients, with the man having referenced far-right conspiracy theories that the virus was "engineered by Jews", online before he was shot and killed in an altercation with FBI agents. [759] [757]

On 30 January, the WHO's Emergency Committee issued a statement advising all countries to be mindful of the "principles of Article 3 of the IHR (the International Health Regulations)", which the WHO says is a caution against "actions that promote stigma or discrimination" when conducting national response measures to the outbreak. [6]

Information dissemination

Many newspapers with paywalls have lowered them for some or all of their coronavirus coverage. [760] Many scientific publishers made scientific papers related to the outbreak available with open access. [761] Some scientists chose to share their results quickly on preprint servers such as bioRxiv. [762]

Misinformation

After the initial outbreak, conspiracy theories and misinformation [763] spread online regarding the origin and scale of the COVID-19 coronavirus. [764] Various social media posts claimed the virus was a bio-weapon, a population control scheme, or the result of a spy operation. [765] [766] [767] Facebook, Google, and Twitter announced that they would take stringent measures against possible misinformation. [768] In a blog post, Facebook stated they would remove content flagged by leading global health organizations and local authorities that violates its content policy on misinformation leading to "physical harm". [769]

On 2 February, the WHO declared there was a "massive infodemic" accompanying the outbreak and response, citing an overabundance of reported information, accurate and false, about the virus that "makes it hard for people to find trustworthy sources and reliable guidance when they need it". The WHO stated that the high demand for timely and trustworthy information has incentivized the creation of a direct WHO 24/7 myth-busting hotline where its communication and social media teams have been monitoring and responding to misinformation through its website and social media pages. [770] [771] The WHO has specifically debunked as false some claims that have circulated on social media, including that a person can tell if they have the virus or not simply by holding their breath, that drinking lots of water will protect against the virus, and that gargling salt water will prevent infection. [772]

Taiwanese authorities accused the 50 Cent Party's internet trolls of spreading disinformation online to sow fear and panic among Taiwanese. [773] [774] Conspiracy theories about COVID-19 being the CIA's creation to keep China down spread across the Chinese internet. [775] [776] Possibly prompted by a press conference on 27 February where Zhong Nanshan, a prominent expert, said that "the coronavirus first appeared in China but may not have originated in China", individual officials have echoed Xinhua's claim that "The WHO has said many times that COVID-19 is a global phenomenon with its source still undetermined." [777] [778] Zhao Lijian, a spokesman from China's Ministry of Foreign Affairs, tweeted in March 2020 that the disease may have been introduced by members of the American Army who visited Wuhan in October 2019. [779] In a move which third party commentators consider state propaganda to deflect blame for poor handling of the epidemic, some officials, including a foreign ministry spokesman, as reported by the state news agency Xinhua, have protested at alleged "politicisation" of the outbreak by countries. [780] Commentators also believe the state propaganda in China is promoting a narrative that China's authoritarian system is uniquely capable of curbing the coronavirus and contrasts that with the chaotic response of the Western democracies. [781] [782] [783]

Iran's Supreme Leader Ayatollah Ali Khamenei has suggested the U.S. government is responsible for the spread of coronavirus. Ali Khamenei in 2020 Friday Prayer 06.jpg
Iran's Supreme Leader Ayatollah Ali Khamenei has suggested the U.S. government is responsible for the spread of coronavirus.

US President Donald Trump's top economic adviser Larry Kudlow and some members of the United States Congress have been accused of giving misinformation about the coronavirus. [785] [786] [787] Some Indian politicians claimed that drinking cow urine and applying cow dung on the body can cure coronavirus. [788] [789] On 22 February, US officials said that they have discovered Russia-linked social media accounts deliberately promoting anti-American conspiracy theories, such as that the virus is part of an American effort to "wag[e] economic war" on China. [790] [791] Russia has denied allegations that they were behind the accounts. [792]

Iranian cleric Seyyed Mohammad Saeedi accused US President Donald Trump of targeting Qom with coronavirus to fulfill his previous promise of retaliation against Iranian cultural sites. [793] Iran's Press TV asserted that "Zionist elements developed a deadlier strain of coronavirus against Iran", [794] while Iran's Supreme Leader Ayatollah Ali Khamenei said that the US created "a special version" of the virus that was affecting the country. [784] According to the Middle East Media Research Institute, numerous writers in the Arabic media have promoted the conspiracy theory that COVID-19 was deliberately created and spread by the United States, as "part of an economic and psychological war waged by the US against China with the aim of weakening it and presenting it as a backward country and a source of diseases". [795]

See also

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References