The world hit yet another grim coronavirus milestone on Monday evening, when known coronavirus infections topped 20 million worldwide, including more than 736,000 fatalities.
It’s a toll that appeared unbelievable when, as the world celebrated New Years Eve, news came that a “pneumonia of unknown origin” had been detected in Wuhan, China.
That the virus would spread so widely perhaps still seemed unlikely a month later when the World Health Organization declared a global health emergency.
“My initial feeling was that this could be localised, that this would be localised,” Maria Van Kerkhove, head of the emerging diseases unit at the WHO, told the Telegraph earlier this month.
But the pandemic has grown exponentially - it took almost six months to hit 10 million cases, but just 43 days for that figure to double to 20 million.
And according to the WHO, Sars-Cov-2 has now infected at least four times the average number of people affected with severe influenza illnesses annually. Studies estimate that between 290,000 and 650,000 are killed by the flu each year - a figure dwarfed by the official Covid-19 death toll.
“Behind these statistics is a great deal of pain and suffering,” Dr Tedros Adhanom Ghebreyesus, director general of the WHO, told a press conference on Monday.
“But I want to be clear, there are green shoots of hope and no matter where a country, a region, a city or a town is – it’s never too late to turn the outbreak around,” he added.
How the pandemic has shifted across the globe
Experts had long warned of the dangers a pandemic posed to today’s hyper-connected world. And these fears were proved right when the virus quickly spread around Asia and then Europe after first emerging in China.
In early February Italy was a wake-up call to the rest of the world as the virus rapidly took hold, overwhelming health services. Then after a handful of imported cases in other parts of Europe the virus spread quickly hitting Spain, Germany, France and the UK hard.
The first imported cases of the disease were recorded in the US at the same time as the pandemic arrived in Europe but only really started to spread in late March and early April - with the more populous states such as California and New York worst affected.
The epidemic seemed to slow down before lockdowns were lifted and bars reopened in the sunbelt states, sparking more outbreaks.
Right from the start of the pandemic experts have warned of the havoc Covid-19 could wreak in developing countries. Many countries in Africa implemented strict lockdowns as soon as the first cases arrived, leading to economic strife but control of the virus.
The virus has spread more slowly here than first feared although last week it recorded a million cases, with the WHO’s director for the region warning that the continent was at a “pivotal point”.
Experts were also worried about the megacities of Asia and South America - India’s million-plus cities were hit hard initially but now the virus appears to be disappearing into the rural areas where it will be hard to control.
It is Latin America that is hardest hit by the pandemic, accounting for almost 28 per cent of the world's cases and more than 30 per cent of deaths.
What is notable about the pandemic is how countries that appeared to escape the worst at the beginning are now experiencing surges in cases - Australia and Vietnam both thought they had got off lightly but have seen surges in the last month. Greece was not hit like its European neighbours but has seen an uptick in cases in recent weeks.
Which countries have detected the most cases?
The United States, Brazil and India account for more than half of all known infections. Experts believe the official data likely undercounts both infections and deaths, particularly in countries with limited testing capacity.
Indonesia has recorded more than 120,000 cases, recently overtaking the Philippines as the south-east Asian country with the biggest number of cases. But most people think this is a vast underestimate because of a lack of testing.
The US is responsible for around five million cases, Brazil three million and India two million. Russia and South Africa are also in the top ten.
All these countries have large populations so it is not surprising that they would have the largest number of cases.
However, China, with a population of 1.4 billion, has seen 88,000 cases, thanks in part to a draconian lockdown and swift control of the disease.
While the worst-hit countries all took different approaches, politics played a part in poor control of the disease. In the US a defunded public health system, a lack of testing and a certain complacency led to the outbreak taking hold.
This was also the problem in Brazil where populist president Jair Bolsonaro downplayed the virus, famously describing it as the “flu or the sniffles”.
India has a huge, densely packed population and a weak health system - it also has little social safety net so when it locked down millions of migrant workers were left without an income. They returned to their home villages, raising fears they brought the virus with them.
South Africa seemed to get on top of the outbreak at the beginning, implementing a harsh lockdown, which included a ban on the sale of cigarettes and alcohol. But as lockdown was lifted the number of cases accelerated.
Where has had the biggest increase in cases in the last week?
As the pandemic has spread the epicentre has shifted from China to Europe to the Americas.
But in the last seven days, the Western Pacific region has seen the biggest spike in cases. According to the WHO daily situation report, there has been a 31 per cent jump in infections, with 46,143 new cases confirmed - though the region is still home to just two per cent of the known total worldwide.
This increase is predominantly driven by the Philippines, where the pandemic is rapidly accelerating. On Monday more than 3,000 new cases were reported in the country, taking the cumulative confirmed total just shy of 130,000.
Meanwhile South East Asia also saw a nine per cent jump in new cases - which largely reflects the worsening situation in India, where more than 50,000 cases have been detected every day since July 29 - peaking at 65,156 on Saturday.
Europe saw 169,629 cases confirmed in the last week, amid growing concerns about a “second wave” of cases.
In its latest risk assessment, published on Monday, the European Centres for Disease Prevention and Control urged countries that had seen an increase in infections after control measures were lifted to “consider reinstating selected measures through a phased, step-wise and sustainable approach.”
Where are the missing cases?
Experts have repeatedly warned that the ‘official’ tally is likely to be a vast underestimate as testing is patchy. In some countries this is a result of a lack of resources, others have bungled their strategies or were slow to ramp up capacity in the early days of the pandemic.
In the UK, for instance, just over 313,000 infections have been reported. But according to estimates from the Medical Research Council Biostatistics Unit at the University of Cambridge, the cumulative total in the UK is somewhere between 3.8 million and 6.1 million.
Part of this may be because the UK’s testing capacity was slow to build. In early April, when the virus was spreading rapidly, almost 25 per cent of tests were coming back positive. This figure is now hovering around 0.6 per cent.
This positive rate is considered the best measure for how adequately a country is testing; according to the WHO a rate of less than five per cent is an indicator that the epidemic is under control.
But in Mexico, where more than 485,000 cases have been identified, the positive rate is around 70 per cent, according to Our World In Data analysis.
By a separate metric - tests conducted per new case - the Central American country is also performing badly - for every positive infection just 1.4 tests are performed. That compares to 173 tests per confirmed case in the UK in August.
Other hard hit countries are also struggling to keep up with testing demand. In South Africa the positivity rate is 23 per cent, while other parts of Africa have far fewer resources.
While the US and India are faring slightly better with a positive test rate of 7.6 and 9.4 per cent respectively, this remains higher than the WHO’s five per cent target.
This means that there are probably many more infections than headline figures suggest. In one study by the Centers for Disease Control and Prevention in the US, researchers estimated that the real number of Covid-19 infections could be 10 times higher than the official toll.
This suggests the US alone could have a cumulative total of 50 million cases, rather than the five million currently reported.
What does the next six months look like?
As countries attempt to reopen more of society, including schools, the potential for transmission could skyrocket, experts have cautioned.
Speaking at a press briefing on Monday Dr Mike Ryan, head of the WHO’s emergencies programme, said that there was “always a likelihood” that flare ups would occur once countries suppressed initial epidemics and lifted control measures.
But he added that it is “never too late” to change the trajectory of an outbreak and countries have the tools to halt transmission.
“The trick for now is to really focus on identifying those clusters of disease, identifying new community transmission, containing the virus, suppressing the virus, and trying to avoid if possible having to reimpose a country-wide lockdown,” he said.
“This requires a very sophisticated response and implementation of measures as localised as possible,” Dr Ryan added.
But in short, countries and individuals should not expect this pandemic to be over in the near future - it’s likely that the coronavirus is here to stay and we will have to get better at living with it.
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