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A family mourns a deceased relative during a mass burial of coronavirus victims in Parque Taruma cemetery on May 19 in Manaus, Brazil — a city in the Amazon region hit hard by the virus.
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50 million world Covid-19 cases: The biggest outbreaks, explained

The actual toll is likely much higher. Here’s how some of the worst outbreaks spread.

Last New Year’s Eve, a hint of what the world might be in for in 2020 arrived in the form of an Associated Press story about 27 people in Wuhan, China, who had fallen ill with a mysterious strain of viral pneumonia. This was the first news of the new illness reported outside of China.

Less than 11 months later, 50 million people worldwide are confirmed to have been infected with the SARS-CoV-2 virus that causes the Covid-19 disease. And more than 1,250,000 Covid-19 deaths have been reported.

It’s a grim milestone, one that reflects the coronavirus’s contagiousness as well as a global failure to contain its spread.

Ten highly populated countries account for about two-thirds of confirmed coronavirus tests since the pandemic began, including the United States, Brazil, and Russia. And the high case counts are not just because they have more people than the average country, though a lack of testing in some regions makes direct comparisons more difficult.

But the virus is now spreading faster and further than ever detected before, with new case records being set regularly in Europe and North America. As Vox’s Julia Belluz reported, European hospitals are once again filling up. The continent’s leaders are reimplementing strict social distancing rules, with curfews and other restrictions imposed in Spain, Italy, and other countries. More sweeping lockdowns have been ordered in some places, including France, Greece, the Czech Republic, and parts of the UK.

The spread is more under control in Australia and New Zealand, as well as much of East Asia and Africa. India and parts of the Middle East, however, have also seen wide disease spread.

And the US has driven up the world’s new case numbers in the past few weeks, due in no small part to a lack of national leadership and a reluctance to implement well-established public health measures like testing, contact tracing, and wearing masks.

How the US became the world’s worst failure in containing Covid-19

The US has the most reported Covid-19 cases and deaths of any country in the world — more than 10 million confirmed cases and more than 237,000 confirmed deaths as of November 9, according to Johns Hopkins University’s tracker. Controlling for population, the United States still has one of the worst outbreaks anywhere.

The actual numbers, both globally and in the US, could well be a lot higher, said Eric Toner, a senior scientist at Johns Hopkins’s Bloomberg School of Public Health.

“The 50 million cases globally, we know is an underestimate, probably by a factor of 10 to 20,” Toner said. “There are many, many more people who have been infected than those confirmed cases. Same thing is true for deaths. So we don’t really know how bad it has been, but it’s certainly the worst thing we’ve seen in 100 years.”

President Donald Trump was briefed on the coronavirus beginning in January, but he has continued to downplay the virus’s threat throughout the pandemic.

On February 10, while campaigning in New Hampshire, the president claimed the virus would “miraculously go away.” But three days before, he had already privately told journalist Bob Woodward that Covid-19 was more deadly than the flu.

“What we’ve seen is the absolute failure of effective emergency health communication, which has basic principles that are straightforward,” says Dr. Tom Frieden, who led the Centers for Disease Control and Prevention (CDC) under President Barack Obama. “Be first, be right, be credible, give people practical, proven things to do. The US government completely failed on all of those components.”

Trump named Vice President Mike Pence to lead the government’s coronavirus response on February 27. On March 11 — the same day the sports world began to shut down and many schools announced plans for remote learning — the president announced travel restrictions from Europe, after restrictions on travel from China the previous month.

Experts disagree on how effective travel restrictions from Europe and China were, especially because by March the virus was already spreading quickly in areas including New York, Washington state, and California. Moreover, Trump did little with the time that travel restrictions may have bought, ignoring the federal government’s botched development and rollout of coronavirus testing.

It took until March 16 for Trump to introduce social distancing guidelines, and on March 19, he admitted to Woodward that he was purposely downplaying the virus to avoid “creating a panic.” He also acknowledged that younger people were susceptible to Covid-19 as well.

Trump has admitted publicly he has pressured officials to “slow down” testing, not wanting revealed Covid-19 cases to set back reopening of the country.

Equivocation around mask-wearing has been one of his most notable other failures in the pandemic response. In early April, the CDC along with the country’s top infectious disease expert, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, recommended that Americans wear masks “in public settings when around people outside their household, especially when social distancing measures are difficult to maintain.”

Trump, however, wore a mask in public for the first time in mid-July, and repeatedly mocked his Democratic opponent in the 2020 election, Joe Biden, for wearing one.

“The general measures are wear a mask, watch your distance, and wash your hands, as well as strategic closures,” Frieden said. “You have to call on people’s collective sense of responsibility, that we’re all in this together. The lack of recognition that we’re all connected, and the lack of acting on that recognition, has been very problematic.”

States that were reluctant to issue mask mandates or close down nonessential businesses again when cases rose did not help matters, although a lack of federal aid may have played a role in those decisions.

Now, the US is in its third — and worst — wave of surging infections, this time across nearly every region. On November 5, the country set a new single-day record with more than 120,000 new cases reported.

As Vox’s German Lopez explained, those rising numbers are “partly due to more testing exposing more cases. But that can’t be the full explanation, because hospitalizations and the overall rate of positive tests are trending up.” It doesn’t have to stay this way — but it probably will:

Cities, counties, states, and the federal government — or, short of all that, the public — could take social distancing seriously again. Governments could mandate masks, and the public could opt to wear them without a mandate. Bars and restaurants could close, voluntarily or not. Places that do open, such as schools, could try to adopt aggressive testing-and-tracing regimes to try to keep the coronavirus under some control.

Without that, America’s coronavirus epidemic will keep getting worse.

How the rest of the world has handled the virus

Other than the US, Europe and Latin America have struggled the most to contain Covid-19. Italy and Spain had the biggest outbreaks to be initially detected in Europe. Italy had just 566 new daily confirmed cases on March 1, but that number rose to more than 6,000 by March 26. A strict lockdown successfully contained the disease, but it came back with a vengeance in the fall.

This time, it was Spain that first showed the alarming resurgence on the continent. The country had followed a similar trajectory, with an initial spike in March and a lockdown that almost totally suppressed the virus.

As Spain reopened, however, social distancing rules and enforcement were lax in some areas, and the disease burden shifted more toward younger people with generally less severe cases. At the same time, the keys to controlling epidemic spread — test, trace, and isolate — were underutilized by a public health system that had deteriorated with a decade of fiscal austerity. Cases began to spike again in July, and some more drastic restrictions such as closing restaurants and bars in Catalonia did not come until October.

Spain now has more than 20,000 confirmed cases per day, and continues to record some of the highest numbers of new cases per million people on the continent.

Meanwhile, some European countries were slow to react to Spain’s case surge and impose measures of their own.

As Julia Belluz explained in September, France soon went down the same path as Spain:

In July, cases started increasing in a way that couldn’t be explained by testing alone — albeit slowly, doubling every two weeks instead of every 3.5 days, like in March. A rise in hospitalizations didn’t follow immediately.

It’s become clear that was because younger people were catching the virus. By mid-August, “the virus started to affect older people, and then a few weeks later, hospitalizations have started to increase,” said [Edouard Mathieu, the Paris-based data manager of Oxford University’s Our World in Data project]. By September 10, the French public health ministry reported that new Covid-19 hospitalizations were growing in all but one region of the country.

As outbreaks have spread across the continent again, several countries have returned to full or partial lockdowns to combat the new surge, including the United Kingdom, France, Germany, Ireland, the Netherlands, and the Czech Republic.

Before Europe’s coronavirus resurgence, South America’s outbreaks had begun to spiral out of control, and the hardest-hit has been Brazil. President Jair Bolsonaro, the country’s far-right populist and a Trump ally, has waved off the virus in much the same way as Trump. He ignored a growing outbreak in the Amazon region in the spring, and touted hydroxychloroquine as an effective treatment for Covid-19 despite a lack of evidence that it helps at all. His government continues to endorse questionable treatments for the virus.

Bolsonaro himself tested positive for the virus in July. He has opposed mask mandates and social distancing measures, and sought to reopen the economy almost as soon as regional restrictions were imposed in March.

Brazil has had by far the most confirmed cases in Latin America, with nearly 5.6 million, though new cases are on a downward trend. Other countries in the region have been hit hard, too: Argentina and Colombia each have more than a million cases, and Peru will likely join them soon. Central America has seen wide disease spread in some countries as well, and Mexico in particular has been criticized for insufficient testing to accurately determine the scope of community transmission.

Other regions have so far done a better job containing the spread, including Africa, despite dire predictions early on about potential spread on the continent. Africa is home to 17 percent of the world’s population but accounted for just 3.5 percent of reported Covid-19 deaths, as of early October. Africa has a younger population compared to other continents, and Covid-19 is most severe in older people.

But that’s likely not the only reason behind the relatively fewer confirmed deaths and cases: Many African countries, including Kenya and Lesotho, acted quickly in issuing health guidance and social distancing measures. And the experience of countries on the continent with previous epidemics may have helped officials and the public prepare better for this one.

Parts of Asia have also fared well. China, where the virus originated, initially sought to hide information about the virus. But officials soon changed course, locking down cities and ordering widespread testing. The country — of more than 1.4 billion people — still has fewer than 100,000 confirmed cases, according to Johns Hopkins data.

South Korea quickly contained an early outbreak. And Australia and New Zealand — it helps being islands — have been among the best in the world at suppressing the virus.

The reasons behind disease spread are complicated, and not every country’s situation can be easily compared.

But these seem to be key factors in stemming the tide of an outbreak: Quick action, clear health guidance, public trust, robust testing and surveillance systems, and thorough contact tracing. Many countries in the Pacific have managed all of these.

“Certainly, we can point to Taiwan, to Singapore, to South Korea, to Japan,” Toner said. “But also places like Vietnam have done a very good job. Certainly, Australia and New Zealand have been great examples. They’ve done a really good job with messaging and containment.”

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