COVID-19 deaths per 100 000 population from selected countries [95]

Transmission
Main article: Transmission of COVID-19

The modes of spread of COVID-19, a new disease caused by the SARS-CoV-2

virus, are under research and investigation. It spreads from person to person, via
several different modes, mainly when people are in close proximity to one another
through respiratory droplets.[96][97] It's currently estimated that one infected person will
on average infect between two and three other people. [98] This is more infectious
than influenza, but less so than measles.[96][99] It can transmit when people are
symptomatic, also for up to two days prior to developing symptoms, and even if a
person never shows symptoms.[98][96] People remain infectious in moderate cases for
7-12 days, and up to two weeks in severe cases. [98]
The disease seems to spread mainly after an infected person breathes, coughs,
sneezes, talks or sings.[96] Actions such as these produce contaminated droplets,
which travel through the air, land on the mouths or noses of others close by, and can
be inhaled into the lungs, thereby causing new infection. [96] Many of these droplets
are too heavy to linger in the air and fall to the ground. [100] However smaller droplets
become airborne, suspended in the air for longer periods of time. [96][101][102] The
relative importance of the smaller aerosols (known as droplet nuclei, which cause
airborne disease) is unknown.[96] Airborne transmission occurs particularly in
crowded and less ventilated indoor spaces, which are particularly effective for
transmitting the virus, such as restaurants, nightclubs, public transport and
gatherings such as funerals.[102][100][96][better  source  needed] It also can occur in the healthcare
setting, where certain medical procedures performed on COVID-19 patients
generate aerosols.
It may be possible that a person can get COVID-19 through indirect contact by
touching a contaminated surface or object, and then touching their own mouth, nose,
or possibly their eyes,[97] though this is not thought to be the main way the virus
spreads, and it has not been conclusively demonstrated. [96] Kissing, physical intimacy
and other forms of direct contact can easily transmit the virus and thus lead to
COVID-19 in people exposed to such contact.
Social distancing and the wearing of cloth face masks, surgical masks, respirators,
or other face coverings are controls for droplet transmission. Transmission may be
decreased indoors with well maintained heating and ventilation systems to maintain
good air circulation and increase the use of outdoor air. [96]
There currently is no significant evidence of COVID-19 virus transmission
through feces, urine, breast milk, food, wastewater, drinking water, animal disease
vectors, or from mother to baby during pregnancy, although research is ongoing and
caution is advised.[97][103]

Signs and symptoms

Further information: Coronavirus disease 2019 §  Signs and symptoms
Symptoms of COVID-19[104]
Symptoms of COVID-19 can be relatively non-specific; the two most common
symptoms are fever (88 percent) and dry cough (68 percent). Less common
symptoms include fatigue, respiratory sputum production (phlegm), loss of the sense
of smell, loss of taste, shortness of breath, muscle and joint pain, sore throat,
headache, chills, vomiting, coughing out blood, diarrhea, and rash.[105][106][107]
Among those who develop symptoms, approximately one in five may become more
seriously ill and have difficulty breathing. [108] Emergency symptoms include 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.[107] Further development of the disease can lead to complications
including pneumonia, acute respiratory distress syndrome, sepsis, septic shock,
and kidney failure.[106]

Cause
Virology
Main article: Severe acute respiratory syndrome coronavirus 2

Illustration of SARSr-CoV virion
SARS-CoV-2 is a Baltimore class IV[109] positive-sense single-stranded RNA
virus[110] that is contagious in humans.[111] As described by the U.S. National Institutes
of Health, it is the successor to SARS-CoV-1,[112][113] the strain that caused the 2002–
2004 SARS outbreak.
Taxonomically, SARS-CoV-2 is a strain of severe acute respiratory syndrome-
related coronavirus (SARSr-CoV).[114] It is believed to have zoonotic origins and has
close genetic similarity to bat coronaviruses, suggesting it emerged from a bat-borne
virus.[115][116][117][118] There is no evidence yet to link an intermediate host, such as
a pangolin, to its introduction to humans.[119][120] The virus shows little genetic
diversity, indicating that the spillover event introducing SARS-CoV-2 to humans is
likely to have occurred in late 2019. [121]
Epidemiological studies estimate each infection results in 5.7 new ones when no
members of the community are immune and no preventive measures taken.[122] The
virus primarily spreads between people through close contact and via respiratory
droplets produced from coughs or sneezes. [123][124] It mainly enters human cells by
binding to the receptor angiotensin converting enzyme 2 (ACE2).[115][125][126][127]

Diagnosis
Main article: COVID-19 testing

Demonstration of a swab for COVID-19 testing

COVID-19 can provisionally be diagnosed on the basis of symptoms and confirmed
using reverse transcription polymerase chain reaction (RT-PCR) testing of infected
secretions or CT imaging of the chest.[128][129]
On 29 September, a letter in Lancet highlighted the increasing likelihood of
overestimating of COVID-19 incidence as more asymptomatic people are included in
RT-PCR testing with consequent "misdirection of policies regarding lockdowns and
school closures," noting that the false-positive rate in the UK is currently unknown,
with "preliminary estimates … somewhere between 0·8% and 4·0%". [130][131] The letter
called for "stricter standards … in laboratory testing, … and pretest probability
assessments … [including] symptoms, previous medical history of COVID-19 or
presence of antibodies, any potential exposure to COVID-19, and likelihood of an
alternative diagnosis."[132]
Viral testing
The standard test for presence of SARS-CoV-2 uses RNA testing of respiratory
secretions collected using a nasopharyngeal swab, though it is possible to test other
samples. This test uses real-time rRT-PCR which detects the presence of viral RNA
fragments.[133] As this test detects RNA but not infectious virus, its "ability to
determine duration of infectivity of patients is limited." [134] Positive tests have been
shown not to correlate with future excess deaths.[135]
A number of laboratories and companies have developed serological tests, which
detect antibodies produced by the body in response to infection. [136] Several have
been evaluated by Public Health England and approved for use in the UK.[137]
On 22 June 2020, UK health secretary Matt Hancock announced the country would
conduct a new "spit test" for COVID-19 on 14,000 key workers and their families
in Southampton, having them spit in a pot, which was collected by Southampton
University, with results expected within 48 hours. Hancock said the test was easier
than using swabs and could enable people to conduct it at home. [138]
The University of Oxford's Centre for Evidence-Based Medicine (CEBM) has pointed
to mounting evidence[139][140] that "a good proportion of 'new' mild cases and people
re-testing positives after quarantine or discharge from hospital are not infectious, but
are simply clearing harmless virus particles which their immune system has
efficiently dealt with" and have called for "an international effort to standardize and
periodically calibrate testing" [141] On 7 September, the UK government issued
"guidance for procedures to be implemented in laboratories to provide assurance of
positive SARS-CoV-2 RNA results during periods of low prevalence, when there is a
reduction in the predictive value of positive test results." [142]
Imaging

A CT scan of a person with COVID-19 shows lesions (bright regions) in the lungs.
Characteristic imaging features on chest radiographs and computed
tomography (CT) of people who are symptomatic include asymmetric
peripheral ground-glass opacities without pleural effusions.[143] Many groups have
created COVID-19 datasets that include imagery such as the Italian Radiological
Society which has compiled an international online database of imaging findings for
confirmed cases.[144] Due to overlap with other infections such as adenovirus,
imaging without confirmation by rRT-PCR is of limited specificity in identifying
COVID-19.[143] 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.[129]

Prevention
Further information: Workplace hazard controls for COVID-19, Pandemic
prevention, preparations prior to COVID-19, COVID-19 surveillance, and COVID-19
apps
Infographic by the U.S. Centers for Disease Control and Prevention (CDC), describing
how to stop the spread of germs

Strategies for preventing transmission of the disease include physical distancing,

wearing of masks, 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.[145][146][147][148]
Social distancing
Main article: Social distancing measures related to the COVID-19 pandemic

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

store
Social distancing (also known as physical distancing) includes infection
control actions intended to slow the spread of the disease by minimising close
contact between individuals. Methods include quarantines; travel restrictions; and the
closing of schools, workplaces, stadiums, theatres, or shopping centres. Individuals
may apply social distancing methods by staying at home, limiting travel, avoiding
crowded areas, using no-contact greetings, and physically distancing themselves
from others.[146][149][150] Many governments are now mandating or recommending
social distancing in regions affected by the outbreak. [151][152] Non-cooperation with
distancing measures in some areas has contributed to the further spread of the
pandemic.[153]
The maximum gathering size recommended by U.S. government bodies and health
organisations was swiftly reduced from 250 people (if there were no known COVID-
19 spread in a region) to 50 people, and later to 10. [154] On 22 March 2020, Germany
banned public gatherings of more than two people. [155] A Cochrane review found that
early quarantine with other public health measures are effective in limiting the
pandemic, but the best manner of adopting and relaxing policies are uncertain, as
local conditions vary.[150]
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. [156][157]
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 through alternative means. [158][159] Some authorities have issued sexual health
guidelines for the pandemic, which include recommendations to have sex only with
someone you live with, and who does not have the virus or symptoms of the virus. [160]
[161]

Face masks and respiratory hygiene

Main article: Face masks during the COVID-19 pandemic

The CDC and WHO advise that masks reduce the spread of coronavirus by
asymptomatic and pre-symptomatic individuals (Taiwan President Tsai Ing-
wen pictured wearing a surgical mask)
The CDC and WHO recommend individuals wear non-medical face coverings in
public settings where there is an increased risk of transmission and where social
distancing measures are difficult to maintain. [162][163][164] This recommendation is meant
to reduce the spread of the disease by asymptomatic and pre-symtomatic individuals
and is complementary to established preventive measures such as social distancing.
[163][165]
 Face coverings limit the volume and travel distance of expiratory droplets
dispersed when talking, breathing, and coughing. [163][165] Many countries and local
jurisdictions encourage or mandate the use of face masks or cloth face coverings by
members of the public to limit the spread of the virus. [166][167]
Masks are also strongly recommended for those who may have been infected and
those taking care of someone who may have the disease. [168] When not wearing a
mask, the CDC recommends covering the mouth and nose with a tissue when
coughing or sneezing and recommends using the inside of the elbow if no tissue is
available.[145] Proper hand hygiene after any cough or sneeze is encouraged.
[145]
 Healthcare professionals interacting directly with COVID-19 patients are advised
to use respirators at least as protective as NIOSH-certified N95 or equivalent, in
addition to other personal protective equipment.[169]
Self-isolation

Without pandemic containment measures—such as social distancing, vaccination,

and use of face masks—pathogens can spread exponentially. [170] This graphic shows
how early adoption of containment measures tends to protect wider swaths of the
population.
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. [171][172]
Many governments have mandated or recommended self-quarantine for entire
populations.[173][174] The strongest self-quarantine instructions have been issued to
those in high-risk groups.[175] Those who may have been exposed to someone with
COVID-19 and those who have recently travelled to a country or region with the
widespread transmission have been advised to self-quarantine for 14 days from the
time of last possible exposure.[108][176][177]
Ventilation and air filtration
The Centers for Disease Control and Prevention (CDC) recommends ventilation in
public spaces to help clear out infectious aerosols, as well several others, including
those regarding air filtration.[178][179]
Hand washing
Main article: Hand washing

Hand washing is recommended to prevent the spread of the disease. The CDC
recommends that people wash hands often with soap and water for at least twenty
seconds, especially after going to the toilet or when hands are visibly dirty; before
eating; and after blowing one's nose, coughing, or sneezing. This is because outside
the human body, the virus is killed by household soap, which bursts its protective
bubble.[180] In addition, soap and water disrupts the sticky bond between pathogens
and human skin which causes the coronavirus pathogen to slide off the hands/body.
[181]
 CDC has recommended using an alcohol-based hand sanitiser with at least 60
percent alcohol by volume when soap and water are not readily available. [145] The
WHO advises people to avoid touching the eyes, nose, or mouth with unwashed
hands.[146][182] It is not clear whether washing hands with ash, if soap is not available,
is effective at reducing the spread of viral infections. [183]
Surface cleaning
Surfaces may be decontaminated with a number of solutions (within one minute of
exposure to the disinfectant for a stainless steel surface), including 62–71
percent ethanol, 50–100 percent isopropanol, 0.1 percent sodium hypochlorite, 0.5
percent hydrogen peroxide, and 0.2–7.5 percent povidone-iodine. Other solutions,
such as benzalkonium chloride and chlorhexidine gluconate, are less effective.
[184]
 Ultraviolet germicidal irradiation may also be used.[178] The CDC recommends
that if a COVID-19 case is suspected or confirmed at a facility such as an office or
day care, all areas such as offices, bathrooms, common areas, shared electronic
equipment like tablets, touch screens, keyboards, remote controls, and ATM
machines used by the ill persons should be disinfected. [185]
Vaccine
Main article: COVID-19 vaccine

A COVID-19 vaccine is a biotechnology product intended to provide acquired

immunity against coronavirus disease 2019 (COVID-19). Previous work to develop a
vaccine against the coronavirus diseases SARS and MERS established knowledge
about the structure and function of coronaviruses – which accelerated development
during early 2020 of varied technology platforms for a COVID-19 vaccine.[186] As of
October 2020, there were 321 vaccine candidates in development, a 2.5 fold
increase since April. However, no candidate has completed clinical trials to prove its
safety and efficacy.[187] In October, some 42 vaccine candidates were in clinical
research: namely 33 in Phase I–II trials and 9 in Phase II–III trials.