12 things everyone needs to know about

the coronavirus pandemic

How deadly is the coronavirus? How is it transmitted? And answers to more questions
about the pandemic, explained.
By Brian Resnick @B_resnick brian@vox.com Apr 2, 2020, 12:00pm EDT

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The Vox guide to navigating the coronavirus crisis

Before December 2019, SARS-CoV-2 — the virus that causes the Covid-19 illness — was
unknown to science. “A pneumonia of unknown cause” was first reported to the World
Health Organization on December 31, after a slew of cases appeared in Wuhan, China.
Since then, the virus has been detected in more than a million people worldwide, and
killed tens of thousands.

This is a pandemic, a global crisis and tragedy on a scale that’s hard to fathom.

There are a lot of new things for the public to learn — about the virus, controlling its spread,
social distancing, treating the sick, and how our governments should react to this chaotic
situation. It’s like we’ve all been dropped in to study for a test in a class that no one signed
up for. It’s confusing and hard to process.

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Here, we’ve tried to distill it into 12 key aspects of this crisis that everyone should
understand. That said, we don’t cover everything, and there’s still a lot of uncertainty about
some of the most important things on the list. (If you think you have Covid-19, and are
curious about what that means for you, read this explainer. If you’re most confused about
the financial crisis the virus is causing, read this one.) This guide focuses mostly on the
properties of the virus, and the implications for public health.

In the few months since this virus emerged, we’ve learned an immense amount about it.
Scientists have decoded its genetics and whom it’s more likely to kill, and have started
working on vaccines that could immunize humans to it. Still, its newness means that a lot of
the figures presented in this article are estimates and subject to change as scientists learn
more. So keep that in mind, too.

1) SARS-CoV-2 is very contagious, and a huge portion of the global population is vulnerable

One thing we do know is that this coronavirus, SARS-CoV-2, is very contagious. Just look
at the headlines: Covid-19, the disease caused by the virus, has now infected nearly a
million people around the globe.

Scientists quantify the contagiousness of a disease with a figure called R0 (pronounced R-

nought.) “The figure refers to how many other people one sick person is likely to infect on
average in a group that’s susceptible to the disease (meaning they don’t already have
immunity from a vaccine or from fighting off the disease before),” Vox’s Julia Belluz
explains. An R0 of 2, for example, means each infected person is expected to spread the
virus to two others, on average. Covid-19 is currently believed to have an R0 between 2
and 2.5.
That makes it more contagious than the seasonal flu. With the flu, there are people in the
population who have some level of immunity to it — either because of a vaccine or because
they have been exposed to that strain of flu in the past. That’s not the case here.

With no mitigation, a statistical modeling report from the Imperial College of London found
that 81 percent of the populations of both Great Britain and the US could be infected over
the course of the pandemic.

The R0 is hard to estimate, even in a pandemic, because “the R0 is not a property of the
virus,” explains Dominique Heinke, an epidemiologist in Massachusetts. The virus’s genetic
code, the proteins that surround it, and the symptoms it causes are properties of the virus.
The R0 is “a combination of the properties of the virus, and the way that humans interact.”

Also important to know: R0 is the rate of transmission within a fully susceptible population,
when no control measures are put into place. “One misconception about the R0 is that it is
a fixed number — but actually, it varies over time and over context,” says Caitlin Rivers, a
professor at the Johns Hopkins Center for Health Security. “So it has been well established
that the R0 with this disease, at least before we implement any interventions, is well over
2.”

Number of confirmed coronavirus cases, by days since

100th case
Hover for exact value or individual country
China data through first 45 days. As of April 2, China had about 83,000 cases. Chart is in log scale to mimic the
exponential rate at which the virus spreads.
Source: Vox analysis of Center for Systems Science and Engineering at Johns Hopkins University data, through April
2; Financial Times

But our actions can bring this figure down. This is sometimes called the Re, or effective
reproduction rate. “If we can get Re [to be less than] 1 through social distancing, natural
immunity, or a vaccine, then we break the cycle of transmission and the epidemic will slow
or be suppressed,” Heinke says.

2) The virus is believed to be spread mainly by respiratory droplets

Why has the virus spread so fast? The WHO recently put out a statement saying its experts
believe Covid-19 is primarily transmitted by respiratory droplets. When infected people
breathe, cough, or sneeze, they expel little droplets of moisture that contain the virus.
Another person in their vicinity could breathe in these particles and get infected. The virus-
laden droplets can also land on surfaces that others may touch (and then get infected by
touching their mouth, nose, or eyes). Scientists now believe the virus can remain viable on
a hard, non-porous surface like plastic or steel for around three days, and a rough surface
like cardboard for about a day.
The 6-feet-away social distancing guideline is meant to keep people out of the splash zone
for these respiratory droplets. (But know there’s no hard cutoff for how far the viral droplets
can spread. A sneeze can propel material from the nose 20 feet or more, a recent MIT
study found.)

It’s also unknown how significant other modes of transmission are in spreading the disease.
There are two other possible routes being explored: fecal-oral and airborne.

Fecal-oral transmission occurs when a virus spreads, well, through feces (usually by
contaminating water or food through improper hygiene). Scientists have noted the
presence of the virus in some feces of infected people. The Centers for Disease Control
and Prevention says, though, that “the risk [of fecal-oral transmission] is expected to be low
based on data from previous outbreaks of related coronaviruses.” (That said, if you weren’t
already: Please wash your hands enthusiastically after defecating.)

You may have heard that the new coronavirus isn’t “airborne” — meaning that unlike
extremely contagious diseases like measles, it’s unlikely to linger in the air for hours on
end. But that doesn’t mean the virus can’t linger in the air for some amount of time.

As Wired explains, although some experts say the novel coronavirus isn’t airborne, that’s
based on a narrow scientific definition of the term. The virus can possibly still linger in
the air for some time and under some conditions. We don’t yet know precisely what
those conditions are. It will definitely be in the air in the moments after an infected person
sneezes or coughs, but it’s unclear when the particles eventually come to rest on the
ground (or on surrounding surfaces).

Overall, it doesn’t appear that airborne contagion is a big factor with this outbreak. “In an
analysis of 75,465 COVID-19 cases in China, airborne transmission was not reported,” the
WHO reports. But it warns that “airborne transmission may be possible in specific
circumstances and settings.” Certain medical procedures like intubation, suctioning, and
ventilation could possibly create airborne viral aerosols. Because these occur in hospital
settings, it’s extra important for health care workers to wear proper personal protective
equipment (PPE) to make sure they don’t get sick.

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Another big reason Covid-19 has spread so far and wide is that people with mild symptoms
— and even people without symptoms — can spread it. (Fever, cough, and shortness of
breath are recognized by the CDC as common symptoms, but others such as loss of
smell and taste have been reported as well, and symptoms may take up to 14 days to
appear.)

There are no firm estimates on this, but it seems that somewhere between 25 and 50
percent of people infected with the virus show no symptoms. Some percentage of those
asymptomatic cases can spread the virus to others. (We’ll need more widespread
surveillance testing to better understand the exact rate of asymptomatic cases.)

On March 13, the journal Science published an analysis that concluded 86 percent of all
the Covid-19 cases in China before January 23 were not detected by public health
authorities at the time (though that doesn’t mean these cases were asymptomatic). It’s
estimated that these undiagnosed cases infected 79 percent of the total cases. The results
suggest that, at least, the bulk of transmission of the virus in China was spread by people
not sick enough to get the attention of doctors.

The fact that this virus can spread sneakily and silently makes it extra dangerous. It’s also
possible to spread it before a person develops symptoms.

On April 1, the CDC published a report on how presymptomatic spread created clusters of
many new cases in Singapore. In one case, the virus appeared to have spread via a church
pew. Two people who had recently visited China attended church services on January 19,
when they had no symptoms (they would develop them in the following days). Three other
people who attended the church that day got sick, the CDC found — one of whom sat in the
same seat as the people who visited China. Another instance of presymptomatic spread
was found in a singing class. In others, presymptomatic cases spread in households.

3) Covid-19 is deadly

The exact death rate of the virus is another figure that’s still being calculated — and is
changing all the time. Here’s the latest: A new paper in Lancet Infectious Diseases found
the case fatality ratio (the percent of confirmed infections that die) to be 1.38 percent,
drawing from Chinese data (which may or may not be complete). The authors also report
an estimated infection fatality rate — this is the percentage of people who become infected,
including those who have mild or no symptoms, who eventually die. This figure is lower, at
0.66 percent.

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But there’s a huge amount of variability on this figure country by country, and demographic
by demographic. South Korea, on the one hand, is estimated to have a death rate of less
than 1 percent. Italy’s seems to be, for now, several percentage points higher.

The Lancet Infectious Diseases paper found that globally, the case fatality rate for those
under age 60 was 1.4 percent. For those over age 60, the fatality rate jumps to 4.5 percent.
The older the population, the higher the fatality rate grows. For those 80 and over, Covid-19
appears to have a 13.4 percent fatality rate.
These likely will not be the final estimates of the fatality rate for Covid-19. Like R0, “the
mortality rate is not a characteristic of the virus,” Heinke explains. “The mortality rate is a
function of both the severity of disease that the virus can cause and treatment. ... The
mortality rate may increase as hospitals become more and more overwhelmed with cases.”

And the figure changes over time. In late February, the WHO estimated the rate in Wuhan
was 5.8 percent. Now, the estimated death rate for Wuhan — the city where the outbreak
began — is 1.4 percent, per a March 9 study in Nature Medicine.

“It feels like you should be able to just divide deaths by cases, and whatever that number is
feels like it should be CFR,” or case fatality rate, Rivers says. But it’s not that simple. “If
there are a lot of people either in the numerator or denominator that aren’t being
recognized, it can change your answer a lot.” With testing lagging in the United States, it’s
hard to know how many cases there are overall, and therefore, it’s hard to estimate the
overall fatality rate.

One thing we do know: Older people, and people with underlying conditions, are much
more likely to die of Covid-19 than younger people.
4) The pandemic in the US will get worse before it gets better

On March 31, the White House’s coronavirus task force presented grim statistics: Under the
best-case scenario for mitigation of the Covid-19 pandemic, there may be between
100,000 and 200,000 deaths in the United States, with the number of deaths peaking in the
next two weeks.

Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases,
also emphasized that the outbreak and its toll are going to get worse before they get better.
“As sobering a number as [100,000 deaths] is,” he said, “we should be prepared for it. Is it
going to be that much? I hope not.” A recent study in The Lancet found that, on average,
the duration from symptoms to death is 17.8 days (and that recovery can take nearly 25
days). Other studies have shown it can take a week for the disease to progress from the
start of symptoms to a person needing hospitalization. Some people just getting infected
now in places that still haven’t enacted strict social distancing measures could die a
month from now.

Look at the Wuhan line on this new graph from@jburnmurdoch. The lockdown was introduced there
on 23rd Jan – 69 days ago – which means this entire Wuhan curve has happened since then. It shows
how long it can take to see the effect of control measures on the number of deaths.
pic.twitter.com/MAsBIzFevj

— Adam Kucharski (@AdamJKucharski) April 1, 2020

Epidemiological modeling is useful in helping the public think through what’s possible with
the disease. It also can help hospitals understand how much staffing and equipment they’ll
need (and where they are likely to fall short).

Independent experts say the models the task force is using are sound: 100,000 to 200,000
deaths “certainly seem to be within the reasonable framework,” said Bill Hanage, associate
professor of epidemiology at Harvard T.H. Chan School of Public Health, in a call with
reporters Tuesday morning. “I would not be particularly surprised by them, I wouldn’t be
surprised if they were higher, I wouldn’t be actually surprised if they were lower. One of the
things that’s difficult for those of us who’ve been involved with modeling this is
communicating the amounts of uncertainty that we have.”
 The CDC recommends several basic measures to help prevent the spread of Covid-19:

Wash your hands often for at least 20 seconds.

Cover your cough or sneeze with a tissue, then throw the tissue in the trash.

Clean and disinfect frequently touched objects.

Stay home as much as possible, and do not go out if you are sick.

Wear a cloth face covering in public.

Contact a health worker if you have symptoms.

Guidance may change. Stay informed, and stay safe, with Vox’s coronavirus coverage hub.

Modeling is not an ironclad prediction of the future, however. “Unlike the weather, which
we’re all accustomed to and incorporating forecasts into decision making, with pandemics
we actually influence the outcome,” Rivers says. Collective actions — continuing to social
distance, self-isolating if you’re sick, supporting health care workers around the country,
raising the capacity of the health care system — over the next few weeks will affect whether
the models are updated for better or for worse.

“I think it’s key not to get fixated on the exact numbers,” Heinke adds. “You can look at a
range of models and say, we can expect it to be at least this bad.”

5) There’s a huge range of severity of illness

Young people may not be dying of Covid-19 in high numbers, but they are still at risk for
severe, debilitating disease.

As of March 16, the CDC reports that 12 percent of known Covid-19 cases in the US have
resulted in hospitalizations, and 20 percent of those hospitalizations were among those
ages 20 to 44. To note: As of March 16, the CDC had reported 4,226 cases in the United
States, so this data may be refined in the coming weeks. As of April 2, there were more
than 216,000 cases in the US.

In New York City, which as of April 2 has the biggest Covid-19 outbreak in the United
States, 9 percent of more than 7,700 hospitalizations were for those ages 18 to 44 as of
March 31.

The bottom line: In all age groups, Covid-19 can present with a huge range of severity.
Many people — an exact figure is still not known — can get the virus and show no
symptoms. Others become near deathly ill.

Scientists have some clues as to what puts someone more at risk than another.

“Patients with underlying health conditions and risk factors, including, but not limited to,
diabetes mellitus, hypertension, COPD, coronary artery disease, cerebrovascular disease,
chronic renal disease, and smoking, might be at higher risk for severe disease or death
from Covid-19,” the CDC found in a recent report.

But there are still a lot of unknowns about what else contributes to risk. Even among older
people, there are unanswered questions: Why do men appear to be dying at higher rates
than women? Differences in severity of illness could also relate to the amount of the virus a
person has been exposed to. Health care workers, when they are infected, seem to get
sicker than their age cohort should suggest, which could be because they are exposed to
higher doses of the virus.
Scientists will soon start to search for genetic clues, too, that might signal a person is
more at risk than another. The reason might have to do more with their own biology than
the virus: In some people, an excessive immune reaction called a “cytokine storm” is what
leads to the most severe symptoms and death, not the virus itself.

“It’s really an open question to try to figure out why some of these younger people are
getting really, really severe disease, and if there are other risk factors that we are not
appreciating,” Angela Rasmussen, a Columbia University virologist, said in March. “Some of
that will just have to wait until we have really detailed clinical data on all the cases that are
coming out now in Italy and in the United States.” Knowing who is most at risk, she says,
“will help in terms of flattening the curve.” If we learn how to protect the young people
most at risk and keep them out of hospitals, we can decrease the strain on health care
systems.

6) The US is still not doing enough testing

It’s worth remembering why hundreds of millions in the US are under stay-at-home orders,
with infection rates soaring across the country.

“The facts remain that we wasted a lot of time in terms of ramping up testing,” Saad Omer,
director of the Yale Institute for Global Health, says. The US could have spent a lot more
time diagnosing and isolating the sick, and tracing their contacts, which could have
prevented at least some of the spread.

Testing in an outbreak provides two functions. One is to diagnose those who are sick. The
other is surveillance: to see where the virus may be lurking, especially in cases where
symptoms are mild or don’t manifest at all. The US has barely had enough testing capacity
to test the sickest, let alone the capacity to do surveillance. Many doctors are telling
patients with milder symptoms to just stay home and not get tested.

The US has caught up to some of the early stumbles. The Atlantic, which has been
aggressively tracking the testing situation across the country, reports that around 104,000
people are being tested a day. But “testing backlogs have ballooned, slowing efficient
patient care and delivering a heavily lagged view of the outbreak to decision makers,” the
Atlantic’s Robinson Meyer and Alexis Madrigal write.

America needs strict social distancing measures in place, in part, because it’s unknown
exactly where the virus is. And it’s unknown because testing still lags.

People need to stay in under the assumption that anyone they come into contact with could
be infected. “The classic epidemiological approach to controlling disease is not to shut
down society; it’s to target the people you know to have the disease and understand who
they’re spreading it to,” Jeremy Konyndyk, a senior policy fellow at the Center for Global
Development, says. “We can’t do that right now because we don’t have enough testing to
know who has the disease.”

Not only does the US need more testing, it also needs testing that can be completed within
minutes. These rapid tests are in the works: Recently, the Food and Drug Administration
approved one that can give results in five minutes. It’s now being rolled out in parts of the
West Coast.

But the US needs other kinds of testing, too, like serology — testing of people’s blood
for antibodies to the virus. That way, health professionals can figure out who has already
had the disease and is now immune and can safely return to be in contact with others.
(Though scientists still need to do more work in determining what immunity looks like in
any given person.)

7) Lockdowns and shelter-in-place orders are not an overreaction

Three out of four Americans are now under some sort of lockdown or shelter-in-place order
from their local authorities. For many of them, the best thing they can do right now is just
be patient.

There may be a lag of a few weeks before these difficult measures are reflected in new
case and death data.

Right now, many people are still getting sick and requiring hospitalization, who were
infected before these orders went into effect. The virus can incubate for up to 14 days
before symptoms appear, and then it can be several more days before severe illness sets
in.

This means many cities and regions are still seeing the early part of the wave of cases
hitting their health care systems. New York Gov. Andrew Cuomo says his state may still be
two weeks away from the virus’s peak.

All of this is reason to keep social distancing: The outright lockdowns of movement in some
cities, as well as the less severe policies in place across the country, can still dramatically
slow the spread of Covid-19. And per at least one poll, people are, by and large,
complying.

Also know: This is likely still going to get worse before it gets better.
“In the next several days to a week, we will continue to see things go up,” Fauci said on
March 31. “We cannot be discouraged by that — the mitigation is working and it will work.”

8) The situation for hospitals and health care workers is dire

First, the US had a shortage of diagnostic tests for Covid-19. Now there’s also a shortage of
personal protective equipment and supplies — from medical masks and gowns to hospital
beds and ventilators. And the fear is there will soon be a shortage of health care workers
responding to the disease. In Italy, more than 60 doctors have died of the disease.

As Vox’s Dylan Scott, Umair Irfan, and Jen Kirby report, “Doctors and nurses are
reporting gear shortages, lax protocols, and a high level of stress in their workplaces —
with the worst still to come. Some of them told Vox that they consider getting infected with
the coronavirus an inevitability.”

Health care workers may even be putting themselves at higher risk of severe disease just
by doing their jobs. “It’s not just that [health care workers] are getting infected at higher
rates; instead, they’re getting sicker than one might expect on the basis of their age,” says
Peter Hotez, the dean of the National School of Tropical Medicine at Baylor College. It’s
possible they’re being exposed to higher concentrations of the virus, which may lead a
person to more severe illness.

Meanwhile, the protective equipment that might stop them from getting sick is in short
supply. Particularly acute is the supply of N95 respirators, which stop health care workers
from inhaling viral-laden droplets and aerosols.

9) America can end social distancing, but an aggressive new plan needs to be in place

It’s understandable that some — maybe most — people want life to go back to normal
already.

But “If we all just went right back to how things were before, transmission would start again
with the same intensity,” Rivers says. To ease off social distancing, the US needs an
aggressive new plan in place to prevent the explosive growth in new cases it’s currently
seeing.

“Social distancing is basically a sledgehammer,” Konyndyk, who has worked on past

outbreaks, like Ebola, says. “You’re just stopping everything and hoping that in the process
you will also slow transmission.” What the US needs to do, he says, is turn that
sledgehammer of social distancing into a scalpel: widespread testing and contact tracing.

The outright lockdowns of movement in some cities can slow the spread of the pandemic.

Once there’s widespread testing, there needs to be a huge team of public health workers in
place to trace the contacts of those who test positive. Everyone who tests positive or who
has come into contact with someone who tests positive then needs to be put into
quarantine or isolation, to not spread the virus further. This is how authorities routinely beat
outbreaks — even of incredibly infectious diseases like measles.

Rivers, along with former FDA Commissioner Scott Gottlieb and other co-authors, released
a plan Sunday for how to ease off social distancing. The plan has several phases: Phase
one is slowing the spread through social distancing while ramping up testing capacity and
ensuring hospitals have the equipment they need. In phase two, social distancing
restrictions ease while public health workers continue to track and isolate cases.

But it will take a lot to get there. The authors argue these decisions need to be made on a
region-by-region basis: Phase two should only begin after 14 days of sustained case
reductions in an area, and only after testing capacity is dramatically increased. Even in
phase two, they stress, if cases go up again, the US will need to go back to severe social
distancing. Before there’s a vaccine, everyone will have to remain vigilant.

10) The pandemic is painful for millions — not just those who are sick with Covid-19

Outbreaks don’t just affect those who get sick with the illness and die — there’s also a lot of
collateral damage. Unemployment is skyrocketing. Health care bills are piling up.
Businesses are furloughing or laying off workers.

As the outbreak progresses, it will expose the cracks in American society and the country’s
preparedness for future outbreaks. Americans need to remember the lessons learned over
the next several months.

Also important: the collateral medical damage. Hospitals are postponing elective surgeries
(ones that are planned in advance) and some other treatments. There could be limited
resources to treat others if another disaster strikes, like a flood or a hurricane.

11) Some parts of life may return to normal. But this won’t be over until there’s a vaccine and widely
available treatments.

The ultimate goal in stopping a pandemic is a safe and effective vaccine that can prevent
people from getting the virus. The good news is that these are already being tested. The
bad news is that it could take a year or more to find one that is safe and effective.
“Honestly, I think the vaccine in 12 to 18 months is a moonshot,” Tara Smith, a Kent State
University epidemiologist, says.

In the meantime, a treatment might be discovered sooner. The World Health Organization
is facilitating a multinational clinical trial, testing medicines — and combinations of
medicines — to treat Covid-19. But even those drugs wouldn’t necessarily stop the
outbreak.

“It would be really great, I think, for saving lives,” Rivers says. “But you wouldn’t really
expect it to slow transmission at all.” People could still be getting sick and spreading the
virus. And everyone would need to be vigilant, and patient, in this scenario, too. Even if the
risk of severe disease and death is reduced, if the number of cases increases, more people
can still get sick and die.

12) The coronavirus came from nature, jumping from animals to humans. Researchers fear this will
happen again.

The novel coronavirus outbreak presents an immense immediate challenge for global
health. But it’s also part of a larger pattern: Viruses that circulate in animals keep jumping
over to infect humans. The story of the novel coronavirus is the story of HIV, of SARS, of
Ebola, and even measles. These are all diseases that have been introduced to humans —
with deadly effects — via animals. And as humans encroach more and more into animal
 habitats, it’s believed these spillover events may only grow more common.

Scientists know this virus jumped from an animal to a human, but they are not sure exactly
how or where. “If you don’t understand where it came from, then it’s hard to make policies,
procedures, to prevent it from happening again,” says Krutika Kuppalli, an infectious
disease physician and Emerging Leader in Biosecurity fellow at the Johns Hopkins
University Center for Health Security.

It likely started with a bat — the genetics of the novel coronavirus suggest that it did. As
Vox’s Eliza Barclay reported:

What researchers have to figure out now is how exactly the coronavirus jumped to humans: perhaps
through a human eating an infected animal, or through humans being exposed to infected feces or
urine. “All we know [is] its likely distant source was bats, but we don’t know who was between bats and
people,” said Vincent Racaniello, a professor of microbiology and immunology at Columbia and host of
the This Week in Virology podcast. “It could be a direct infection [between bats and humans] as well.”

A lot of the evidence points toward the outbreak either starting or significantly gaining steam
at a live animal market in Wuhan, China. The more we know about how this virus jumped
from animals to humans, the more authorities can help make sure an outbreak with this
origin doesn’t spiral out of control and spread around the world again. ■

The Vox guide to navigating the coronavirus crisis

Understanding the virus

Why it can be so hard to tell if you have Covid-

19
Covid-19 is not the flu. It’s
worse.

Preparing and protecting yourself

9

Social distancing, the right way

7

Traveling
3

Self-care
4

Parenting during the outbreak

6

Responding to the financial crisis

3

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