COVID-19, a path of death and destruction - Nurses-Hands/ Clinicians-Hands Across the Globe: A Global Support Network for Nurses and Clinicians of All Disciplines

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The Impact of COVID-19 on Nurses

COVID-19, A Path of Death and Destruction

Mary C. Vrtis, Ph.D., MSN, RN, OCN, NEA-BC, FCN

May 16, 2025

Read time (chapter):

32–49 minutes

COVID-19 A Path of Death and Destruction 5-16-25 Download

June 2024– 1 Year Post Public Health Emergency

The global public health emergency started December 28, 2019, and the SARS-CoV-2 virus claimed the lives of 6,932,576 people worldwide. Of those who died during the emergency, 16.2% lived in the U.S. In that the U.S. accounts for only 4.2% of the world population, the country’s COVID-19 death rates were disproportionately high.

(Secondary analysis: World Clock https://www.worldometers.info/world-population/us-population/; World Health Organization COVID-19 dashboard, analyzed by Our World in Data https://ourworldindata.org; and CDC COVID data tracker. https://covid.cdc.gov/covid-data-tracker/#datatracker-home

When compared to all of the countries in the world, the U.S. ranked number 16 in the list of countries with the highest number of COVID-19 deaths per 100,000 population (JHU, 2023 March 16).

The COVID-19 public health emergency ended on May 11, 2023, in the U.S., and on May 5, 2023, by the World Health Organization. From May 12, 2023, to May 12, 2024, an additional 116,720 people died (secondary analysis WHO COVID-19 dashboard, ourworldindata.org). In that the official COVID-19 statistics included only confirmed cases and deaths, the counts were known to be lower than the actual numbers – especially given that many patient infections may have been unrecognized as the patient may not have had symptoms or was pre-symptomatic when initially tested (Li, L., et al., 2021).

The Omicron strains that suppressed more lethal strains such as Delta were/are associated with less severe illness and as of mid-May 2025 case fatality rates remain comparatively low. Vaccinations have also been available since December of 2020, and are currently updated to address mutations in the circulating Omicron strains annually[i].

However, it is very important to recognize that 1,800,331 people died worldwide after the first Omicron mutations became the dominant type in December of 2021 (secondary analysis WHO COVID-19 dashboard, ourworldindata.org). Since the Omicron BA.1 and BA.2 subvariants were first identified in South Africa, there have been at least nine Omicron variants of concern that have emerged. Each of the new mutations that has evolved to become dominant has increased how easily the virus is transmitted from one person to the next and conferred a competitive advantage.

Disease management has improved as a result of ongoing collaborative and global research to rapidly identify the most effective treatments for each new strain that emerges. With the rate at which SARS-CoV-2 mutates combined with the number of mutations that are present in new variants, more contagious and virulent strains could evolve at any time. Surveillance to identify the genetic sequences and characteristics of new variants and subvariants is a continuous, worldwide effort. In 2024, most countries were using some method to track and report changes in variants identified. Figure 1 shows examples of global tracking from the U.S. Centers for Disease Control and Prevention, the World Health Organization, and GISAID.org. As most patients ill with an Omicron variant are less symptomatic, few people need to seek formal medical treatment. The number of cases reported to public health departments decreased even further with self-test kits, as labs had been reporting most of the positive tests. Self-test results are accurate and primary care providers can trust the results when reported. Having results of testing within 15 minutes promotes self-quarantine to protect others (Newman, 2024). But if a PCP is not notified of a positive result, then a positive self-test will not be reported or counted as a case. If the number of confirmed cases of COVID-19 infections is inaccurate, then the numbers for case fatality and infection fatality rates will also be inaccurate.

Back to the Beginning: China December 2019 to February 2020

The history of SARS-CoV-2 (COVID-19) as reported by Chinese authorities to the World Health Organization: On December 29, 2019, clinical staff at a local hospital in Wuhan City, located in the Hubei Province of China, admitted four patients with pneumonia due to a novel coronavirus infection. Local municipal and provincial investigations linked all four patients to the Huanan Seafood Wholesale Market in Wuhan. This market sold seafood, live poultry, and wild animals. The national China Center for Infection Control and Prevention was notified on December 29 and a field investigation began (China CDC January 31, 2020; Li, et al., 2020). There has been much debate as to the accuracy of data coming from China.

China was able to identify the emergence of the new virus and respond quickly because the country has a national sentinel surveillance system designed to rapidly identify outbreaks of severe acute respiratory illnesses and influenza. The surveillance was initiated following the outbreak of the first severe acute respiratory syndrome (SARS) that spread rapidly in China in 2002 to 2003.That outbreak was caused by a different novel coronavirus then named SARS-CoV. Hospitals, healthcare personnel, and laboratories in China are required to report possible cases and submit relevant laboratory data that is then processed through the China Center for Disease Control and Prevention. At the time, Wuhan City had a population of 11.1 million (population density 3,280 per square mile) and 59 million people resided in Hubei Province (WHO, February 2021). An extremely infectious, highly transmissible novel virus in such a crowded population center would likely spread very quickly.

On December 31, 2019, China notified the World Health Organization (WHO) through the China Country Office that a cluster of patients with pneumonia of unknown etiology were identified. As of January 3, 2020, the outbreak involved 44 patients in Wuhan City. At that time, the source of infection was not known (World Health Organization, Jan. 21, 2020).

Field investigations by the national China CDC and local China CDC branches identified 47 patients who were infected before December 31, 2019. Twenty-six of those patients (55%) had contact with the same market, and an additional four had contact with another market that sold similar products. Thirty percent (14 people) had contact with someone who had respiratory symptoms, but 12 confirmed patients had no known exposure to anyone who was ill (Li, Q., et al., 2020).

The virus that causes COVID-19 was named by the World Health Organization severe acute respiratory syndrome coronavirus 2, also known as SARS-CoV-2, in February of 2020. It is a pathogenic coronavirus (abbreviated CoV), part of the family of coronaviruses that includes viruses that cause respiratory infections that range in severity from the common cold to severe, acute respiratory syndromes (SARS). The new virus was deemed (CoV-2) because it was a new, previously unknown genome.

The disease caused by SARS-CoV-2 virus was named COVID-19 by the World Health Organization on February 11, 2020. CO stands for coronavirus, VI stands for virus, and D stands for disease. The -19 is because the disease was identified in 2019 (WHO, n.d.)

A Deadly Mutation: Probable Zoonotic Origin of SARS-CoV2

Although the viral genome had been sequenced, little was known about the evolution of SARS-CoV-2 or the source of the infecting organism. Early on, the working hypothesis was that COVID-19 was a novel virus that emerged from a genetic mutation of a coronavirus that was present in an animal (zoonotic) host. The mutated virus reproduced in some type of host animal, and the most likely candidate was a bat given how close the COVID-19 genome is to a specific coronavirus found in a particular type of bat. Viral mutation within the host animal resulted in a novel variant or strain that was pathogenic to humans, highly contagious and easily transmitted from human to human. Human beings had no protective immunity against this novel virus, see figure 2 (Cohen, 2023; Tan, et al., 2023).

As shown in figure 2, it is not known how the SARS-CoV-2 virus mutated, making it capable of “jumping” from an animal source to human beings. The first human infection may have been due to touching a contaminated surface, food, bat guano or some other yet unknown contaminant. A human may have been infected directly by handling or eating meat from a sick animal, or the virus could have been transferred from a yet unknown intermediate reservoir animal who was infected from the source animal. There has been much speculation about the origin of the virus and there are many theories that we won’t address in this document. As China is a communist country where scientists may be limited in what they are allowed to share, there may well be other parts of the COVID-19 origin story that will never be known. On the other hand, the Chinese CDC has countless documents that have been translated into various language, including English and the history of the infectious spread is consistent throughout. We have used many of these documents to verify information as best we could (see References for this chapter.

Advanced Technologies, Genetic Sequencing and Global Sharing of Information

By January 3, 2020, the novel virus had been isolated from respiratory samples obtained from one hospitalized patient in Wuhan. It was identified as a coronavirus and was most closely related to a type found in bats. Genetic sequencing was performed, and three distinct strains of the virus were obtained from one patient (the virus had already started to mutate within that patient’s cells). The first three genome sequences were uploaded to gisaid.org with submission numbers EPI_L_402119, EPI_ISL_ 402020 and EPI_ISL_402121 (Tan, et al., 2020).

GISAID (the Global Initiative on Sharing Avian Influenza Data), is a global public/ private, international organization initially formed to develop a database to track genetic sequences and mutations of influenza viruses. Founded in 2008 the GISAID structure was already in place to track influenza variants, and scientists were able to use the database to communicate the highly infectious SARS-CoV-2 genetic sequences to a world of researchers. GISAID was notified of the newly emerged SARS-CoV-2 viral illness on January 8, 2020, and launched the EpiCoV program the next day so that countries could submit genetic sequencing data for this newly emerged pathogen. GISAID was one of several databases available to track variants. This information has been invaluable in tracking viral variants of concern and in vaccine development (GISAID, 2023a). Sequence WIV04 (submission EPI_ISL_402124) in GISAID is the official ancestral reference sequence used for comparison purposes. This genetic sequence of the virus was isolated from a bronchoalveolar lavage specimen by physicians at the Wuhan Institute of virology from a patient who was in Wuhan Jinyintan Hospital on December 30, 2019. The patient was a seller at the seafood market (GISAID, 2023b).

Once a viral genome is sequenced, the new strain can be compared with the older strains to see what has been changed through mutation(s). The SARS-CoV-2, like many other viruses, is made up of ribonucleic building blocks that determine what will happen when it comes into contact with a cell that can be infected. Ribonucleic acids (RNA) are similar to the more familiar DNA (deoxynucleic acids) in that the building blocks are chained together to provide a code that instructs the virus to do some things. In this case, as with most RNA viruses, there is a single strand of code that instructs the virus on how to attach to and enter the human cells. DNA has a double strand of acid building blocks. Viruses can’t live on their own, they must take over certain parts of the human cells so they can replicate copies of themselves over and over. Eventually the human cells are too damaged to function normally. Because SARS-CoV-2 has been so heavily studied, once the gene is sequenced and compared to older versions of the virus, it is possible for the virologists to identify the areas that are different and sometimes to even project what the mutation will do. Changes may make it easier for the virus to hold on to (adhere to) and enter the human cell. Some mutations make it easier for the virus to escape from the natural or vaccine induced human immune cells that normally respond to, attack, and kill viral invaders. Other mutations allow the virus to make more copies and that makes it easier for the virus to be transmitted from one person to the next, etc.

Contact Tracing in China

Extensive contact tracing and testing were initiated in China immediately, starting with the first patients who contracted a COVID-19 infection. Between January 1 and January 11, 2020, another 248 patients were diagnosed with COVID-19. For 141 of the new patients, there was no known exposure to anyone who was ill, and that led researchers to suspect asymptomatic transmission was likely. Of the additional 130 patients identified by January 22, 2020, 59 (73%) had not been exposed to anyone who was ill. Chinese medical and science teams started publishing information about the virus as soon as possible to inform other countries (Li, Q.et al., 2020). On February 21, 2020, Chinese researchers reported results of a larger study that confirmed that people could be infected with COVID-19 yet still be asymptomatic. The China Centers for Disease Control Novel Coronavirus Pneumonia Emergency Response Epidemiology Team reviewed 72,314 records for patients infected up to February 11, 2020. There were 889 (1.2%) people who tested positive for COVID-19 using a nucleic acid test who were completely asymptomatic. This study was published on February 21, 2020, in the China CDC Weekly and it was available in several languages, including English (China CDC, 2020 February 21).

The Situation in China and the World Worsened in January 2020

China provided the genetic sequence by January 12, 2020, so that other countries could develop virus specific diagnostic kits for testing. Unfortunately, by January 20^th, the date of this first World Health Organization situation report, cases of human SARS-CoV-2 had already been found in Thailand, Japan, and Korea (WHO, Jan. 21, 2020).

China quarantined the population of Wuhan and neighboring cities as of January 23, 2020 (Li, L., et al., 2020). These efforts were futile as it was already too late to contain the infection in one city.

As shown in figure 3, the COVID-19 virus spread very quickly and by the date of World Health Organization Situation Update – 8, on January 28^th, there were 4,593 patients with this new, highly contagious pneumonia identified in at least 15 countries. The World Health Organization reported that the first five U.S. cases were identified by this date (WHO, Jan. 28, 2020). China focused on:

Identifying new, active infections using RT-PCR (reverse transcription-polymerase chain reaction) testing of nasopharyngeal and respiratory secretions to detect COVID-19 viral RNA.
Mapping of the viral genome using next generation sequencing (NGS).
Applying comprehensive epidemiological contact tracing techniques to locate others who may have been infected.
Isolating patients with COVID-19 in designated hospitals.
Providing information to scientists across the globe.

The goal was to contain the infection by quickly identifying and quarantining sick individuals and their contacts (China CDC, 2020, January 22; China CDC, 2020, January 31).

Other Factors that Contributed to Early Widespread Infections

By January 21, 2020, four patients with COVID-19 were diagnosed in other countries. Cases of patients with infection were identified in Thailand (2), Japan (1), Republic of Korea (1) In all four cases, the infection was acquired during travel (WHO, 2020 January 21).

Factors that were predictive of the impending worldwide disaster were:

The SARS-CoV2 virus was highly contagious and spread rapidly from person to person.
Humans had NO IMMUNITY as no one had ever been exposed to this particular, newly mutated, novel form of coronavirus.
SARS-CoV-2 mutates frequently, and some of the emerging variants were even more capable of causing significant harm (virulence) to the host than the ancestral version.
Infected patients could transmit the infection for several days before symptoms were present, even if totally asymptomatic.
Some people who are infected and capable of transmitting the infection have no symptoms at all.

Researchers in China published an early report that provided more information. Most patients who sought medical attention did so within two days of onset of symptoms. Hospitalizations were generally not needed until at least the 5^th day of illness for 89% of patients. The authors suggested a 14-day quarantine period with medical observation, but at the time that was only a best estimate based on rapidly emerging data. As of January 22, 2020, the numbers of cases were doubling every 7.2 days (Li, et al, 2020).

As the infection spread rapidly through the highly mobile human population it was apparent to China and the World Health Organization that this was going to be a global public health emergency. Despite precautions and restrictions put in place in Wuhan, the virus had already spread to other parts of China and had reached three other countries via individuals who traveled by air, most likely before knowing they were ill (World Health Organization, 2020, January 21).

Containment within the city of Wuhan was attempted, but it was no longer possible to contain the virus as it was spreading within the huge country of China. Seven days later, on January 28, 2020, the virus had been identified in patients throughout China and there were individuals who tested positive for SARS-CoV-2 in a total of 56 countries (WHO, 2020 January 28). The World Health Organization began publishing daily situation reports. By January 31, the infection was in 106 countries (World Health Organization, 2020 January 31).

Factors that were predictive of the impending worldwide disaster were:

The SARS-CoV2 virus was highly contagious and spread rapidly from person to person.
Humans had NO IMMUNITY as no one had ever been exposed to this particular, newly mutated, novel form of coronavirus.
SARS-CoV-2 mutates frequently, and some of the emerging variants were even more capable of causing significant harm (virulence) to the host than the ancestral version.
Infected patients could transmit the infection for several days before symptoms were present, even if totally asymptomatic.
Some people who are infected and capable of transmitting the infection have no symptoms at all.

How Humans Spread the Virus Throughout the World

SARS-CoV-2 proved to be a very capable traveler, spreading rapidly within infected humans from one country to the next via planes, trains, ships, and other forms of mass travel, see figure 4. The travel network today is massive and global. The respiratory virus SARS-CoV-2 can be transmitted from human to human during the symptomatic and pre-symptomatic stages, as well as by completely asymptomatic individuals. Therefore, airport and other transportation screenings were ineffective.

Individuals traveling on cruise ships were also vulnerable due to the high volume of people on board a single vessel. One of the first superspreader events occurred on the Diamond Princess international cruise ship that was carrying 2,666 passengers and 1,045 crew. One passenger became symptomatic and had to disembark in Hong Kong. Ultimately, 19.2% of passengers and crew tested positive for COVID-19. Public health travel restrictions were implemented, and U.S. passengers had to travel back to the states via two chartered aircraft, with federal government supervised quarantine that continued for 14 days (Medley, et al., 2021).

As early as January 2020, there was strong evidence that asymptomatic and/or possibly pre-symptomatic people were able to pass on the infection to others who then developed symptoms of the disease. COVID-19 was confirmed by PCR (polymerase chain reaction) testing in people who did not know they were sick. Chinese scientists published information regarding asymptomatic transmission in The New England Journal of Medicine online on January 29, 2020 (Li, et al., 2020).

China Published One of the First Epidemiological Studies in February 2020

A team from China published results of a large epidemiological study in February 2020. The epidemic had spread throughout China despite travel restrictions, quarantines, lockdowns of vast territories, and other actions taken to curtail it. By February 11 there were 72,314 cases identified. Of those, 44,672 were cases where the patient’s diagnosis of COVID-19 was confirmed, 10,567 where the infection was clinically diagnosed, 889 patients who were asymptomatic with presence of viral nucleic acids, and 10,567 where COVID-19 was suspected. Asymptomatic patients accounted for 1.2% of the overall sample of medical records (China CDC Novel Coronavirus Pneumonia Emergency Response Epidemiology Team, 2020, February 21).

Fatalities in China February 2020

Of the 44,672 patients with COVID-19 confirmed by the presence of viral nucleic acid in throat swabs, the fatality rate was 2.3%. Of the patients with confirmed COVID-19 infections, 3.8% (1,716) were health workers and the infection had been fatal for five health workers.

Deaths due to COVID-19 infection were highest for those 60 years and older. Of the 8,583 infected patients aged 60 to 69, 30.2% died. Another 30.5% of patients the 3,918 patients aged 70 to 79 years old died as well. There were fewer patients 80 and over, 1,408 and the disease was fatal for 20.3%. Gender also made a difference, though the reasons for this were not identified. Whereas 51.4% (22,981) of infected patients were male, 63.8% of those who died were men. A total of 21,691 (48.6%) of the 44,672 patients with confirmed COVID-19 were women, but only 370 women died compared to 653 men (China CDC Novel Coronavirus+ Pneumonia Emergency Response Epidemiology Team, 2020, February 21).

Cases were categorized as mild, severe, or critical. Most patients, 80.9% had mild disease. The disease was considered severe when patients had an oxygen saturation of 93% or less, dyspnea, a respiratory rate of 30 or higher and lung infiltrates. Severe disease was evident for 13.8% of patients with a confirmed COVID-19 diagnosis (China CDC Novel Coronavirus Pneumonia Emergency Response Epidemiology Team, 2020, February 21).

Patients who showed evidence of respiratory failure, septic shock, and/ or multi-organ dysfunction were categorized as critical. Almost half (49%) of the 2,087 patients who were critically ill expired. There were no deaths among patients with mild to severe disease (China CDC Novel Coronavirus Pneumonia Emergency Response Epidemiology Team, 2020, February 21).

The authors concluded that from first identified case on December 31, 2019, to the end of the study period on February 11, 2020, the highly contagious novel coronavirus had spread from one city in China to the entire country. “Moreover, it has achieved such far-reaching effects even in the face of extreme response measures including the complete shutdown and isolation of whole cities, cancellation of Chinese New Year celebrations, prohibition of attendance at school and work, massive mobilization of health and public health personnel as well as military medical units, and rapid construction of entire hospitals” (China CDC Novel Coronavirus Pneumonia Emergency Response Epidemiology Team, 2020, February 21).

A U.S. COVID-19 Study – Outcomes in March 2020

During February and March of 2020, the number of patients diagnosed with COVID-19 in the U.S. rose rapidly. Thirty one percent of patients with a confirmed COVID-19 diagnosis, 45% of patients who were hospitalized, and over half (53%) of those admitted to intensive care units (ICU) were over the age of 65. Individuals in this age group were most likely to die. During this time period 80% of hospitalized patients in the U.S. over the age of 65 did not survive (CDC COVID-19 Response Team, 2020, March 27). These findings were consistent with the 80% mortality rate reported by Chinese scientists for patients over 60 (China CDC Novel Coronavirus Pneumonia Emergency Response Epidemiology Team, 2020, February 21).

COVID-19 Raged Uncontrolled

With 114 countries affected, over 118,000 cases, and 4,291 deaths – the World Health Organization declared a worldwide pandemic on March 11, 2020.

There were several phases and interventions as the situation progressed from a local cluster of four patients linked to a single location ð to a local outbreak in Wuhan, a city in China, ð to a country wide epidemic, and then ð to a global pandemic with unbelievable speed. COVID-19 infections had been confirmed in 53 countries, including the U.S., see figure 6, with a global total of 85,403 (WHO 2020, February 29).

To summarize:

12/29/19 – four patients were hospitalized in Wuhan, China with an unknown respiratory disease (China CDC, The 2019-nCoV Outbreak Joint Field Epidemiology Investigation Team, 2020, January 31).
12/31/19 – China notified the World Health Organization that there was an outbreak of 47 patients with an unknown respiratory illness (China CDC, The 2019-nCoV Outbreak Joint Field Epidemiology Investigation Team, 2020, January 31).
1/3/20 – China had isolated the virus, identified it as a previously unknown Coronavirus, and completed genetic sequencing of the virus. The virus was named SARS-CoV-2 (severe acute respiratory syndrome, coronavirus 2), and the disease that the virus caused was named COVID-19 (China CDC, The 2019-nCoV Outbreak Joint Field Epidemiology Investigation Team, 2020, January 31).
1/3/20 – China entered the first three ancestral viral genomes for the novel Coronavirus into the international database GISAID so that scientists worldwide could begin development of diagnostic tests that would identify the virus in clinical samples from patients and start working on a vaccine (China CDC, 2020, January 20).
1/11/20 – 248 patients had been identified and tested positive for SARS-CoV-2, all in China. Travel restrictions and stay-at-home orders in Wuhan, China were in place (Li, Q., et al., 2020, January 29).
1/20/20 – 16 healthcare workers were known to be infected by this date (China CDC The 2019-nCoV Outbreak Joint Field Epidemiology Investigation Team, 2020, January 31).
1/21/20 – Cases in China were increasing, and the World Health Organization reported that patients with COVID-19 infections had been found in Thailand (2), the Republic of Korea (1), and Japan (1) – all of those who were ill had traveled to China (WHO, 2020, January 21 situation report).
1/22/20 – Epidemiological studies showed that cases of COVID-19 were doubling every 7.2 days.
1/22/20 – Asymptomatic transmission was identified, as 53% of the 378 patients with confirmed infections had not been exposed to a sick person. Fourteen-day quarantines were recommended.
1/28/20 – The disease had spread to 15 countries and 106 deaths were recorded, there were 4,593 cumulative patients with confirmed disease and another 6,973 patients with suspected infection (WHO, 2020, January 28 situation report).
1/29/20 – Chinese scientists published concerns about asymptomatic transmission in the New England Journal of Medicine (Li, Q., et al. (2020, January 29).
2/28/20 – Patients with infections were diagnosed in 53 countries and 705 patients had been become ill on the Diamond Princess, an international cruise ship based out of Japan. There were 85,403 patients who had been diagnosed worldwide. The case fatality rate had increased from 2.3% to 3.6% (Medley, 2021).
3/11/20 – The World Health Organization and many countries declared COVID-19 a pandemic.
3/16/20 – The transmission rate for COVID-19 was determined to be 2.75, each infected person passed on the infection to 2.75 other people, see figure 6, (Li, Q., 2020; Zhao, 2020).

By March 15, 2020, when the World Health Organization published situation report-55, the SARS-CoV-2 virus had caused 153,517 confirmed infections and 5,735 deaths. As shown in figure 7, there were clusters of cases in many countries.

Despite all the pre-pandemic preparation that preceded arrival of this virus on earth, and worldwide efforts to contain COVID-19, the SARS-CoV-2 virus was able to overcome human interventions and burn through the population faster than a wildfire.

The World Health Organization situation report number 40 from February 29, 2020, highlighted three important interventions that had been initiated. A team of infection prevention and control specialists was deployed to Italy where the COVID-19 case count was disproportionally high at 888. An open access online course “Infection Prevention and Control (IPC) for COVID-19” was launched on February 28^th and the course had already been accessed 15,391 times by international users the first day it was available. A set of Frequently Asked Questions was answered online to provide information on a variety of COVID-19 related concerns.

Outcomes: Cumulative Cases and Deaths per 1,000,000 population

For the entire year of 2020 there was a rapid rise in the number of people ill with COVID-19 and deaths related to the infection in every country. There were differences in how each country initially responded to the pandemic. Some countries had specific plans for a novel coronavirus pandemic based on effective strategies used during the 2002 to 2003 severe acute respiratory syndrome SARS-CoV virus epidemic, for example China and South Korea. Other countries had pandemic plans based on the expectation that influenza would be the causative organism for future pandemics, for example the United Kingdom.

The United States had well defined pandemic plans based on extensive experience with influenza pandemics and assisting with management and control of outbreaks of viral and bacterial diseases in other countries. Unfortunately, as a result of the deep political divisions within Congress and society at large, and a general tendency for the Republicans in power in 2020 to discount science, the U.S. response was totally inadequate. The U.S. response is covered in depth in chapters: The United States: Consequential Failures in 2020, The United States: Too and too late, and Pandemic Preparation, United States.

Low income, developing countries did not have the financial resources needed to survive the pandemic and needed help. The costs involved in addressing a worldwide pandemic were astronomical. The cost of intensive global efforts to develop vaccines within a year alone were unprecedented. Without public/ private partnerships, such as the Bill and Melinda Gates foundation, funds to pay for vaccinations in low income, developing countries would have resulted in even higher death and disability rates worldwide.

Healthcare Acquired Transmission in 2020

The COVID-19 pandemic burned through the human population like wildfire and healthcare providers did not have time in advance to prepare. Because this was a new, novel virus, nurses and other healthcare workers were taking care of seriously ill and extremely contagious patients before they were educated on precautions and how to perform safe care. In addition, it is important to understand that during the first years of caring for patients with this infection, the guidance on transmission-based precautions was changing based on supply chain issues as well as research findings.

When SARS-CoV-2 arrived it was a completely new virus that had never existed before and though researchers in China and then worldwide were scrambling to understand more about how it behaved. The constant emergence of variants from the ancestral wild type that were, and studies were published the dominant circulating version of the virus characterized had already been superseded. By necessity, assumptions were made from day one that each adaptation of this virus would be similar to other less lethal respiratory viruses, or previous variants.

The most serious error made was that the guidance from the U.S. Centers for Disease Control and Prevention, and the World Health Organization regarding how SARS-CoV-2 was transmitted was incorrect and based on outdated science (Hadiso, et al., 2022; Stadnytskyi, et al., 2020).

Exposures to COVID-19 can occur through inhalation of airborne or virus containing droplets, or indirectly by touching contaminated surfaces and then the eyes, nose, or mouth. Initially it was thought that the virus was only airborne following aerosolizing procedures, such as nebulizer use, intubation, resuscitation efforts, mechanical ventilation, and bronchoscopy – and patients with severe illness due to the viral infection often needed such procedures (Ting, et al., 2023).

The initial guidance for respiratory transmission assumed that the virus was transmitted person to person via “heavy” oral and nasal droplets that would drop to the floor within six foot or two meters. Social distancing of at least six feet apart was recommended to avoid contagion. General mask wearing was not recommended, even in healthcare settings (World Health Organization, 2020 February 27).

Eventually, it was determined that SARS-CoV-2 was actually an airborne pathogen and could be transmitted from the ill person to others during normal, relaxed breathing and the six foot/ two-meter social distancing was inadequate (CDC, 2024, March 1; Hadiso, et al., 2022). See chapter COVID-19 Pathophysiology and Disease Process for more information.

Unfortunately, there was a worldwide shortage of personal protective equipment due to supply chain issues as China was one of the largest producers and distributors of such equipment. Disruptions in production and shipment of respiratory protective equipment, such as N-95, KN95 respirators, powered air purifying equipment (PAPR), medical grade face masks, face shields, gowns, and even gloves put front line clinical staff at very high risk for infection. See chapter A Global Shortage of Personal Protective Equipment for more information.

Nurses in clinical settings with varying degrees of experience and knowledge regarding transmission-based precautions had to make the best decisions possible for themselves and their staff members with what they had available. Based on conversations with many U.S. nurses, either they themselves, their family members, or volunteers, hand-made and donated fabric masks to fill the gap. See chapters: The Kindness of Strangers and A Global Shortage of Personal Protective Equipment.

In many countries, clinicians were not aware of the need for respiratory protective equipment or even the importance of basic barriers such as a medical facemask. In countries with limited healthcare, supplies of personal protective equipment were likely to be even less available than in higher income countries, especially as costs escalated. Nurses and other healthcare professionals DID become infected globally. Some providers experienced limited symptoms and recovered quickly. It is impossible to know how many were asymptomatic. An unknown number of nurses and healthcare professionals died in countries throughout the world, and they will never be counted because deaths records did not provide occupation (Banyopadhyay, et al., 2020; Canadian Institute for Health Information, 2022, March 31; Canadian Institute for Health Information, 2022, March 31; Chutiyami, M., et al., 2022). Infected healthcare providers passed the infection on to vulnerable patients and in some cases with brief hospitalizations the patient was sent home before symptoms of COVID-19 emerged (Knight, G. M., et al, 2022; UK SAGE, 2020, March 20). See also chapter Nurse and Other Healthcare Provider COVID-19 Related Illnesses and Deaths.

The Impact of An Infodemic

As the number of cases of COVID-19 worldwide increased, so did the amount of information that positively and negatively impacted the spread of the virus. For example, positive strategies included education from public health officials on prevention strategies via official websites, clinician letters, phone meetings, and information on “for healthcare providers” links. Countries with positive outcomes provided comprehensive education for clinicians on the disease process, patient management, transmission-based precautions, and safety as soon as information was available.

Education on the protective equipment needed for transmission-based precautions was complicated by the fact that nurses and other healthcare professionals all over the globe did not have the necessary equipment available.

Accurate information regarding public health measures needed to prevent the spread of the infection was announced through mainstream television and radio reports. Physician and public health experts used mainstream media as well as social media, videos, and podcasts to explain the situation and in lay terms.

The most important measures that everyone needed to know to prevent the spread of this highly contagious disease were basic and easy to accomplish:

Hand hygiene with soap and water or alcohol based handrub.
Social distancing to limit spread.
Avoidance of crowds.
Disinfection of surfaces and contaminated objects.

Unfortunately, as the crisis worsened, the crucial information that was needed for people to have to protect themselves and their families was drowned out in the infodemic.

The volume of communication circulating contained useful information, but misinformation, disinformation, and conspiracy theories put forth, especially on social media created a worldwide “infodemic”.

This caused a great deal of confusion. Due to the amount of misinformation already spreading within the first days of the pandemic, the World Health Organization developed a “Mythbuster” website for fact checking (https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/myth-busters).

Disinformation and conspiracy theories had a major negative impact on worldwide efforts to mitigate the developing pandemic. Misinformation put forth by individuals in high level government positions, as occurred in the United States, created confusion, divisiveness, and resulted in unnecessary deaths and long-term disabilities. For further information see the chapters: “Coronavirus is a Hoax:” The Conspiracy Theories Begin and The United States: Consequential Failures in 2020.

To Mask or Not to Mask

As more and more Americans were touched by reality because co-workers, family members, friends, or they themselves were infected, people sought face masks as this was a respiratory virus. Costs reached all-time highs for fabric masks, knock offs, face coverings of various types, medical/ surgical-grade face masks, N95 respirators, and KN95 respirators were increasingly difficult to obtain. As discussed in the chapters Consequential Failures The United States – Too Little, Too Late and A Global Shortage of Personal Protective Equipment, the supply chain was essentially broken. The inability to manufacture adequate supplies of respirators was a constant problem, and front-line staff often worked without respiratory protection or reused respirators that were one-time disposal N95s (see chapters cited for more information).

Much of the personal protective equipment used in the U.S. is manufactured in China and when the country closed down to reduce the number of people sick and dying. Much later, the news that some 17.8 tons of medical supplies, including PPE was sent to China on February 7^th, (Pompeo, February 7). which left nurses working at Elmhurst Hospital in New York wearing black plastic trash bags for lack of PPE.

On February 29, 2020, Jerome Adams, the Surgeon General sent a tweet that said:

“Seriously people, STOP BUYING MASKS!

They are NOT effective in preventing general public from catching #Coronavirus, but if healthcare providers can’t get them to care for sick patients, it puts them and our communities at risk!” (Adams, 2020).

Adams reversed this position and recorded a video that showed how to use an old T-shirt and rubber bands for ear loops to make a face covering on April 4, 2020 (Adams, 2020 April 4). People in Asian countries that had experience with the first lethal Coronavirus outbreak (SARS-CoV) were wearing masks and dying less. Many people in the U.S. refused to believe COVID-19 was real and fought mask mandates in courtrooms in several states.

Summary

The SARS-CoV-2 virus was identified as the cause of a deadly and highly contagious virus in China in late December of 2019. Carried by humans who had visible symptoms and those who had no evidence of illness, the virus assaulted the human family. Throughout 2020, the COVID-19 infection spread to every part of the world leaving a trail of death and destruction. With no immunity to this virus that caused severe acute lung damage and lower respiratory infections, 82.3 million people throughout the world had been infected. Of those, 19.6 million people had contracted the virus in the United States. The latest available data to date is from April 27 of 2025. Worldwide this invisible virus made 777.7 million people in the world.

SARS-CoV-2 mutates constantly and each variant that was considered “of concern” was more contagious than the last. Until vaccines were approved in December 2020, there was nothing available to even slow the virus down.

Cities with large populations living and working in close quarters were at high risk for peaks in cases and deaths. Spread of COVID-19 infections into new locations was spurred by a huge amount of accurate, but changing guidance as the science has always been behind the virus as no one can study a variant of a virus before it exists. Guidance for new mutations has been retrospective as the characteristics of each variant of concern have been studied after the variant becomes widespread, and often at the point in time where the given variant is no longer dominant.

Changing guidance was compounded by confusing and inaccurate delivery by government officials, for example, the 2020 Surgeon General said masks were not effective in reducing infections at the end of February 2020 and in April of 2020, he did a video saying face coverings were important and even showed how to make a fabric “mask from an old T-shirt and rubber bands. The volume of information on mainstream news sources, cable TV, official websites, social media, and health authorities created an “infodemic.” The infodemic contained accurate information, confusing and conflicting information, deliberate disinformation, and conspiracy theories. Many people could not figure out how to protect themselves and their families.

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