Lessons Learned from a Global Perspective of Coronavirus Disease-2019

Abstract

Coronavirus disease-2019 has impacted the world globally. Countries and health care organizations across the globe responded to this unprecedented public health crisis in a varied manner in terms of public health and social measures, vaccination development and rollout, the conduct of research, developments of therapeutics, sharing of information, and in how they continue to deal with the widespread aftermath. This article reviews the various elements of the global response to the pandemic, focusing on the lessons learned and strategies to consider during future pandemics.

Key points

• •Non-pharmacological measures (NPMs) are effective in containing the spread of the severe acute respiratory syndrome coronavirus 2 virus.
• •Robust peer-reviewed research played an integral role in responding to the coronavirus disease-2019 (COVID-19) pandemic, from studying the role of NPM to treatments and vaccines.
• •Collaboration of regional, national, and international public health organizations and social media or mass communication platforms is vital to decrease the spread of misinformation.
• •COVID-19 vaccines were the central element in reducing the morbidity and mortality of the COVID-19 pandemic. Vaccine equity is a top priority to ensure the most vulnerable are also protected.
• •Access to appropriate health care and preventative measures reduced morbidity and mortality from COVID-19.

Introduction

On March 11, 2020, the World Health Organization (WHO) declared the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (coronavirus disease-2019 [COVID-19]), a pandemic (Table 1 ).¹ A few months before this declaration, a cluster of severe pneumonia cases was reported in Wuhan, China. As of September 30, 2022, the WHO recorded 614,385,693 cases worldwide of COVID-19 with 6,522,600 cumulative deaths.²

Table 1.

Lessons learned from coronavirus disease-2019: summary of considerations for future respiratory virus pandemics

Global spread	•Non-pharmacological measures are effective in containing the spread of the virus •Contact tracing can help limit the spread •Face masks, in conjunction with other public health measures can tangibly reduce transmission
Impact on health care	•Rapid and generous sharing of information between researchers, clinicians, agencies, and countries is instrumental in planning, preparation, treatment, and prevention •Resource allocation strategies should be considered at all levels to prepare for equitable distribution of resources between areas suffering varying degrees of impact •Supply chain challenges can be effectively addressed by robust deployment of public-private collaborations •Telehealth can be effectively used to provide care •Attention needs to be paid to the mental and physical well-being of health care workers •Evaluation of health care worker needs, provision of meaningful incentives, and infusing effort into training future generation of health care workers should be prioritized to ensure long-term retention
Dissemination of knowledge	•Preprint articles provide rapid dissemination of information but the need for rapidity must be balanced with robust peer-review to avoid inaccurate publications •Peer-reviewed research plays an integral role to ensure accurate science is shared between stakeholders •Living guidelines promote unity and availability of timely evidence-based guidance •Collaboration of regional, national, international public health organizations along with mass media channels is vital to decrease the spread of misinformation
Vaccination	•Equitable sharing of vaccines and other resources among countries is a top priority •Misinformation hinders vaccination efforts globally •Low- and middle-income areas can have lower vaccinations rates than the high-income areas, further exacerbating the socioeconomic disparity
Socioeconomic impact	•Disparity in access to robust health care in areas of low socioeconomic status can lead to worse outcomes •Despite increases in hospital beds, good quality care is limited by availability of trained personnel and appropriate resources •Pandemics can have a significant impact on the financial well-being of society and balancing mitigation strategies with socio-economic feasibility remains an ongoing learning curve

The Wuhan seafood wholesale market was shut down with the hopes of local mitigation. China’s Viral Pneumonia of Unknown Etiology system, which was created after the SARS epidemic, was activated by January 3, 2020, followed by a limitation of travel in and out of the region by January 23, 2020.3, 4, 5 Around the same time, patients with symptoms of the virus were asked to quarantine. These measures required the individual to stay isolated for up to 14 days to curb the spread of the virus.

On January 13, 2020, a case of SARS-CoV-2 infection was reported in Thailand. This was the first report of a case outside of China.⁶ Without a known vaccine or cure available, stricter measures were implemented including holiday extensions, city-wide lockdowns, and quarantine of suspected patients.⁷

On February 20, 2020, a young patient in Codogno hospital (Lombardy, Italy) with no known risk factors for SARS-CoV-2 infection tested positive for the virus. By February 21, 2020, there was a rapid rise in the number of cases of COVID-19 in the Northern part of Italy. Intensive care units (ICUs) had to double their pre-pandemic capacity in less than 6 weeks to accommodate the large number of patients arriving at the hospital with severe COVID-19.^{8 , 9} By March 17, 2020, there were 31,506 positive cases despite the whole country of Italy having been placed under lockdown by March 9, 2020.¹⁰ Lockdowns were similarly instituted by numerous countries. By March 25, 2020, a third of countries in the world were in lockdown.¹¹

The virus was spreading unabated by now. Thailand declared a State of Emergency Decree on March 26, 2020. Additional measures included a stay-at-home policy, canceled national holidays, imposed school closures, and suspended international flights.¹² Nevertheless, COVID-19 continued to spread.

Non-pharmacological measures

Containment of SARS-CoV-2 spread was necessary to reduce morbidity and mortality from COVID-19 and to reduce the pressure on the health care system. Non-pharmacological measures (NPMs) aimed at transmission mitigation were implemented including quarantines, mobility restrictions, socioeconomic restrictions, physical distancing measures, face masking, and hygiene measures. Many countries used travel restrictions to varying degrees throughout the pandemic, ranging from complete isolation as implemented by the Australian and New Zealand Governments to temporary border closures implemented by countries like France, the United Kingdom, and the United States. A study model showed that sustained 90% travel restrictions to and from mainland China, for example, were only modestly effective unless they were also associated with behavioral changes, likely due to the ability of the virus to be transmitted by asymptomatic and oligosymptomatic individuals in an airborne route.^{13 , 14} Travel restrictions applied reactively to countries that were reporting variants and ignoring countries with little or no reported surveillance data worsened the inequity of the global response.¹⁵

On the basis of the now accumulated data on the transmissibility of the SARS-CoV-2, it is now known that travel restriction measures in isolation failed to halt the spread of the pandemic. Rather, demanding mask use during traveling, a proof of a negative COVID-19 test shortly before airline boarding, and more recently––demanding a complete vaccination status––seem to be more reasonable measures to help reduce transmissibility without unreasonably compromising travel mobility.

Contact Tracing

Contact tracing was another measure adopted by some countries with varying levels of strictness to identify probable or confirmed cases. Individuals in contact with those diagnosed with or exposed to COVID-19 were instructed to quarantine. Accessibility to testing and rapid turnaround times were crucial to the success of contact tracing and proved to be a challenge. It took many months for countries committed to contact tracing to be able to effectively implement it. The disparity in the availability of testing highlighted the known biases in global health.16, 17, 18

Mobility Restrictions

Mobility is a variable associated with the spread of the virus spread. Mobility restrictions included limitations on public transportation use, air traffic travel, and indoor as well as outdoor activities.¹⁹ Although these measures appeared to be effective initially at limiting the spread outside of the Wuhan region, there has been evidence of SARS-CoV-2 present in the United States since at least January 20, 2020. The impact of the pandemic on mobility was either determined by governments or by the population themselves perceiving the risk, which varied significantly throughout the world.

Brazil, for example, saw a natural decline in mobility in March 2020, when the first official death was reported in the country. This had a direct impact on slowing the increase in the number of cases during the first wave of the pandemic in the country, when vaccines didn’t exist.

The United Kingdom also saw a significant impact on its mobility; however, the population changed its behavior at each lockdown. The first lockdown came into effect on March 26, 2020; gradual reopening started on June 1 of the same year. The second and third national lockdowns were enforced on May 5, 2021 and August 3, 2021. Mobility during those lockdowns was 47% higher than in the first lockdown, where the mobility dropped to 73% lower than in the pre-pandemic period (Fig. 1 ).

Fig. 1.

Mobility in the United Kingdom over time. The zero mark in the y-axis refers to pre-pandemic mobility levels. Note an attenuated reduction in mobility from the first, second, and third lockdowns.

(From Rede Análise Available at: http://bit.ly/Rede_MobilitySymptoms. Accessed Jun 22 2022.)

The Delta variant surge in India offered another example where cases started to rise exponentially in the second week of March 2021. As a result, deaths began to rise at the beginning of April 2021, whereas the mobility dropped only in the second week of April 2021 – after deaths increased exponentially by more than a week (Fig. 2 ).

Fig. 2.

Relationship between new daily cases of COVID-19 in India (A), daily deaths (B), and mobility (C). Note the mobility reduction following an exponential rise in deaths after one week. The zero mark in the mobility graph refers to pre-pandemic mobility levels.

Mobility reductions have had a clear impact in reducing the transmission of COVID-19. When informed by changes in trends in COVID-19 case monitoring, mobility restrictions were useful in controlling the effective reproduction number (Rt) and preventing deaths, especially before widespread use of vaccination.

Socioeconomic Restrictions

Socioeconomic restrictions refer to the placement of limitations on or closure of community gatherings such as schools, workplaces, daycares, elderly housing, swimming pools, bars/restaurants, banks, grocery stores, etc. Complete lockdowns had large effects in controlling COVID-19 community transmission; however, these measures come with significant impacts in the economy and in the mental health of the population, disproportionately affecting resource-poor areas^{20 , 21} Restrictions lighter than a complete lockdown proved effective for control of community transmission in 2020 (to drive the reproduction number – Rt – below 1).²² On the basis of the data from Reuters, Italy, and Spain had a 94% decrease in retail and recreational trips during the pandemic. A reduction of over 60% was noted in physical presence in workplaces. It is evident that these measures contributed to decreased transmission but at high socioeconomic costs that led countries to implement these changes in different degrees.¹³

Physical Distancing

Physical distancing, also known as social distancing, is a regulation of the distance and number of people per square meter in a location. On the basis of the studies published during the SARS outbreak, six feet was determined to be potentially effective in the reduction of transmission.²³ A significant focus was placed on reducing mass gatherings, closing of workplaces, and isolating households, towns, and cities. A combination of these measures has been reported to have an approximately 60% reduction in transmission.²⁴ Similarly, personal hygiene measures were implemented and aimed to reduce other routes of SARS-CoV-2 transmission, such as fomites. These measures included hand washing, avoidance of contact with contaminated surfaces, appropriate utilization of personal protective equipment (PPE) such as eye and hand protection with the use of face shields/goggles with gloves, protective glass, and temperature checks upon entrance.

Facemasks

Facemasks played a notable role in shaping the course of the pandemic. The utility of universal face masks was gradually learned leading to various mask mandates across the globe.²⁵ At the beginning of the pandemic, with a lack of in-depth knowledge about how transmission occurred (whether by aerosols or direct/indirect contact, or both) and with concern about the scarcity of masks for health professionals, the WHO delayed recommending the use of masks to the general population. On April 3, 2020, the Centers for Disease Control (CDC) recommended wearing a face covering to reduce the spread in the community.²⁶ This recommendation was followed by similar advice from the WHO on April 6, 2020.²⁷ However, these initial recommendations encouraged the use of masks that could be manufactured by hand, even with the folding of cotton cloths, and used with elastics, albeit without clarification on the issue of adjustment and filtration efficiency. On June 5, WHO published an updated guide, including placing a table with the filtration efficiencies of masks made with different fabrics (ranging from 0.7% to 26%).²⁷ In 2020, the number of fabric masks made by the textile industry increased, mainly in developing countries.²⁸ A systematic review and meta-analysis published by Sharma and colleagues²⁹ in 2020 noted that the effectiveness of cloth masks was very low for the prevention of COVID-19, but that they could be used in outdoor public spaces to reduce transmission. However, a portion of the population with greater purchasing power chose to use professional masks (surgical or FFP2/N95). The most penetrating particle size (MPPS) for N95s ranges from 30 to 100 nm, whereas that for surgical masks ranges from 200 to 500 nm. The MPPS for cloth masks is similar as surgical masks. The particle filtration efficiency (PFE) for various masks however depends on several factors including type of the mask, condition of the mask, and mask fit.³⁰ A study in patients with seasonal coronaviruses showed that the surgical face masks significantly reduced the detection of viral RNA in both respiratory droplets and aerosols in the air. Those who did not use masks were found to have a 40% rate of aerosol detection, compared with a zero detection rate in those who used face masks.³¹

Since the pandemic, many studies evaluated the efficiency of masks. Experiments performed using particle counters and probes coupled to different models of masks to simulate coughing, speech, sneezing, or breathing³² showed that the filtration efficiencies of masks/respirators FFP2/N95 were much higher (92% to 98%) than those obtained with the use of surgical masks (around 70%) or cloth masks (between 0.7% and 30%).³³ These studies helped the scientific community to claim that FFP2/N95 respirators, previously only used by health professionals, would be the most protective against an airborne disease such as COVID-19.³⁴ A study from Bangladesh compared the use and nonuse of cloth and surgical masks in more than 340,000 people, and a randomized clinical study in health professionals published for influenza in 2019³⁵ comparing surgical masks and N95 in health professionals, showed the efficacy of mask use in reducing SARS-CoV-2 transmission. Importantly, masks should not be regarded as single measures or with 100% efficiency. Proof-of-concept studies, experimental laboratory projections, and mathematical and physical models, have shown that the effectiveness of masks is related not only to their filtration efficacy, but to proper fitting, the viral load of infectious sources, environment aeration, and the reproduction rate of the predominant viral variant.³⁶ For this reason, it is challenging to make projections regarding the "percentage" of generalized protection, as different combinations of the aforementioned factors yield different risks. Nevertheless, well-aerated outdoor environments, even with many infected sources, provide less transmission risk, which allows the use of masks of lower efficacy but with relative safety. On the contrary, indoor environments, such as public transport and medical centers that treat patients with COVID-19, require more efficient masks. Finally, as SARS-CoV-2 is highly dispersed through aerosol droplets, in general terms, the more efficient the mask is (in terms of filtration), the better the protection.³⁷

Surveillance

Surveillance was pivotal for understanding the pandemic and giving early warnings to the population, so that risk management could be more effective. Several initiatives were launched, like the Covid Trends and Impacts Survey (CTIS), developed by the University of Maryland and Facebook Health.³⁸ This survey inquired Facebook users on the presence of COVID-like symptoms. COVID-like symptoms were a sum of fever, cough, and shortness of breath. A rise in COVID-like symptoms anticipated official data by approximately 15 days The CTIS survey showed that using masks lowered the incidence of COVID-19 symptoms as questions on the use of masks were also part of the survey.³⁹ The data from Brazil’s Rio Grande do Sul state showed the impact of mask mandates on the incidence of symptoms (Fig. 3 ).

Fig. 3.

Impact of mask mandates on mask-wearing reports on CTIS survey. On the state of Rio Grande do Sul, Brazil. The graph shows patients with COVID-like symptoms and the dark blue line depicts persons reporting mask usage outside of their homes. On the wave depicted in May 2022, a rise in symptoms is noted when the mask usage reporting is the lowest.

(From Rede Análise Available at: http://bit.ly/Rede_MobilitySymptoms. Accessed June 22, 2022.)

During the COVID-19 pandemic, we have learned about the colossal impact of contact tracing, mobility and socioeconomic restrictions, physical distancing, face masking, and surveillance. These NPMs to control disease transmission came with their own difficulties, such as real and perceived limitations in personal freedom. Public dissatisfaction also stemmed from the impacts of social isolation on the economy, behavioral and mental health.⁴⁰ Wide-ranging debates on ideal long-term strategies to limit transmission while maintaining sustainable social, financial, and mental health are ongoing.

Impact on health care and resource allocation

Temporal heterogeneity marked the pandemic worldwide, which meant that there were regions experiencing a spike in cases, weeks or months before others (as was the case for China followed by Europe and then the Americas). Rising cases led to a rise in emergency room visits followed by hospitalizations, including utilization of the ICUs. During the “surges'' the wise use of rapid and generously shared information by countries helped some regions to prepare for these acute burdens on health care. Allocation of scarce resources such as the supply of oxygen and ventilators were great challenges and in some highly burdened areas led to catastrophic system collapse such as in Brazil, India, or in Iran.^{41 , 42} As the pandemic progressed, and the medical systems were overwhelmed on a wider scale, countries going through periods of increased transmission and case burden struggled to keep up with the needs of the patients.

During the initial wave, the lack of PPE and medical devices such as ventilators was an important limiting factor. The lack of resources was less stark during subsequent waves compared with the deficit of trained personnel.⁴³ Regional and wide-scale redeployment of personnel from noncritical care areas was necessary. These redeployments led to physical, mental, emotional, and financial strain on health care personnel, with an increased rate of burnout. These challenges highlighted the importance of proactive personnel management during future pandemics.

The lack of evidence-based strategies for resource allocation and the most appropriate models for local, regional, national, and international resource sharing was starkly evident.^{44 , 45} The sparse existing guidelines for resource allocation were revisited.⁴⁶ What stood out was the variation in guidelines across various states even within one country.⁴⁷ Evidence abounds on the overburdening of health system posed by COVID-19. Lack of appropriate public health measures to control disease transmission and the ICU bed occupancy in Sao Paulo state in Brazil illustrates that after the ICU bed occupancy reached approximately 100%, there was a rapid increase in new deaths despite the added ICU beds. These newly available ICU beds could not provide high-standard ICU care as critical care health professionals were not available to staff them. This shortage of health care workers resulted from a significant burden of stress and negative socioeconomic, psychological, and physical impacts across the spectrum of health care workers with successive waves during the pandemic.⁴⁸ Studies reported a significant increase in the turnover intention in nurses, which was also noted among the rest of the health care workers.⁴⁹ By the spring of 2020, Canadian health care workers reported more than 30% prevalence of severe burnout.⁵⁰ Half of the health care workers reported decreased likelihood of maintaining their current occupation due to the pandemic in the United States while a study found that only 4.8% of nurses at a hospital in Egypt reported no intention to leave their current job.^{51 , 52} As institutions recover in the aftermath of the pandemic, workforce retention, and well-being will prove to be an uphill battle while providing quality care to the community making workforce satisfaction and well-being a top priority at all levels of policy making in health care.

In the out-of-hospital setting, outpatient clinics pivoted to providing telehealth services to allow social distancing measures that in turn limited in-person health care. A retrospective study noted an 80% reduction of utilization in outpatient resources compared with pre-pandemic years with a four-fold increase in telehealth resources.⁵³ A large review of countries implementing telehealth during the pandemic had a positive sentiment about its use going forward – an enormous 84.9%. This was based on data from high-income countries: 43.6% of the articles reviewed originated in the United States. On the contrary, the feasibility of telehealth in countries that are low- and middle-income or resource-scarce may continue to be an issue.⁵⁴

Governments took unprecedented measures to address resource shortages. In the United States, the Defense Production Act was invoked to allow robust public-private partnerships to accelerate the development and testing of therapeutics, ventilators, vaccines, and time-sensitive release of funds for the same.⁵⁵ In the United Kingdom, companies produced 14,000 ventilators in 3 months as part of the “Ventilator Challenge”, one part of the government’s three-pronged approach to increase ventilator production in a short period of time.⁵⁶

The international health care supply chain is a dynamic multi-tiered process. It involves manufacturers, vendors, purchasers, storage, distribution, and providers. As the chain requires constant flow without disruption, the consequences of the pandemic were felt worldwide due to the multifactorial impact on every single step of the supply chain across various countries. A shortage of PPE due to a drastic uptick in use and limited global supplies was the hallmark of resource limitation at the beginning of the pandemic. With China as the primary producer, as well as the pandemic epicenter, international efforts shifted toward reclaiming, reusing, and repurposing the existing supply. Manufacturing infrastructure was repurposed to bolster supply and fulfill the deficits.⁵⁷ As an example, India stopped the export of 26 active pharmaceutical ingredients due to the fear of shortages for use within the country.⁵⁸

With the unsettling rise in cases globally, many lessons were learned from the direct and indirect impact on health care delivery. Information sharing between countries is vital and constant evaluation of local and national resource allocation plans is important to stay prepared for future pandemics. Telehealth visits rose as resource shortages were observed. The importance of public-private partnership to address shortages will serve as benchmarks for future crises.

Literature in coronavirus disease and research efforts

The COVID-19 pandemic, with its unprecedented needs, led to an acceleration in research on COVID-19 and concomitant rise in the number of scientific articles. The rapid spread of COVID-19 was paralleled by the speed of literature being published. The first publication on COVID-19 was on January 2, 2020 and the rate of published articles related to COVID-19 hit an all-time high of 2276 in a week by the 22nd week of 2020. Between January 2, 2020 and July 21, 2020 the mean number of publications per week was 990.⁵⁹ Both researchers and journals were overstretched by COVID-19. The use of preprint online platforms to speed up the release of information was another consequence of the pandemic that had its own pros and cons. Publishing on preprint platforms allowed for rapid dissemination of data by overcoming that limitation of traditional publishing processes including slow timelines of peer-review, time to publication, and challenges with formatting per different journals’ guidelines. However, the importance of robust peer-review became evident as incomplete, fabricated, or improperly analyzed data led to spread of information that eventually was proven to be incorrect.⁶⁰ Although open to public comment which serves as form of peer-review, about 5% of pre-print articles were commented on, usually with only one comment per article.⁶¹ Traditional publications also suffered from the challenges of need of rapid publication such as the retracted article regarding use of hydroxycholoroquine in COVID-19.⁶²

Impressive robust scientific initiatives were also launched. A highlight was the implementation of adaptive platforms to run multiple research questions in COVID-19 simultaneously, such as RECOVERY,^{63 , 64} REMAP-CAP⁶⁵ and the ACTT.⁶⁶ Adaptive trials such as these allowed rapid reaction to changing knowledge and therapeutics while evaluating different target candidates for the treatments. These trials subsequently provided guidance and clarity on the role of multiple therapeutics such as the role of antivirals, systemic steroids, and other immunomodulators, among others.

Another critical achievement of the global medical research community was the creation and maintenance of the “living” guidelines on therapeutics for COVID-19 published by the WHO.⁶⁷ The first version of these guidelines was published in September 2020 and most recently the twelfth iteration of the guidelines was released on September 26, 2022. Curated by a review committee with global representation, these guidelines provided front-line clinicians with the ability to deliver evidence-based care that was in keeping with the most recent high-quality literature.

Misinformation

COVID-19 is the first pandemic in history during which technology and social media were used on a large scale to keep people safe, informed, productive, and connected. At the same time, the technology we rely on to keep us connected and informed enabled and amplified a deluge of inaccurate information that undermined the global response and jeopardized the measures to control the pandemic due to conflicting messaging.

With the deluge of data and information came a similarly impressive amount of confusion and misinformation.⁵⁹ Although the discordance in statements from official sources was based on available literature, the interpretation and implementation of the information were often askew by the populace leading to confusion in the community. From vital information on the origin and therapies of a pandemic to ongoing published literature, we saw the emergence of an “infodemic”.⁶⁸ In a rapidly changing situation, with millions of individuals in isolation, social media became a frontrunner source for major updates. Research conducted in Italy showed that in March of 2020, an average of daily 46,000 Twitter posts were linked to misinformation.⁶⁹ A survey published in the UK indicated that 46% of adults had seen misleading information about the pandemic; 40% reported finding it hard to know what is true or false.⁷⁰ Over a quarter of the most-viewed 75 videos regarding COVID-19 in March 2020 on YouTube contained misinformation.⁷¹

Misinformation also stemmed from poor conduct of research; examples include studies published by researchers in both pre-print and traditional publications who claimed passionately that hydroxychloroquine or proxalutamide were effective.^{72 , 73} Medical journals faced a herculean task of processing submitted manuscripts while ensuring standards.^{74 , 75}

This pandemic highlighted the importance of rapid development and sharing of research findings while ensuring consistent messaging. The role of social media was significant and provided impetus for health care personnel to actively participate in ensuring accurate information dissemination.⁷⁶ Health care agencies recognized the importance of cohesive messaging as noted by increased connectivity of messaging between different stakeholder agencies on Twitter as the pandemic progressed.⁷⁷

Vaccination

The development of vaccines required unprecedented efforts to bring resources, manpower, and intellectual strengths together. As discussed earlier, the public-private partnerships fostered across the globe were critical for this endeavor. In December 2020, two mRNA vaccines were approved for administration in the United States.⁷⁸ Since then several types of vaccines against COVID-19 have been developed and deployed across the globe including nucleic acid vaccines, viral vector vaccines, inactivated vaccines, and protein-based vaccines.⁷⁹ The WHO COVAX initiative declared that “no one is safe, unless everyone is safe'', in a bid to ensure equitable distribution of vaccines globally.⁸⁰ The goal was to fundraise capital to ensure vaccine access for 100 low- to-middle-income countries.⁸¹ By mid-December 2020, approximately half of the expected production of 5.3 billion doses of vaccines for 2021 had been preordered by the 27 countries of the European Union, the United States, the United Kingdom, Canada, Australia, and Japan. Cumulatively these high-income countries represented only 13% of the global population.⁸² In contrast, the COVAX facility had only reserved a few hundred million doses.⁸¹ Several countries developed vaccines indigenously and provided a robust vaccine program for their population, demonstrating the importance of engaging all shareholders internationally. India launched its vaccine program in January of 2021 and as of April 2, 2022 reported 91% of the whole population was at least partially vaccinated.⁸¹ By the end of 2021, Latin America was one of the leaders in vaccination numbers globally, where existing resources for vaccine deployment were crucial for the success of vaccination campaigns.⁸³

The global vaccination efforts have been hindered by hesitancy, among other reasons, with misinformation playing a significant role.⁸⁴ As of April 2022, vaccination efforts across the globe have reached a plateau, with many countries such as the United States reporting only 67% of the population as being completely immunized. Countries such as Nigeria and Ethiopia at the same time reported 10% to 20% vaccination rates, starkly bringing into focus the impact of resource limitation, imbalance of sharing these resources, and factors such as hesitancy causing a dent in acceptance.⁸⁵

The vaccine coverage in some countries revealed these inequities. In May of 2022, the African continent had 17% of its population vaccinated with two doses and 1.65% of its population vaccinated with three doses. In Brazil, a low-middle income country (LMIC), with significant socioeconomic disparities, vaccine inequity has been clearly shown. The southeast and south regions had the most robust coverage: Sao Paulo State was the most vaccinated state, with 84% of its total population vaccinated with two doses. The north region had the lowest coverage, with less than 50% of the population in states like Amapá and Roraima vaccinated with two doses. When the third dose coverage was analyzed, the northern states in Brazil had less than 15% of their total population covered, which was directly associated with worse socioeconomic status in the north and northeast of Brazil. Lower-income regions, like the north, reported an average of 55% of two doses of vaccinal coverage, and the higher-income regions, like south and southeast, reported an average of 75% of two doses (Fig. 4 ).

Fig. 4.

Vaccine inequality in Brazil. The graph shows the northern region of Brazil had a lower vaccine coverage than the southeast (mainly São Paulo, the richest state of the country).

(From Rede Análise Available at: https://redeanalise.com.br/. Accessed June 22, 2022.)

As we have learned from the pandemic, age-based vaccine distribution strategies were crucial for mortality reduction.^{86 , 87} Countries globally adopted this recommendation prioritizing older-age individuals and health care workers.^{86 , 87} As the vaccine supply is currently plentiful, nations with low vaccine supplies have become the focal point for vaccination efforts. Models have shown that dose sharing between countries with high and low vaccine availability is beneficial from a global perspective as vaccine sharing lessens the costs of surveillance such as from border testing and genomic surveillance as well as decreases the risk of evolution of the virus.⁸⁸ In certain populations, specific targeting such as social media campaigns, slogans, and trusted messengers proved beneficial. Vaccine uncertainty was eased by involving communities hit the hardest by the pandemic.⁸⁹ Africa, a continent that has experience vaccinating large numbers of its population, had systems in place to effectively implement vaccinations. Such efforts include storing vaccines at cold temperatures, a requirement for the Ebola vaccine, and establishing vaccine sites such as churches, mosques, banks, and markets.⁹⁰

Vaccination efforts continue to heighten. Access to vaccines plagued the initial rollout, but governments quickly combated the issue. During future pandemics, ensuring equitable access to vaccines will be key to address the global spread of agents.

Socioeconomic impact

The socioeconomic impact of this pandemic was evident early in the pandemic. In Brazil, for example, regional health disparities played a massive role in disease burden and mortality. In low-income areas, the mortality rates in the young were similar to the rates seen in the elderly, in contrast to regions with a high-income status and greater availability of higher quality of care. The need for high-quality care in these disadvantaged regions of critically ill patients was highlighted. These findings can be extrapolated to other low-income and middle-income countries with similar socioeconomic status.⁹¹ Brazil had remarkable differences between the first (March-October 2020) and second (January-May 2021) waves. During the second wave, Brazil faced the Gamma variant of SARS-CoV-2 and an increase in mobility likely due to pandemic fatigue, whereas the vaccine coverage was still very low. This led to an increase in admissions for invasive and noninvasive ventilation by 192%. However, the admissions to the ICU were similar, suggesting a limitation in access to critical care. Also noted was a decrease in admissions in the state capitals, which again pointed toward socioeconomic challenges in specific regions.⁹² The second wave proved to be more devastating with an increased burden of severe cases resulting in a higher mortality. Similar situations were seen in both the UK and Africa.⁹³ In Africa, despite the first wave, many countries had not instituted similar degrees of public health measures, and those that had instituted them, experienced fatigue in adherence to the measures which contributed in part to the subsequent waves.⁹⁴

In South Africa, women experienced increased vulnerability to domestic trauma.⁹⁵ Police reported 87,000 cases of violence during the first week of lockdown. This further suggested an increased need for mental health professionals during these stressful times,⁹⁶ whereas a significant decrease in motor vehicle accidents, pedestrian-vehicle accidents, and assaults was seen. In particular, assaults involving a knife decreased dramatically.⁹⁷ The unemployment rate was a striking 30.1% during the lockdown. Measures such as social distancing, mask-wearing, and avoiding close contact were more consistently implemented by individuals of educated and higher socioeconomic status, as opposed to those of lower socioeconomic status.⁹⁸

The profound socioeconomic impact of the pandemic is a major lesson learned. High-income regions have access to high-quality care which in turn decreases mortality rates as highlighted. To reiterate: addressing inequities is as important to delivery of health care as innovation in therapies and preventative strategies.

The path forward

Progress in technology, diagnostics, networks, and preparedness for pandemics must continue. Following the 2009 influenza pandemic, the Member States of the WHO adopted the Pandemic Influenza Preparedness (PIP) Framework, which supports fair access to measures to alleviate threats and financing. Each country has a different risk profile. Going forward, attention needs to be placed on an immediate response plan to implement national strategies similar to the WHO-adopted method, keeping existing inequities in mind so as not to exacerbate them during a pandemic situation.⁹⁹

Continued research on public health and mitigation measures will accelerate the positive impact we have noted and minimize harm going forward. The mistrust in science and health care will likely be restored as vaccines and effective COVID-19 treatments become established. Reliance on inter-organizational consistency, trusted leaders, and accessible, evidence-based guidelines will pave the way toward rebuilding public trust. Lastly, ongoing efforts are needed to protect the health and safety of health care workers who experienced the burdens of burn-out, discrimination, risk of occupational exposure, and illness from COVID-19.⁹⁹

The use of facemasks, indoor aeration, and distancing can mitigate the airborne transmission of virus. Early implementation of quarantine and contact tracing in conjunction with common-sense public health measures are effective in controlling transmission. A global effort to keep resources, knowledge, and implementation equitably distributed and available at all levels is critical for success.

Many possible scenarios exist going forward. Endemicity similar to influenza and other human coronaviruses is entirely possible.¹⁰⁰ Vaccinations and previous infections may achieve herd immunity. However, a broad application of vaccines worldwide and accurate and available diagnostic testing is needed for accurate monitoring and local mitigation.¹⁰¹ As for now, COVID-19 will continue to circulate for the foreseeable future.

Conflicts of interest and disclosure statement

None of the authors have conflicts of interest to declare.