Log in using your username and password

  • Search More Search for this keyword Advanced search
  • Latest content
  • Current issue
  • BMJ Journals More You are viewing from: Google Indexer

You are here

  • Volume 76, Issue 2
  • COVID-19 pandemic and its impact on social relationships and health
  • Article Text
  • Article info
  • Citation Tools
  • Rapid Responses
  • Article metrics

Download PDF

  • http://orcid.org/0000-0003-1512-4471 Emily Long 1 ,
  • Susan Patterson 1 ,
  • Karen Maxwell 1 ,
  • Carolyn Blake 1 ,
  • http://orcid.org/0000-0001-7342-4566 Raquel Bosó Pérez 1 ,
  • Ruth Lewis 1 ,
  • Mark McCann 1 ,
  • Julie Riddell 1 ,
  • Kathryn Skivington 1 ,
  • Rachel Wilson-Lowe 1 ,
  • http://orcid.org/0000-0002-4409-6601 Kirstin R Mitchell 2
  • 1 MRC/CSO Social and Public Health Sciences Unit , University of Glasgow , Glasgow , UK
  • 2 MRC/CSO Social and Public Health Sciences Unit, Institute of Health & Wellbeing , University of Glasgow , Glasgow , UK
  • Correspondence to Dr Emily Long, MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow G3 7HR, UK; emily.long{at}glasgow.ac.uk

This essay examines key aspects of social relationships that were disrupted by the COVID-19 pandemic. It focuses explicitly on relational mechanisms of health and brings together theory and emerging evidence on the effects of the COVID-19 pandemic to make recommendations for future public health policy and recovery. We first provide an overview of the pandemic in the UK context, outlining the nature of the public health response. We then introduce four distinct domains of social relationships: social networks, social support, social interaction and intimacy, highlighting the mechanisms through which the pandemic and associated public health response drastically altered social interactions in each domain. Throughout the essay, the lens of health inequalities, and perspective of relationships as interconnecting elements in a broader system, is used to explore the varying impact of these disruptions. The essay concludes by providing recommendations for longer term recovery ensuring that the social relational cost of COVID-19 is adequately considered in efforts to rebuild.

  • inequalities

Data availability statement

Data sharing not applicable as no data sets generated and/or analysed for this study. Data sharing not applicable as no data sets generated or analysed for this essay.

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/ .


Statistics from Altmetric.com

Request permissions.

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


Infectious disease pandemics, including SARS and COVID-19, demand intrapersonal behaviour change and present highly complex challenges for public health. 1 A pandemic of an airborne infection, spread easily through social contact, assails human relationships by drastically altering the ways through which humans interact. In this essay, we draw on theories of social relationships to examine specific ways in which relational mechanisms key to health and well-being were disrupted by the COVID-19 pandemic. Relational mechanisms refer to the processes between people that lead to change in health outcomes.

At the time of writing, the future surrounding COVID-19 was uncertain. Vaccine programmes were being rolled out in countries that could afford them, but new and more contagious variants of the virus were also being discovered. The recovery journey looked long, with continued disruption to social relationships. The social cost of COVID-19 was only just beginning to emerge, but the mental health impact was already considerable, 2 3 and the inequality of the health burden stark. 4 Knowledge of the epidemiology of COVID-19 accrued rapidly, but evidence of the most effective policy responses remained uncertain.

The initial response to COVID-19 in the UK was reactive and aimed at reducing mortality, with little time to consider the social implications, including for interpersonal and community relationships. The terminology of ‘social distancing’ quickly became entrenched both in public and policy discourse. This equation of physical distance with social distance was regrettable, since only physical proximity causes viral transmission, whereas many forms of social proximity (eg, conversations while walking outdoors) are minimal risk, and are crucial to maintaining relationships supportive of health and well-being.

The aim of this essay is to explore four key relational mechanisms that were impacted by the pandemic and associated restrictions: social networks, social support, social interaction and intimacy. We use relational theories and emerging research on the effects of the COVID-19 pandemic response to make three key recommendations: one regarding public health responses; and two regarding social recovery. Our understanding of these mechanisms stems from a ‘systems’ perspective which casts social relationships as interdependent elements within a connected whole. 5

Social networks

Social networks characterise the individuals and social connections that compose a system (such as a workplace, community or society). Social relationships range from spouses and partners, to coworkers, friends and acquaintances. They vary across many dimensions, including, for example, frequency of contact and emotional closeness. Social networks can be understood both in terms of the individuals and relationships that compose the network, as well as the overall network structure (eg, how many of your friends know each other).

Social networks show a tendency towards homophily, or a phenomenon of associating with individuals who are similar to self. 6 This is particularly true for ‘core’ network ties (eg, close friends), while more distant, sometimes called ‘weak’ ties tend to show more diversity. During the height of COVID-19 restrictions, face-to-face interactions were often reduced to core network members, such as partners, family members or, potentially, live-in roommates; some ‘weak’ ties were lost, and interactions became more limited to those closest. Given that peripheral, weaker social ties provide a diversity of resources, opinions and support, 7 COVID-19 likely resulted in networks that were smaller and more homogenous.

Such changes were not inevitable nor necessarily enduring, since social networks are also adaptive and responsive to change, in that a disruption to usual ways of interacting can be replaced by new ways of engaging (eg, Zoom). Yet, important inequalities exist, wherein networks and individual relationships within networks are not equally able to adapt to such changes. For example, individuals with a large number of newly established relationships (eg, university students) may have struggled to transfer these relationships online, resulting in lost contacts and a heightened risk of social isolation. This is consistent with research suggesting that young adults were the most likely to report a worsening of relationships during COVID-19, whereas older adults were the least likely to report a change. 8

Lastly, social connections give rise to emergent properties of social systems, 9 where a community-level phenomenon develops that cannot be attributed to any one member or portion of the network. For example, local area-based networks emerged due to geographic restrictions (eg, stay-at-home orders), resulting in increases in neighbourly support and local volunteering. 10 In fact, research suggests that relationships with neighbours displayed the largest net gain in ratings of relationship quality compared with a range of relationship types (eg, partner, colleague, friend). 8 Much of this was built from spontaneous individual interactions within local communities, which together contributed to the ‘community spirit’ that many experienced. 11 COVID-19 restrictions thus impacted the personal social networks and the structure of the larger networks within the society.

Social support

Social support, referring to the psychological and material resources provided through social interaction, is a critical mechanism through which social relationships benefit health. In fact, social support has been shown to be one of the most important resilience factors in the aftermath of stressful events. 12 In the context of COVID-19, the usual ways in which individuals interact and obtain social support have been severely disrupted.

One such disruption has been to opportunities for spontaneous social interactions. For example, conversations with colleagues in a break room offer an opportunity for socialising beyond one’s core social network, and these peripheral conversations can provide a form of social support. 13 14 A chance conversation may lead to advice helpful to coping with situations or seeking formal help. Thus, the absence of these spontaneous interactions may mean the reduction of indirect support-seeking opportunities. While direct support-seeking behaviour is more effective at eliciting support, it also requires significantly more effort and may be perceived as forceful and burdensome. 15 The shift to homeworking and closure of community venues reduced the number of opportunities for these spontaneous interactions to occur, and has, second, focused them locally. Consequently, individuals whose core networks are located elsewhere, or who live in communities where spontaneous interaction is less likely, have less opportunity to benefit from spontaneous in-person supportive interactions.

However, alongside this disruption, new opportunities to interact and obtain social support have arisen. The surge in community social support during the initial lockdown mirrored that often seen in response to adverse events (eg, natural disasters 16 ). COVID-19 restrictions that confined individuals to their local area also compelled them to focus their in-person efforts locally. Commentators on the initial lockdown in the UK remarked on extraordinary acts of generosity between individuals who belonged to the same community but were unknown to each other. However, research on adverse events also tells us that such community support is not necessarily maintained in the longer term. 16

Meanwhile, online forms of social support are not bound by geography, thus enabling interactions and social support to be received from a wider network of people. Formal online social support spaces (eg, support groups) existed well before COVID-19, but have vastly increased since. While online interactions can increase perceived social support, it is unclear whether remote communication technologies provide an effective substitute from in-person interaction during periods of social distancing. 17 18 It makes intuitive sense that the usefulness of online social support will vary by the type of support offered, degree of social interaction and ‘online communication skills’ of those taking part. Youth workers, for instance, have struggled to keep vulnerable youth engaged in online youth clubs, 19 despite others finding a positive association between amount of digital technology used by individuals during lockdown and perceived social support. 20 Other research has found that more frequent face-to-face contact and phone/video contact both related to lower levels of depression during the time period of March to August 2020, but the negative effect of a lack of contact was greater for those with higher levels of usual sociability. 21 Relatedly, important inequalities in social support exist, such that individuals who occupy more socially disadvantaged positions in society (eg, low socioeconomic status, older people) tend to have less access to social support, 22 potentially exacerbated by COVID-19.

Social and interactional norms

Interactional norms are key relational mechanisms which build trust, belonging and identity within and across groups in a system. Individuals in groups and societies apply meaning by ‘approving, arranging and redefining’ symbols of interaction. 23 A handshake, for instance, is a powerful symbol of trust and equality. Depending on context, not shaking hands may symbolise a failure to extend friendship, or a failure to reach agreement. The norms governing these symbols represent shared values and identity; and mutual understanding of these symbols enables individuals to achieve orderly interactions, establish supportive relationship accountability and connect socially. 24 25

Physical distancing measures to contain the spread of COVID-19 radically altered these norms of interaction, particularly those used to convey trust, affinity, empathy and respect (eg, hugging, physical comforting). 26 As epidemic waves rose and fell, the work to negotiate these norms required intense cognitive effort; previously taken-for-granted interactions were re-examined, factoring in current restriction levels, own and (assumed) others’ vulnerability and tolerance of risk. This created awkwardness, and uncertainty, for example, around how to bring closure to an in-person interaction or convey warmth. The instability in scripted ways of interacting created particular strain for individuals who already struggled to encode and decode interactions with others (eg, those who are deaf or have autism spectrum disorder); difficulties often intensified by mask wearing. 27

Large social gatherings—for example, weddings, school assemblies, sporting events—also present key opportunities for affirming and assimilating interactional norms, building cohesion and shared identity and facilitating cooperation across social groups. 28 Online ‘equivalents’ do not easily support ‘social-bonding’ activities such as singing and dancing, and rarely enable chance/spontaneous one-on-one conversations with peripheral/weaker network ties (see the Social networks section) which can help strengthen bonds across a larger network. The loss of large gatherings to celebrate rites of passage (eg, bar mitzvah, weddings) has additional relational costs since these events are performed by and for communities to reinforce belonging, and to assist in transitioning to new phases of life. 29 The loss of interaction with diverse others via community and large group gatherings also reduces intergroup contact, which may then tend towards more prejudiced outgroup attitudes. While online interaction can go some way to mimicking these interaction norms, there are key differences. A sense of anonymity, and lack of in-person emotional cues, tends to support norms of polarisation and aggression in expressing differences of opinion online. And while online platforms have potential to provide intergroup contact, the tendency of much social media to form homogeneous ‘echo chambers’ can serve to further reduce intergroup contact. 30 31

Intimacy relates to the feeling of emotional connection and closeness with other human beings. Emotional connection, through romantic, friendship or familial relationships, fulfils a basic human need 32 and strongly benefits health, including reduced stress levels, improved mental health, lowered blood pressure and reduced risk of heart disease. 32 33 Intimacy can be fostered through familiarity, feeling understood and feeling accepted by close others. 34

Intimacy via companionship and closeness is fundamental to mental well-being. Positively, the COVID-19 pandemic has offered opportunities for individuals to (re)connect and (re)strengthen close relationships within their household via quality time together, following closure of many usual external social activities. Research suggests that the first full UK lockdown period led to a net gain in the quality of steady relationships at a population level, 35 but amplified existing inequalities in relationship quality. 35 36 For some in single-person households, the absence of a companion became more conspicuous, leading to feelings of loneliness and lower mental well-being. 37 38 Additional pandemic-related relational strain 39 40 resulted, for some, in the initiation or intensification of domestic abuse. 41 42

Physical touch is another key aspect of intimacy, a fundamental human need crucial in maintaining and developing intimacy within close relationships. 34 Restrictions on social interactions severely restricted the number and range of people with whom physical affection was possible. The reduction in opportunity to give and receive affectionate physical touch was not experienced equally. Many of those living alone found themselves completely without physical contact for extended periods. The deprivation of physical touch is evidenced to take a heavy emotional toll. 43 Even in future, once physical expressions of affection can resume, new levels of anxiety over germs may introduce hesitancy into previously fluent blending of physical and verbal intimate social connections. 44

The pandemic also led to shifts in practices and norms around sexual relationship building and maintenance, as individuals adapted and sought alternative ways of enacting sexual intimacy. This too is important, given that intimate sexual activity has known benefits for health. 45 46 Given that social restrictions hinged on reducing household mixing, possibilities for partnered sexual activity were primarily guided by living arrangements. While those in cohabiting relationships could potentially continue as before, those who were single or in non-cohabiting relationships generally had restricted opportunities to maintain their sexual relationships. Pornography consumption and digital partners were reported to increase since lockdown. 47 However, online interactions are qualitatively different from in-person interactions and do not provide the same opportunities for physical intimacy.

Recommendations and conclusions

In the sections above we have outlined the ways in which COVID-19 has impacted social relationships, showing how relational mechanisms key to health have been undermined. While some of the damage might well self-repair after the pandemic, there are opportunities inherent in deliberative efforts to build back in ways that facilitate greater resilience in social and community relationships. We conclude by making three recommendations: one regarding public health responses to the pandemic; and two regarding social recovery.

Recommendation 1: explicitly count the relational cost of public health policies to control the pandemic

Effective handling of a pandemic recognises that social, economic and health concerns are intricately interwoven. It is clear that future research and policy attention must focus on the social consequences. As described above, policies which restrict physical mixing across households carry heavy and unequal relational costs. These include for individuals (eg, loss of intimate touch), dyads (eg, loss of warmth, comfort), networks (eg, restricted access to support) and communities (eg, loss of cohesion and identity). Such costs—and their unequal impact—should not be ignored in short-term efforts to control an epidemic. Some public health responses—restrictions on international holiday travel and highly efficient test and trace systems—have relatively small relational costs and should be prioritised. At a national level, an earlier move to proportionate restrictions, and investment in effective test and trace systems, may help prevent escalation of spread to the point where a national lockdown or tight restrictions became an inevitability. Where policies with relational costs are unavoidable, close attention should be paid to the unequal relational impact for those whose personal circumstances differ from normative assumptions of two adult families. This includes consideration of whether expectations are fair (eg, for those who live alone), whether restrictions on social events are equitable across age group, religious/ethnic groupings and social class, and also to ensure that the language promoted by such policies (eg, households; families) is not exclusionary. 48 49 Forethought to unequal impacts on social relationships should thus be integral to the work of epidemic preparedness teams.

Recommendation 2: intelligently balance online and offline ways of relating

A key ingredient for well-being is ‘getting together’ in a physical sense. This is fundamental to a human need for intimate touch, physical comfort, reinforcing interactional norms and providing practical support. Emerging evidence suggests that online ways of relating cannot simply replace physical interactions. But online interaction has many benefits and for some it offers connections that did not exist previously. In particular, online platforms provide new forms of support for those unable to access offline services because of mobility issues (eg, older people) or because they are geographically isolated from their support community (eg, lesbian, gay, bisexual, transgender and queer (LGBTQ) youth). Ultimately, multiple forms of online and offline social interactions are required to meet the needs of varying groups of people (eg, LGBTQ, older people). Future research and practice should aim to establish ways of using offline and online support in complementary and even synergistic ways, rather than veering between them as social restrictions expand and contract. Intelligent balancing of online and offline ways of relating also pertains to future policies on home and flexible working. A decision to switch to wholesale or obligatory homeworking should consider the risk to relational ‘group properties’ of the workplace community and their impact on employees’ well-being, focusing in particular on unequal impacts (eg, new vs established employees). Intelligent blending of online and in-person working is required to achieve flexibility while also nurturing supportive networks at work. Intelligent balance also implies strategies to build digital literacy and minimise digital exclusion, as well as coproducing solutions with intended beneficiaries.

Recommendation 3: build stronger and sustainable localised communities

In balancing offline and online ways of interacting, there is opportunity to capitalise on the potential for more localised, coherent communities due to scaled-down travel, homeworking and local focus that will ideally continue after restrictions end. There are potential economic benefits after the pandemic, such as increased trade as home workers use local resources (eg, coffee shops), but also relational benefits from stronger relationships around the orbit of the home and neighbourhood. Experience from previous crises shows that community volunteer efforts generated early on will wane over time in the absence of deliberate work to maintain them. Adequately funded partnerships between local government, third sector and community groups are required to sustain community assets that began as a direct response to the pandemic. Such partnerships could work to secure green spaces and indoor (non-commercial) meeting spaces that promote community interaction. Green spaces in particular provide a triple benefit in encouraging physical activity and mental health, as well as facilitating social bonding. 50 In building local communities, small community networks—that allow for diversity and break down ingroup/outgroup views—may be more helpful than the concept of ‘support bubbles’, which are exclusionary and less sustainable in the longer term. Rigorously designed intervention and evaluation—taking a systems approach—will be crucial in ensuring scale-up and sustainability.

The dramatic change to social interaction necessitated by efforts to control the spread of COVID-19 created stark challenges but also opportunities. Our essay highlights opportunities for learning, both to ensure the equity and humanity of physical restrictions, and to sustain the salutogenic effects of social relationships going forward. The starting point for capitalising on this learning is recognition of the disruption to relational mechanisms as a key part of the socioeconomic and health impact of the pandemic. In recovery planning, a general rule is that what is good for decreasing health inequalities (such as expanding social protection and public services and pursuing green inclusive growth strategies) 4 will also benefit relationships and safeguard relational mechanisms for future generations. Putting this into action will require political will.

Ethics statements

Patient consent for publication.

Not required.

  • Office for National Statistics (ONS)
  • Ford T , et al
  • Riordan R ,
  • Ford J , et al
  • Glonti K , et al
  • McPherson JM ,
  • Smith-Lovin L
  • Granovetter MS
  • Fancourt D et al
  • Stadtfeld C
  • Office for Civil Society
  • Cook J et al
  • Rodriguez-Llanes JM ,
  • Guha-Sapir D
  • Patulny R et al
  • Granovetter M
  • Winkeler M ,
  • Filipp S-H ,
  • Kaniasty K ,
  • de Terte I ,
  • Guilaran J , et al
  • Wright KB ,
  • Martin J et al
  • Gabbiadini A ,
  • Baldissarri C ,
  • Durante F , et al
  • Sommerlad A ,
  • Marston L ,
  • Huntley J , et al
  • Turner RJ ,
  • Bicchieri C
  • Brennan G et al
  • Watson-Jones RE ,
  • Amichai-Hamburger Y ,
  • McKenna KYA
  • Page-Gould E ,
  • Aron A , et al
  • Pietromonaco PR ,
  • Timmerman GM
  • Bradbury-Jones C ,
  • Mikocka-Walus A ,
  • Klas A , et al
  • Marshall L ,
  • Steptoe A ,
  • Stanley SM ,
  • Campbell AM
  • ↵ (ONS), O.f.N.S., Domestic abuse during the coronavirus (COVID-19) pandemic, England and Wales . Available: https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/articles/domesticabuseduringthecoronaviruscovid19pandemicenglandandwales/november2020
  • Rosenberg M ,
  • Hensel D , et al
  • Banerjee D ,
  • Bruner DW , et al
  • Bavel JJV ,
  • Baicker K ,
  • Boggio PS , et al
  • van Barneveld K ,
  • Quinlan M ,
  • Kriesler P , et al
  • Mitchell R ,
  • de Vries S , et al

Twitter @karenmaxSPHSU, @Mark_McCann, @Rwilsonlowe, @KMitchinGlasgow

Contributors EL and KM led on the manuscript conceptualisation, review and editing. SP, KM, CB, RBP, RL, MM, JR, KS and RW-L contributed to drafting and revising the article. All authors assisted in revising the final draft.

Funding The research reported in this publication was supported by the Medical Research Council (MC_UU_00022/1, MC_UU_00022/3) and the Chief Scientist Office (SPHSU11, SPHSU14). EL is also supported by MRC Skills Development Fellowship Award (MR/S015078/1). KS and MM are also supported by a Medical Research Council Strategic Award (MC_PC_13027).

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Read the full text or download the PDF:

Coronavirus disease 2019 (COVID-19): A literature review


  • 1 Medical Research Unit, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia; Tropical Disease Centre, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia; Department of Microbiology, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia. Electronic address: [email protected].
  • 2 Division of Infectious Diseases, AichiCancer Center Hospital, Chikusa-ku Nagoya, Japan. Electronic address: [email protected].
  • 3 Department of Family Medicine, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia. Electronic address: [email protected].
  • 4 Department of Pulmonology and Respiratory Medicine, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia. Electronic address: [email protected].
  • 5 School of Medicine, The University of Western Australia, Perth, Australia. Electronic address: [email protected].
  • 6 Siem Reap Provincial Health Department, Ministry of Health, Siem Reap, Cambodia. Electronic address: [email protected].
  • 7 Department of Microbiology and Parasitology, Faculty of Medicine and Health Sciences, Warmadewa University, Denpasar, Indonesia; Department of Medical Microbiology and Immunology, University of California, Davis, CA, USA. Electronic address: [email protected].
  • 8 Medical Research Unit, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia; Tropical Disease Centre, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia; Department of Microbiology, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia; Department of Clinical Microbiology, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia. Electronic address: [email protected].
  • 9 Department of Epidemiology, University of Michigan, Ann Arbor, Michigan, MI 48109, USA. Electronic address: [email protected].
  • 10 Medical Research Unit, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia; Tropical Disease Centre, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia; Department of Microbiology, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia. Electronic address: [email protected].
  • PMID: 32340833
  • PMCID: PMC7142680
  • DOI: 10.1016/j.jiph.2020.03.019

In early December 2019, an outbreak of coronavirus disease 2019 (COVID-19), caused by a novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), occurred in Wuhan City, Hubei Province, China. On January 30, 2020 the World Health Organization declared the outbreak as a Public Health Emergency of International Concern. As of February 14, 2020, 49,053 laboratory-confirmed and 1,381 deaths have been reported globally. Perceived risk of acquiring disease has led many governments to institute a variety of control measures. We conducted a literature review of publicly available information to summarize knowledge about the pathogen and the current epidemic. In this literature review, the causative agent, pathogenesis and immune responses, epidemiology, diagnosis, treatment and management of the disease, control and preventions strategies are all reviewed.

Keywords: 2019-nCoV; COVID-19; Novel coronavirus; Outbreak; SARS-CoV-2.

Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.

Publication types

  • Betacoronavirus
  • Clinical Trials as Topic
  • Coronavirus Infections* / epidemiology
  • Coronavirus Infections* / immunology
  • Coronavirus Infections* / therapy
  • Coronavirus Infections* / virology
  • Disease Outbreaks* / prevention & control
  • Pneumonia, Viral* / epidemiology
  • Pneumonia, Viral* / immunology
  • Pneumonia, Viral* / therapy
  • Pneumonia, Viral* / virology

Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here .

Loading metrics

Open Access


Research Article

The impact of COVID-19 pandemic on physical and mental health of Asians: A study of seven middle-income countries in Asia

Roles Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

Affiliation Institute of Cognitive Neuroscience, Faculty of Education, Huaibei Normal University, Huaibei, China

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Validation, Visualization, Writing – original draft, Writing – review & editing

Affiliation College of Medicine, University of the Philippines, Manila, Philippines

Roles Conceptualization, Supervision, Visualization

Affiliation University Malaysia Sarawak (UNIMAS), Sarawak, Malaysia

ORCID logo

Roles Conceptualization, Methodology, Supervision, Visualization, Writing – original draft, Writing – review & editing

Affiliation Department of Psychology, Zahedan Branch, Islamic Azad University, Zahedan, Iran

Roles Conceptualization, Investigation, Methodology, Supervision, Visualization

Affiliation College of Public Health Sciences, Chulalongkorn University, a member of Thailand One Health University Network (THOHUN), Bangkok, Thailand

Roles Conceptualization, Investigation, Methodology, Supervision, Visualization, Writing – original draft, Writing – review & editing

Affiliation Institute of Clinical Psychology, University of Karachi, Karachi, Pakistan

Affiliations Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States of America

Roles Formal analysis, Investigation, Methodology, Supervision, Validation

Affiliation DHQ Hospital Jhelum, Jhelum, Pakistan

Roles Formal analysis, Investigation, Methodology, Supervision

Affiliation Institute for Global Health Innovations, Duy Tan University, Da Nang, Vietnam

Roles Investigation, Methodology, Project administration, Supervision, Validation

Affiliation Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam

Roles Data curation, Investigation, Methodology, Project administration, Supervision, Validation

Roles Investigation, Methodology, Supervision, Validation

Affiliation Faculty of Medicine, Duy Tan University, Da Nang, Vietnam

Roles Data curation, Investigation, Methodology, Supervision, Validation

Affiliation Department of Psychology, University of Sistan and Baluchestan, Zahedan, Iran

Affiliation Center of Excellence in Evidence-based Medicine, Nguyen Tat Thanh University, Ho Chi Minh City, Vietnam

Roles Data curation, Project administration, Validation

Affiliation Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore

Roles Formal analysis, Writing – original draft, Writing – review & editing

Affiliation Mood Disorders Psychopharmacology Unit, University Health Network, University of Toronto, Toronto, Canada

Roles Formal analysis, Validation, Writing – original draft, Writing – review & editing

Affiliation Department of Psychological Medicine, National University Health System, Singapore, Singapore

Roles Conceptualization, Formal analysis, Funding acquisition, Project administration, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Institute for Health Innovation and Technology (iHealthtech), Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore

  •  [ ... ],

Roles Conceptualization, Investigation, Methodology, Supervision, Validation, Writing – original draft, Writing – review & editing

Affiliation Southeast Asia One Health University Network (SEAOHUN), Chiang Mai, Thailand

  • [ view all ]
  • [ view less ]
  • Cuiyan Wang, 
  • Michael Tee, 
  • Ashley Edward Roy, 
  • Mohammad A. Fardin, 
  • Wandee Srichokchatchawan, 
  • Hina A. Habib, 
  • Bach X. Tran, 
  • Shahzad Hussain, 
  • Men T. Hoang, 


  • Published: February 11, 2021
  • https://doi.org/10.1371/journal.pone.0246824
  • Reader Comments

Fig 1

The coronavirus disease (COVID-19) pandemic has impacted the economy, livelihood, and physical and mental well-being of people worldwide. This study aimed to compare the mental health status during the pandemic in the general population of seven middle income countries (MICs) in Asia (China, Iran, Malaysia, Pakistan, Philippines, Thailand, and Vietnam). All the countries used the Impact of Event Scale–Revised (IES-R) and Depression, Anxiety and Stress Scale (DASS-21) to measure mental health. There were 4479 Asians completed the questionnaire with demographic characteristics, physical symptoms and health service utilization, contact history, knowledge and concern, precautionary measure, and rated their mental health with the IES-R and DASS-21. Descriptive statistics, One-Way analysis of variance (ANOVA), and linear regression were used to identify protective and risk factors associated with mental health parameters. There were significant differences in IES-R and DASS-21 scores between 7 MICs (p<0.05). Thailand had all the highest scores of IES-R, DASS-21 stress, anxiety, and depression scores whereas Vietnam had all the lowest scores. The risk factors for adverse mental health during the COVID-19 pandemic include age <30 years, high education background, single and separated status, discrimination by other countries and contact with people with COVID-19 (p<0.05). The protective factors for mental health include male gender, staying with children or more than 6 people in the same household, employment, confidence in doctors, high perceived likelihood of survival, and spending less time on health information (p<0.05). This comparative study among 7 MICs enhanced the understanding of metal health in the general population during the COVID-19 pandemic.

Citation: Wang C, Tee M, Roy AE, Fardin MA, Srichokchatchawan W, Habib HA, et al. (2021) The impact of COVID-19 pandemic on physical and mental health of Asians: A study of seven middle-income countries in Asia. PLoS ONE 16(2): e0246824. https://doi.org/10.1371/journal.pone.0246824

Editor: Tauqeer Hussain Mallhi, Jouf University, Kingdom of Saudi Arabia, SAUDI ARABIA

Received: October 17, 2020; Accepted: January 27, 2021; Published: February 11, 2021

Copyright: © 2021 Wang et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting Information files.

Funding: This study has the following funding sources: 1. Author C.W, 1 grant, Huaibei Normal University, China. 2. Author R.H, 1 grant, National University of Singapore iHealthtech Other Operating Expenses (R-722-000-004-731) 3. Author B.X.T, 1 grant, Vingroup Innovation Foundation (VINIF) COVID research grant (VINIF.2020.Covid19.DA07) in Vietnam

Competing interests: The authors have declared that no competing interests exist.


Emerging psychiatric conditions and mental well-being were identified as the tenth most frequent research topic during the COVID-19 pandemic [ 1 ]. A recent systematic review found that relatively high rates of symptoms of anxiety, depression, post-traumatic stress disorder and stress were reported in the general population and health care professionals during the COVID-19 pandemic globally [ 2 , 3 ]. Asia has a number of middle income countries (MICs) that face tremendous economic challenges and limited medical resources to maintain physical and mental well-being during the pandemic [ 4 ]. This extended to North America as well, with the sudden change in economic security during COVID-19 projected to increase suicide rates [ 5 ]. During the pandemic, the Asia Pacific Disaster Mental Health Network recommended to establish a mental health agenda for Asia [ 6 ]. It is therefore important to conduct research to assess psychiatric status of Asians living in MICs to develop capacity of various health systems to respond to COVID-19. Previous studies mainly focused on mental health of individual Asian countries during the pandemic without cross comparison [ 7 – 9 ].

With no prior comparative study found on physical and mental health of Asians living in MICs during the COVID-19 pandemic, this study aimed to investigate the impact of the pandemic on physical and mental health in 7 Asian MICs (China, Iran, Malaysia, Pakistan, Philippines, Thailand and Vietnam), identify differences among countries, understand their concerns and precautions toward COVID-19, as well as to identify protective and risk factors associated with mental health outcomes.


Study design and study population.

This was a cross-sectional study that involved seven countries. The recruitment was conducted after COVID-19 became an epidemic in each country. To minimize risks of COVID-19 infection, a respondent-driven sampling strategy on recruiting the general public was utilized where new participants were electronically invited by existing study respondents rather than face-to-face interaction. The respondents completed the questionnaires through an online survey platform (‘SurveyStar’, Changsha Ranxing Science and Technology in China, SurveyMonkey in Philippines, and Google Forms in other countries).

Ethics approval

The study was approved by the Institutional Review Boards from each MIC, China (Huaibei Normal University of China, HBU-IRB-2020-001/002), Iran (Islamic Azad University, Protocol Number: IRB-2020-001), Malaysia (Universiti Malaysia Sarawak, UNIMAS/NC-21.02/03-02 Jld.4 (85)), Pakistan (University of Karachi Protocol Number: ICP-1 (101) 2698), Philippines (University of Philippines Manila Research Ethics Board, UPMREB 2020-198-01), Thailand (Chulalongkorn University, COA No. 147/2563), and Vietnam (Hanoi Medical University, QD 75/QD-YHDP&YHDP). All IRBs allowed participants aged 12 years to 17 years to participate in this study and provide their own consent because the online survey did not pose any risk to research participants. All respondents provided informed consent. Confidentiality was maintained because no personally identifiable information was collected.

Measures and instruments

The COVID-19 online questionnaire designed by the National University of Singapore [ 10 ] had five sections: demographic, physical symptoms related to COVID-19 in the past 14 days, knowledge and concerns about COVID-19, precautionary measures against COVID, and views of health information required. Psychometric properties of the questionnaire were established in the initial phase and peak of the COVID-19 epidemic [ 8 , 9 ].

The psychological impact of COVID-19 was measured using the well-validated Impact of Event Scale-Revised (IES-R) in the Asians for determining the extent of psychological impact after exposure to a traumatic event (i.e., the COVID-19 pandemic) within one week of exposure [ 11 – 14 ]. In this study, the Cronbach’s alpha for different versions of IES-R is very high in all countries and ranges from 0.912–0.950. Cronbach’s alpha of 0.70 or higher in measuring the internal consistency is considered “acceptable” in most social science research [ 15 ].

The mental health status of respondents was measured using the Depression, Anxiety and Stress Scale (DASS-21) [ 16 ], which has been used to assess mental health in Asians [ 17 , 18 ]. Furthermore, DASS-21 assessed three domains (i.e. anxiety, depression and stress) and its psychometric properties was validated across clinical and non-clinical samples in different cultures and languages during the COVID-19 pandemic [ 19 ]. In this study, the Cronbach’s alpha (internal consistency) for different versions of DASS-21 is as follows: stress scale ranges from 0.839–0.934, anxiety scale ranges from 0.784–0.914, and depression scale ranges from 0.878–0.943. The IES-R and DASS-21 scales were previously used in research related to the COVID-19 epidemic [ 8 , 12 , 20 , 21 ]. The DASS and IES-R questionnaires are available in the public domain, and so permission is not required to use these two questionnaires [ 22 , 23 ].

Statistical analysis

Descriptive statistics were calculated to compare demographic characteristics, physical symptoms and health service utilization, contact history, knowledge and concern, precautionary measure and additional health information variables among 7 MICs. One-Way analysis of variance (ANOVA) was calculated to compare the mean IES-R and DASS-21 scores between 7 MICs in order to determine whether the associated population mean IES-R or DASS-21 scores were significantly different. If there were significant differences among 7 MICs, the Least Significant Difference (LSD) would calculate the smallest significant between mean scores of two countries with different combinations. Any difference larger than the LSD is considered a significant result. We used linear regressions to calculate the univariate associations between independent and dependent variables including the IES-S score and DASS-21 stress, anxiety and depression subscale scores for all respondents separately. All tests were two-tailed, with a significance level of p <0.05. Statistical analysis was performed on IBM SPSS Statistics version 21.0.

A total of 4479 participants from 7 MICs in Asia completed the survey. The distribution of the number of participants by country is listed as follows: China (27%), Philippines (19%), Malaysia (16.2%), Iran (12.3%), Thailand (11.6%), Pakistan (11.3%), and Vietnam (2.7%). Fig 1 compares the IES-R and DASS-21 scores amongst all 7 MICs in Asia.


  • PPT PowerPoint slide
  • PNG larger image
  • TIFF original image


The top three countries with highest IES-R scores were Thailand (mean 42.35, SD 13.39), China (mean 32.98, SD 15.42), and Iran (mean 30.42, SD 15.82). The top three countries with highest DASS-21 stress scores were Thailand (mean 21.94, SD 7.74), Pakistan (mean 14.02, SD 11.53) and Philippines (mean 10.60, SD 8.01). The top three countries with highest DASS-21 anxiety scores were Thailand (mean 18.66, SD 5.98), Pakistan (mean 8.23, SD 9.69) and Malaysia (mean 7.80, SD 10.95). The top three countries with highest DASS-21 depression scores were Thailand (mean 19.74, SD 6.99), Pakistan (mean 11.33, SD 11.28) and Philippines (mean 9.72, SD 8.99).

Differences in IES-R scores and DASS-21 stress, anxiety, depression scores amongst the 7 MICs were all statistically significant (IES-R: F(6, 4472) = 144.47, p<0.001, η2 = 0.16; Stress: F(6,4472) = 167.49 p<0.001, η2 = 0.18; Anxiety: F (6,4471) = 172.03, p<0.001, η2 = 0.19; Depression: F(6, 4472) = 137.11, p<0.001, η2 = 0.16). Vietnam had the lowest scores of IES-R (mean 17.39, SD 13.72), stress (mean 3.80, SD 5.81), anxiety (mean 2.10, SD 4.91) and depression (mean 2.28, SD 5.43). The LSD analysis revealed that the scores of Vietnam were significantly lower than the other countries (p<0.05).

S1 Table compares the demographics of 7 MICs. More than half of participants were women in all countries (Range: 52.6% in Pakistan to 76.8% in Thailand). More than half of Chinese, Filipino, Iranian and Pakistani participants were below age of 31 years. Majority of Chinese, Vietnamese and Malaysian respondents were married while majority of Filipino and Thai respondents were single. Majority of Filipino, Iranian, Pakistani, Malaysian and Thai respondents did not have children. More than half of participants stayed in a household with more than 3–5 people across all countries except Pakistan (49%). Majority of respondents from Philippines, Pakistan, Vietnam and Malaysia were employed when the study was conducted.

Table 1 shows the association between demographic characteristics of all participants and mental health parameters. Demographic characteristics associated with lower psychological impact were male gender whereas age younger than 30 years and students were associated with higher psychological impact. Participants who have children were associated with lower stress, anxiety and depression whereas participants with higher education, single and separated status were associated with higher stress, anxiety and depression. Staying with 6 or more people and those who were employed were associated with lower anxiety and depression.



S2 Table shows the frequency of physical symptoms that resemble COVID-19 infection and there were significant differences among all countries. During the COVID-19 pandemic, the most common physical symptoms reported by general population in the 7 countries were headache (23.13%), cough (21.86%) and sore throat (19.29%). About 8.13% of respondents consulted General Practitioner (GP); 2.69% were hospitalized; 3.89% were tested positive for COVID-19 and 57.1% had a health insurance. Pakistani had the significantly highest proportion of respondents consulted GP (27.5%), hospitalized (16.4%), receiving COVID-19 test (17.2%) and being isolated (17.8%). Table 2 shows the association between physical symptoms and mental health outcomes. The physical symptoms that were significantly associated with higher scores in all mental health outcomes (IES-R and DASS-21 subscales) including rhinitis and persistent fever with cough or breathing difficulties. Chills or rigors, headache and nausea or vomiting were associated with higher DASS-21 stress and anxiety scores. Myalgia, cough, dizziness and sore throat were associated with higher score of IES-R. Usage of medical services such as seeing a doctor, hospitalization, recent COVID-19 testing, quarantine, poor rating of health status that were significantly associated with higher scores in all mental health outcomes (IES-R and DASS-21 subscales). History of chronic illness were significantly associated with higher DASS-21 subscale scores. Having medical insurance coverage was associated with higher IES-R scores.



S3 Table shows the belief of route of transmission among participants in 7 MICs and there were significant differences among all countries. Out of all participants, there were a small number of participants who did not agree with transmission of COVID-19 being via droplets (10.34%) and contaminated objects (17.21%). It is interesting to note that China (60.5%) and Vietnam (59.8%) demonstrated significantly higher percentage of participants who believed in airborne transmission compared to .64.76% of participants from the other five countries who did not agree that COVID-19 was airborne transmitted.

Participants expressing confident and very confident in their doctors diagnosing COVID-19 were very high in Malaysia (93.8%) and China (92.9%); level of confidence was much lower in Iran (65.5%) and Pakistan (62.6%). About 50.26% of participants reported that they were likely and very likely to contract COVID-19, with Malaysian participants demonstrating the highest perceived risk of COVID-19 (72.8%) whilst the Filipino demonstrated the highest proportion of participants believing that they would not contract COVID-19 (53.2%). About 89.8% of Thai participants believed that they would survive if contracted with COVID-19 while the Pakistani had the highest proportion who believed that they would not survive COVID-19 (15.4%). About 78.43% of participants were satisfied with health information related to COVID-19; Vietnamese participants reported the highest proportion of satisfaction (97.5%). About 77.38% of participants were worried their family members contracting COVID-19. Pakistani participants reported the highest proportion of people who faced discrimination (42.7%). About 44.68% of participants spent more than 2 hours per day to view information on COVID-19 with Filipino participants having the highest proportion for spending more than 2 hours per day to view information (47.2%).

Table 3 shows the association between knowledge and concerns related to COVID-19 and mental health parameters. Agreement with airborne, contact with contaminated objects and droplet transmission was associated with higher DASS-21 in all subscales. Likelihood of contracting COVID-19, discrimination against by other countries and contact with people infected with COVID-19 were associated with higher IES-R or DASS-21 scores. Confidence in one’s own doctor diagnosing COVID-19, high likelihood of survival if infected with COVID-19 and spent less than two hours per day to monitor information relating to COVID-19 were associated with lower level of IES-R or DASS-21 scores.



S4 Table shows the prevalence of precautionary measures and there were significant differences among 7 MICs (p<0.001). High percentages were reported by participants covering their mouth and nose after sneezing (98.0%), avoided sharing utensils (90.8%), practised hand hygiene (98.9%), washed hand after touching contaminated objects (96.2%), and wear face masks (93.5%). All Vietnamese participants (100%) responded wearing a face mask. About 68% of respondents felt that people were too worried about COVID-19 with Malaysia (90.5%), Thailand (90.5%) and Pakistan (86.6%) as the top three countries. Approximately 53% of respondents spent 20–24 hours per day at home; with China (84.7%), Iran (73.5%) and Philippines (55%) as the top three countries.

Table 4 shows the association between precautionary measures related to COVID-19 and mental health parameters. Avoidance of sharing cutlery dealing meals was associated with higher anxiety and depression. In contrast, hand hygiene practice was associated with lower IES-R and DASS-21 in all subscales. Wearing a face mask was associated with lower levels of stress and depression. Worries about COVID-19 was associated with significantly higher levels of DASS-21 in all subscales. Shorter duration of homestay was associated with higher levels of anxiety, depression and stress as compared to those who stayed at home for 20–24 hours per day.



S5 Table compares the health information needs of participants from 7 MICs and there were significant differences among 7 MICs. The Chinese had the highest proportion who wanted to understand the symptoms of COVID-19 (91.6%), the prevention method (93.7%), effectiveness of drugs and vaccines (94.1%), number of infected cases and location (95.9%), travel advice (96.9%), mode of transmission (94.5%), required regular information update (92.7%) and personalized information (96.8%). The Iranians had the highest proportion who sought advices regarding treatment methods (90.4%) and Malaysians had the highest proportion who wanted to understand local outbreaks (94.2%).

Table 5 shows the association between health information needs about COVID-19 and mental health parameters. Most additional information including information on COVID-19 symptoms, prevention, treatment advice, needs for regular updates, knowledge on local transmission, effectiveness on drugs and vaccines, number of infected people based on geographical locations, travel advice and transmission mode of COVID were associated with higher IES-R scores. In contrast, the need for more personalized information, information on the effectiveness of drugs and vaccines, travel advices, transmission mode were associated with significantly lower level of depression.



The main findings of this first multinational population-based study in MICs in Asia during the COVID-19 pandemic are summarized as follows. First, Thai respondents reported the highest levels of IES-R and DASS-21 scores. Second, Pakistani respondents reported the second highest levels of DASS-21 scores. Comparatively, Vietnamese respondents reported the lowest levels in DASS-21 scores. Third, Iranian respondents demonstrated the lowest confidence in their doctors whilst Pakistani respondents had the highest proportion who believed they would not survive COVID-19 and reported discrimination.

Assessing COVID-19’s association with respondents’ mental health, the three most common physical symptoms associated with adverse mental health were headache, cough and sore throat. Risk factors associated with adverse mental health during the COVID-19 pandemic include age <30 years old, high education background, single and separated status, discrimination by other countries, contact with people with COVID-19 and worries about COVID-19. Protective factors for mental health during the COVID-19 pandemic include male gender, staying with children, staying with 6 or more people, employment, confidence in own’s doctors diagnosing COVID-19, high perceived likelihood of surviving COVID-19, spending less time on health information, hand hygiene practice and wearing a face mask. Importantly, these findings will be significantly helpful for healthcare administrators in Asia at the national and local community levels [ 24 ] when preparing for the next wave of COVID-19 outbreak and future pandemics [ 25 ].

Iran had the highest total reported COVID cases (386,658) and number of COVID cases per 1 million people (4,593), as well as the highest number of deaths from COVID (22,293) and deaths per 1 million people (265) [ 26 ]. Pakistan had the second highest number of cases (298,509) and deaths (6,342) [ 26 ]. Of the 7 MICs, Vietnam had the lowest total numbers and rates across all seven countries, with 1,049 reported cases, 35 deaths and rates of just 11 cases and 0.4 deaths per 1 million [ 26 ]. As a result, Vietnamese respondents reported the lowest IES-R and DASS-21 scores. Vietnam has adopted several strategies to combat COVID-19 including development of the action plan and response strategies to optimize the utilization of human resources and equipment [ 24 ]; address the health information needs based on the diverse socioeconomic, demographic, and ethnic factors [ 27 ]; re-design communication activities for a more effective dissemination of information related to the epidemic [ 28 ]; safeguarding the health of workforce [ 29 ] to ensure minimal impact on economy and involvement of the grassroot system and village health collaborators to combat pandemics [ 30 , 31 ].

Thailand recorded the second lowest number of total cases (3,444) and deaths (58), and similarly the second lowest case rates (49) and death rates (0.8) per 1 million [ 26 ]. Surprisingly, we found that Thailand was the country with the highest IES-R and DASS-21 depression scores. This could be due to the impact of COVID-19 on the economy in Thailand. Among all MICs in Asia, the disruption on COVID-19 pandemic is the most severe on Thailand economy, due to its reliance on tourism as compared to other MICs. For 2020, the International Monetary Fund has predicted Thailand’s GDP to be reduced by 6.7 percent which is highest among Asian countries [ 32 ]. Pakistan ranked second in terms of DASS-21 scores and number of COVID cases and deaths. The congruence between psychological parameters and epidemiology of COVID-19 in Pakistan was due to poor sanitation, lack of basic preventive measures, lack of proper testing and medical facilities. Pakistani health professionals started protesting and threatened to quit work due to lack of Personal Protective Equipment (PPE) [ 33 ]. Currently, the vaccination coverage in rural Pakistan remains unsatisfactory amid various barriers including price, hesitancy, and low level of awareness [ 34 ]. Eid-ul-Adha is an annual religious festival that could not be cancelled due to religious obligations and led to a sharp spike in COVID-19 cases [ 35 ]. The unpreparedness and contradictory policies resulted in an alarming high rate of COVID-19 spread and worsening mental health and discrimination faced by Pakistani people. Iranian respondents demonstrated lowest confidence in their doctors. The economic sanctions that prevented medical supplies, equipment and drugs from arriving in Iran could lead to low confidence among Iranians [ 36 ].

This study highlighted unique protective factors for mental health in MICs of Asia. In this study, more than 90% of respondents agreed to wear masks to prevent COVID-19. During the initial stage of COVID-19 pandemic, medical and public health experts from the US and some European countries believed that there was no direct evidence of airborne transmission of COVID-19 [ 37 ]. In contrast, respiratory clinicians and public health experts from Asia argued that lack of evidence does not equate to evidence of ineffectiveness of face masks [ 38 ]. The use of face masks by Asians have played an important role in controlling the spread of COVID-19 [ 39 ]. This study showed the association between the use of face mask and lower DASS-21 anxiety and depression scores. This finding might support the postulation that wearing face mask could offer psychological benefits, such as feeling less vulnerable to infection via perceived control [ 37 ]. Staying with children and more than 6 people in the same household were protective factors due to the values of family support among Asians. Compared with western countries, family support has a greater influence on reducing the risk of adverse mental health in Asia [ 10 ].

The findings of this first multinational study have several implications for health and government policies. Firstly, the health authorities should offer psychological interventions to the general population who are at higher risk of developing adverse mental health including women, people younger than 30 years and single and separated status. High education background is a risk factor and online psychological interventions such as cognitive behaviour therapy (CBT) and mindfulness-based therapy could improve mental health for highly educated individual [ 40 ]. For countries with high IES-R scores (Thailand, China and Iran), online trauma-focused CBT that promotes trauma narration, problem solving related to problems associated with COVID-19 and home based relaxation could be helpful in reducing psychological impact [ 9 ]. Second, as physical symptoms resembling COVID-19 infection (e.g., rhinitis, persistent fever with cough, breathing difficulties) were associated with high IES-R and DASS-21 scores groups. There is an urgent need to develop accurate, rapid diagnostic tests in general practitioners’ clinics, community and rural settings [ 31 ]. A negative COVID-19 test result may alleviate anxiety, depression, stress and psychological impact. Enhancing the capacity of health system to combat COVID-19 may increase the confidence of public and improve mental health. Third, based on our findings, the WHO, governments and health authorities should provide regular updates on the effectiveness of vaccines and treatment methods. Mis-information related to the cause of COVID-19 [ 41 ], rumours [ 42 ] and inconsistent information [ 43 ] on COVID-19 symptoms, prevention, treatment and transmission mode were associated with negative psychological impact. Local governments, news agencies, professional and advocacy organisations should all provide health information and advices related to COVID-19 that are consistent with national guidelines and avoid mis-information [ 44 ]. It is important to identify group-specific demands would be helpful to provide proper information related to COVID-19 to fulfil the need of different population groups [ 27 ]. Various governments should offer relief packages to safeguard employment and economy to protect mental health. Additionally, the level of policy stringency in response to COVID-19 or pandemics, as measured by the Oxford Stringency Index, may influence mental health and should be moderated accordingly by respective governments [ 45 ].

This study has several limitations. First, the findings of this study were based on seven MICs in Asia and could not be generated to other countries. The study population had different sociodemographic characteristics as compared to the general population in the world due to sampling bias because only participants with Internet access could participate in this online survey. The respondent sampling method also compromised the representativeness of samples. The study population was female predominant (proportion of female in the study population: 67.76%; world population 49.58%) [ 46 ] and a high proportion of the study population possessed a university degree (85.6%). Thus, there is a potential risk of sampling bias because we could not reach out to potential respondents without Internet access. The second limitation was the cross-sectional nature of this study and inability to demonstrate cause and effect relationship. The third limitation was that we did not record demographic data regarding pre-existing mental illness of the study participants. The fourth limitation is that self-reported levels of psychological impact, anxiety, depression and stress may not always be aligned with objective assessment by mental health professionals. Nevertheless, psychological impact, anxiety, depression and stress are based on personal feelings, and self-reporting was paramount during the COVID-19 pandemic. The fifth limitation is that we did not study other aspects of the pandemic such as the potential threat of self-medication of hydroxychloroquine and cholorquine [ 47 ] and precautionary measures of walkthrough sanitization gates [ 48 ]. Lastly, we were unable to calculate the response rate. For potential respondents who were not keen to participate in the online survey, no response was recorded, and we could not collect any information from them.


In conclusion, this multi-national study across 7 MICs in Asia showed that Thai reported the highest mean IES-R and DASS-21 anxiety, depression and stress scores. In contrast, Vietnamese reported the lowest mean scores in IES-R and DASS-21 anxiety, depression and stress scales. The risk factors for adverse mental health include age < 30 years, high education background, single and separated status, discrimination by other countries, contact with people with COVID-19 and worries about COVID-19. The protective factors for mental health include male gender, staying with children, staying with 6 or more people, employment, confidence in own’s doctors diagnosing COVID-19, high perceived likelihood of surviving COVID-19, spending less time on health information, hand hygiene practice and wearing a face mask.

Supporting information

S1 table. comparison of demographics of the participants from seven countries..


S2 Table. Physical symptoms resembling COVID-19 infection reported by the participants from seven countries.


S3 Table. Comparison of knowledge related to COVID-19 in participants of the seven countries.


S4 Table. Comparison of precautionary measures related to COVID-19 in the participants of the seven countries.


S5 Table. Comparison of information needs about COVID-19 in the participants of the seven Asian countries.


  • View Article
  • Google Scholar
  • PubMed/NCBI
  • 15. UCLA. What Does Cronbach’s Alpha Mean? 2020 [Available from: https://stats.idre.ucla.edu/spss/faq/what-does-cronbachs-alpha-mean/ .
  • 22. Frequently asked questions Permission to use DASS-21: University of New South Wales; [Available from: http://www2.psy.unsw.edu.au/DASS/DASSFAQ.htm#_3.__How_do_I_get_permission_to_use_ .
  • 23. Impact of Event Scale-Revised: National Health Service; [Available from: https://www.quest.scot.nhs.uk/hc/en-gb/articles/115002862649-Impact-of-Events-Scale-Revised .
  • 26. Worldmeters. COVID Cases Data 2020 2020 [Available from: https://www.worldometers.info/coronavirus/#countries .
  • 32. O.P.IMF. Thai GDP Down 6.7% 2020 [Available from: https://www.bangkokpost.com/business/1900795/imf-thai-gdp-down-6-7 .
  • 36. G. M. Iran Says U.S. Sanctions Blocked Delivery of UK-Made Masks 2020 [Available from: https://www.bloomberg.com/news/articles/2020-03-21/iran-says-u-s-sanctions-blocked-delivery-of-u-k-made-masks .
  • 43. Geddie J SJ. To mask or not to mask: confusion spreads over coronavirus protection: Reuter; 2020 [updated 31 January 2020. Available from: https://uk.reuters.com/article/us-china-health-masks-safety/to-mask-or-not-to-mask-confusion-spreads-over-coronavirus-protection-idUKKBN1ZU0PH .
  • 46. Worldbank. Population, Female (% of Total Population) 2020 [Available from: https://data.worldbank.org/indicator/SP.POP.TOTL.FE.ZS .

The complexity of managing COVID-19: How important is good governance?

  • Download the essay

Subscribe to Global Connection

Alaka m. basu , amb alaka m. basu professor, department of global development - cornell university, senior fellow - united nations foundation kaushik basu , and kaushik basu nonresident senior fellow - global economy and development @kaushikcbasu jose maria u. tapia jmut jose maria u. tapia student - cornell university.

November 17, 2020

  • 13 min read

This essay is part of “ Reimagining the global economy: Building back better in a post-COVID-19 world ,” a collection of 12 essays presenting new ideas to guide policies and shape debates in a post-COVID-19 world.

The COVID-19 pandemic has exposed the inadequacy of public health systems worldwide, casting a shadow that we could not have imagined even a year ago. As the fog of confusion lifts and we begin to understand the rudiments of how the virus behaves, the end of the pandemic is nowhere in sight. The number of cases and the deaths continue to rise. The latter breached the 1 million mark a few weeks ago and it looks likely now that, in terms of severity, this pandemic will surpass the Asian Flu of 1957-58 and the Hong Kong Flu of 1968-69.

Moreover, a parallel problem may well exceed the direct death toll from the virus. We are referring to the growing economic crises globally, and the prospect that these may hit emerging economies especially hard.

The economic fall-out is not entirely the direct outcome of the COVID-19 pandemic but a result of how we have responded to it—what measures governments took and how ordinary people, workers, and firms reacted to the crisis. The government activism to contain the virus that we saw this time exceeds that in previous such crises, which may have dampened the spread of the COVID-19 but has extracted a toll from the economy.

This essay takes stock of the policies adopted by governments in emerging economies, and what effect these governance strategies may have had, and then speculates about what the future is likely to look like and what we may do here on.

Nations that build walls to keep out goods, people and talent will get out-competed by other nations in the product market.

It is becoming clear that the scramble among several emerging economies to imitate and outdo European and North American countries was a mistake. We get a glimpse of this by considering two nations continents apart, the economies of which have been among the hardest hit in the world, namely, Peru and India. During the second quarter of 2020, Peru saw an annual growth of -30.2 percent and India -23.9 percent. From the global Q2 data that have emerged thus far, Peru and India are among the four slowest growing economies in the world. Along with U.K and Tunisia these are the only nations that lost more than 20 percent of their GDP. 1

COVID-19-related mortality statistics, and, in particular, the Crude Mortality Rate (CMR), however imperfect, are the most telling indicator of the comparative scale of the pandemic in different countries. At first glance, from the end of October 2020, Peru, with 1039 COVID-19 deaths per million population looks bad by any standard and much worse than India with 88. Peru’s CMR is currently among the highest reported globally.

However, both Peru and India need to be placed in regional perspective. For reasons that are likely to do with the history of past diseases, there are striking regional differences in the lethality of the virus (Figure 11.1). South America is worse hit than any other world region, and Asia and Africa seem to have got it relatively lightly, in contrast to Europe and America. The stark regional difference cries out for more epidemiological analysis. But even as we await that, these are differences that cannot be ignored.


To understand the effect of policy interventions, it is therefore important to look at how these countries fare within their own regions, which have had similar histories of illnesses and viruses (Figure 11.2). Both Peru and India do much worse than the neighbors with whom they largely share their social, economic, ecological and demographic features. Peru’s COVID-19 mortality rate per million population, or CMR, of 1039 is ahead of the second highest, Brazil at 749, and almost twice that of Argentina at 679.


Similarly, India at 88 compares well with Europe and the U.S., as does virtually all of Asia and Africa, but is doing much worse than its neighbors, with the second worst country in the region, Afghanistan, experiencing less than half the death rate of India.

The official Indian statement that up to 78,000 deaths 2 were averted by the lockdown has been criticized 3 for its assumptions. A more reasonable exercise is to estimate the excess deaths experienced by a country that breaks away from the pattern of its regional neighbors. So, for example, if India had experienced Afghanistan’s COVID-19 mortality rate, it would by now have had 54,112 deaths. And if it had the rate reported by Bangladesh, it would have had 49,950 deaths from COVID-19 today. In other words, more than half its current toll of some 122,099 COVID-19 deaths would have been avoided if it had experienced the same virus hit as its neighbors.

What might explain this outlier experience of COVID-19 CMRs and economic downslide in India and Peru? If the regional background conditions are broadly similar, one is left to ask if it is in fact the policy response that differed markedly and might account for these relatively poor outcomes.

Peru and India have performed poorly in terms of GDP growth rate in Q2 2020 among the countries displayed in Table 2, and given that both these countries are often treated as case studies of strong governance, this draws attention to the fact that there may be a dissonance between strong governance and good governance.

The turnaround for India has been especially surprising, given that until a few years ago it was among the three fastest growing economies in the world. The slowdown began in 2016, though the sharp downturn, sharper than virtually all other countries, occurred after the lockdown.

On the COVID-19 policy front, both India and Peru have become known for what the Oxford University’s COVID Policy Tracker 4 calls the “stringency” of the government’s response to the epidemic. At 8 pm on March 24, 2020, the Indian government announced, with four hours’ notice, a complete nationwide shutdown. Virtually all movement outside the perimeter of one’s home was officially sought to be brought to a standstill. Naturally, as described in several papers, such as that of Ray and Subramanian, 5 this meant that most economic life also came to a sudden standstill, which in turn meant that hundreds of millions of workers in the informal, as well as more marginally formal sectors, lost their livelihoods.

In addition, tens of millions of these workers, being migrant workers in places far-flung from their original homes, also lost their temporary homes and their savings with these lost livelihoods, so that the only safe space that beckoned them was their place of origin in small towns and villages often hundreds of miles away from their places of work.

After a few weeks of precarious living in their migrant destinations, they set off, on foot since trains and buses had been stopped, for these towns and villages, creating a “lockdown and scatter” that spread the virus from the city to the town and the town to the village. Indeed, “lockdown” is a bit of a misnomer for what happened in India, since over 20 million people did exactly the opposite of what one does in a lockdown. Thus India had a strange combination of lockdown some and scatter the rest, like in no other country. They spilled out and scattered in ways they would otherwise not do. It is not surprising that the infection, which was marginally present in rural areas (23 percent in April), now makes up some 54 percent of all cases in India. 6

In Peru too, the lockdown was sudden, nationwide, long drawn out and stringent. 7 Jobs were lost, financial aid was difficult to disburse, migrant workers were forced to return home, and the virus has now spread to all parts of the country with death rates from it surpassing almost every other part of the world.

As an aside, to think about ways of implementing lockdowns that are less stringent and geographically as well as functionally less total, an example from yet another continent is instructive. Ethiopia, with a COVID-19 death rate of 13 per million population seems to have bettered the already relatively low African rate of 31 in Table 1. 8

We hope that human beings will emerge from this crisis more aware of the problems of sustainability.

The way forward

We next move from the immediate crisis to the medium term. Where is the world headed and how should we deal with the new world? Arguably, that two sectors that will emerge larger and stronger in the post-pandemic world are: digital technology and outsourcing, and healthcare and pharmaceuticals.

The last 9 months of the pandemic have been a huge training ground for people in the use of digital technology—Zoom, WebEx, digital finance, and many others. This learning-by-doing exercise is likely to give a big boost to outsourcing, which has the potential to help countries like India, the Philippines, and South Africa.

Globalization may see a short-run retreat but, we believe, it will come back with a vengeance. Nations that build walls to keep out goods, people and talent will get out-competed by other nations in the product market. This realization will make most countries reverse their knee-jerk anti-globalization; and the ones that do not will cease to be important global players. Either way, globalization will be back on track and with a much greater amount of outsourcing.

To return, more critically this time, to our earlier aside on Ethiopia, its historical and contemporary record on tampering with internet connectivity 9 in an attempt to muzzle inter-ethnic tensions and political dissent will not serve it well in such a post-pandemic scenario. This is a useful reminder for all emerging market economies.

We hope that human beings will emerge from this crisis more aware of the problems of sustainability. This could divert some demand from luxury goods to better health, and what is best described as “creative consumption”: art, music, and culture. 10 The former will mean much larger healthcare and pharmaceutical sectors.

But to take advantage of these new opportunities, nations will need to navigate the current predicament so that they have a viable economy once the pandemic passes. Thus it is important to be able to control the pandemic while keeping the economy open. There is some emerging literature 11 on this, but much more is needed. This is a governance challenge of a kind rarely faced, because the pandemic has disrupted normal markets and there is need, at least in the short run, for governments to step in to fill the caveat.

Emerging economies will have to devise novel governance strategies for doing this double duty of tamping down on new infections without strident controls on economic behavior and without blindly imitating Europe and America.

Here is an example. One interesting opportunity amidst this chaos is to tap into the “resource” of those who have already had COVID-19 and are immune, even if only in the short-term—we still have no definitive evidence on the length of acquired immunity. These people can be offered a high salary to work in sectors that require physical interaction with others. This will help keep supply chains unbroken. Normally, the market would have on its own caused such a salary increase but in this case, the main benefit of marshaling this labor force is on the aggregate economy and GDP and therefore is a classic case of positive externality, which the free market does not adequately reward. It is more a challenge of governance. As with most economic policy, this will need careful research and design before being implemented. We have to be aware that a policy like this will come with its risk of bribery and corruption. There is also the moral hazard challenge of poor people choosing to get COVID-19 in order to qualify for these special jobs. Safeguards will be needed against these risks. But we believe that any government that succeeds in implementing an intelligently-designed intervention to draw on this huge, under-utilized resource can have a big, positive impact on the economy 12 .

This is just one idea. We must innovate in different ways to survive the crisis and then have the ability to navigate the new world that will emerge, hopefully in the not too distant future.

Related Content

Emiliana Vegas, Rebecca Winthrop

Homi Kharas, John W. McArthur

Anthony F. Pipa, Max Bouchet

Note: We are grateful for financial support from Cornell University’s Hatfield Fund for the research associated with this paper. We also wish to express our gratitude to Homi Kharas for many suggestions and David Batcheck for generous editorial help.

  • “GDP Annual Growth Rate – Forecast 2020-2022,” Trading Economics, https://tradingeconomics.com/forecast/gdp-annual-growth-rate.
  • “Government Cites Various Statistical Models, Says Averted Between 1.4 Million-2.9 Million Cases Due To Lockdown,” Business World, May 23, 2020, www.businessworld.in/article/Government-Cites-Various-Statistical-Models-Says-Averted-Between-1-4-million-2-9-million-Cases-Due-To-Lockdown/23-05-2020-193002/.
  • Suvrat Raju, “Did the Indian lockdown avert deaths?” medRxiv , July 5, 2020, https://europepmc.org/article/ppr/ppr183813#A1.
  • “COVID Policy Tracker,” Oxford University, https://github.com/OxCGRT/covid-policy-tracker t.
  • Debraj Ray and S. Subramanian, “India’s Lockdown: An Interim Report,” NBER Working Paper, May 2020, https://www.nber.org/papers/w27282.
  • Gopika Gopakumar and Shayan Ghosh, “Rural recovery could slow down as cases rise, says Ghosh,” Mint, August 19, 2020, https://www.livemint.com/news/india/rural-recovery-could-slow-down-as-cases-rise-says-ghosh-11597801644015.html.
  • Pierina Pighi Bel and Jake Horton, “Coronavirus: What’s happening in Peru?,” BBC, July 9, 2020, https://www.bbc.com/news/world-latin-america-53150808.
  • “No lockdown, few ventilators, but Ethiopia is beating Covid-19,” Financial Times, May 27, 2020, https://www.ft.com/content/7c6327ca-a00b-11ea-b65d-489c67b0d85d.
  • Cara Anna, “Ethiopia enters 3rd week of internet shutdown after unrest,” Washington Post, July 14, 2020, https://www.washingtonpost.com/world/africa/ethiopia-enters-3rd-week-of-internet-shutdown-after-unrest/2020/07/14/4699c400-c5d6-11ea-a825-8722004e4150_story.html.
  • Patrick Kabanda, The Creative Wealth of Nations: Can the Arts Advance Development? (Cambridge: Cambridge University Press, 2018).
  • Guanlin Li et al, “Disease-dependent interaction policies to support health and economic outcomes during the COVID-19 epidemic,” medRxiv, August 2020, https://www.medrxiv.org/content/10.1101/2020.08.24.20180752v3.
  • For helpful discussion concerning this idea, we are grateful to Turab Hussain, Daksh Walia and Mehr-un-Nisa, during a seminar of South Asian Economics Students’ Meet (SAESM).

Global Economy and Development

Sam Boocker, Alexander Conner, David Wessel

May 29, 2024

Raymond Gilpin, Daouda Sembene, Daniel Cash, Jacob Assa, Aloysius Uche Ordu

Amit Jain, Landry Signé

How to Write About Coronavirus in a College Essay

Students can share how they navigated life during the coronavirus pandemic in a full-length essay or an optional supplement.

Writing About COVID-19 in College Essays

Serious disabled woman concentrating on her work she sitting at her workplace and working on computer at office

Getty Images

Experts say students should be honest and not limit themselves to merely their experiences with the pandemic.

The global impact of COVID-19, the disease caused by the novel coronavirus, means colleges and prospective students alike are in for an admissions cycle like no other. Both face unprecedented challenges and questions as they grapple with their respective futures amid the ongoing fallout of the pandemic.

Colleges must examine applicants without the aid of standardized test scores for many – a factor that prompted many schools to go test-optional for now . Even grades, a significant component of a college application, may be hard to interpret with some high schools adopting pass-fail classes last spring due to the pandemic. Major college admissions factors are suddenly skewed.

"I can't help but think other (admissions) factors are going to matter more," says Ethan Sawyer, founder of the College Essay Guy, a website that offers free and paid essay-writing resources.

College essays and letters of recommendation , Sawyer says, are likely to carry more weight than ever in this admissions cycle. And many essays will likely focus on how the pandemic shaped students' lives throughout an often tumultuous 2020.

But before writing a college essay focused on the coronavirus, students should explore whether it's the best topic for them.

Writing About COVID-19 for a College Application

Much of daily life has been colored by the coronavirus. Virtual learning is the norm at many colleges and high schools, many extracurriculars have vanished and social lives have stalled for students complying with measures to stop the spread of COVID-19.

"For some young people, the pandemic took away what they envisioned as their senior year," says Robert Alexander, dean of admissions, financial aid and enrollment management at the University of Rochester in New York. "Maybe that's a spot on a varsity athletic team or the lead role in the fall play. And it's OK for them to mourn what should have been and what they feel like they lost, but more important is how are they making the most of the opportunities they do have?"

That question, Alexander says, is what colleges want answered if students choose to address COVID-19 in their college essay.

But the question of whether a student should write about the coronavirus is tricky. The answer depends largely on the student.

"In general, I don't think students should write about COVID-19 in their main personal statement for their application," Robin Miller, master college admissions counselor at IvyWise, a college counseling company, wrote in an email.

"Certainly, there may be exceptions to this based on a student's individual experience, but since the personal essay is the main place in the application where the student can really allow their voice to be heard and share insight into who they are as an individual, there are likely many other topics they can choose to write about that are more distinctive and unique than COVID-19," Miller says.

Opinions among admissions experts vary on whether to write about the likely popular topic of the pandemic.

"If your essay communicates something positive, unique, and compelling about you in an interesting and eloquent way, go for it," Carolyn Pippen, principal college admissions counselor at IvyWise, wrote in an email. She adds that students shouldn't be dissuaded from writing about a topic merely because it's common, noting that "topics are bound to repeat, no matter how hard we try to avoid it."

Above all, she urges honesty.

"If your experience within the context of the pandemic has been truly unique, then write about that experience, and the standing out will take care of itself," Pippen says. "If your experience has been generally the same as most other students in your context, then trying to find a unique angle can easily cross the line into exploiting a tragedy, or at least appearing as though you have."

But focusing entirely on the pandemic can limit a student to a single story and narrow who they are in an application, Sawyer says. "There are so many wonderful possibilities for what you can say about yourself outside of your experience within the pandemic."

He notes that passions, strengths, career interests and personal identity are among the multitude of essay topic options available to applicants and encourages them to probe their values to help determine the topic that matters most to them – and write about it.

That doesn't mean the pandemic experience has to be ignored if applicants feel the need to write about it.

Writing About Coronavirus in Main and Supplemental Essays

Students can choose to write a full-length college essay on the coronavirus or summarize their experience in a shorter form.

To help students explain how the pandemic affected them, The Common App has added an optional section to address this topic. Applicants have 250 words to describe their pandemic experience and the personal and academic impact of COVID-19.

"That's not a trick question, and there's no right or wrong answer," Alexander says. Colleges want to know, he adds, how students navigated the pandemic, how they prioritized their time, what responsibilities they took on and what they learned along the way.

If students can distill all of the above information into 250 words, there's likely no need to write about it in a full-length college essay, experts say. And applicants whose lives were not heavily altered by the pandemic may even choose to skip the optional COVID-19 question.

"This space is best used to discuss hardship and/or significant challenges that the student and/or the student's family experienced as a result of COVID-19 and how they have responded to those difficulties," Miller notes. Using the section to acknowledge a lack of impact, she adds, "could be perceived as trite and lacking insight, despite the good intentions of the applicant."

To guard against this lack of awareness, Sawyer encourages students to tap someone they trust to review their writing , whether it's the 250-word Common App response or the full-length essay.

Experts tend to agree that the short-form approach to this as an essay topic works better, but there are exceptions. And if a student does have a coronavirus story that he or she feels must be told, Alexander encourages the writer to be authentic in the essay.

"My advice for an essay about COVID-19 is the same as my advice about an essay for any topic – and that is, don't write what you think we want to read or hear," Alexander says. "Write what really changed you and that story that now is yours and yours alone to tell."

Sawyer urges students to ask themselves, "What's the sentence that only I can write?" He also encourages students to remember that the pandemic is only a chapter of their lives and not the whole book.

Miller, who cautions against writing a full-length essay on the coronavirus, says that if students choose to do so they should have a conversation with their high school counselor about whether that's the right move. And if students choose to proceed with COVID-19 as a topic, she says they need to be clear, detailed and insightful about what they learned and how they adapted along the way.

"Approaching the essay in this manner will provide important balance while demonstrating personal growth and vulnerability," Miller says.

Pippen encourages students to remember that they are in an unprecedented time for college admissions.

"It is important to keep in mind with all of these (admission) factors that no colleges have ever had to consider them this way in the selection process, if at all," Pippen says. "They have had very little time to calibrate their evaluations of different application components within their offices, let alone across institutions. This means that colleges will all be handling the admissions process a little bit differently, and their approaches may even evolve over the course of the admissions cycle."

Searching for a college? Get our complete rankings of Best Colleges.

10 Ways to Discover College Essay Ideas

Doing homework

Tags: students , colleges , college admissions , college applications , college search , Coronavirus

2024 Best Colleges

a thesis on covid 19

Search for your perfect fit with the U.S. News rankings of colleges and universities.

College Admissions: Get a Step Ahead!

Sign up to receive the latest updates from U.S. News & World Report and our trusted partners and sponsors. By clicking submit, you are agreeing to our Terms and Conditions & Privacy Policy .

Ask an Alum: Making the Most Out of College

You May Also Like

The degree for investment bankers.

Andrew Bauld May 31, 2024

a thesis on covid 19

States' Responses to FAFSA Delays

Sarah Wood May 30, 2024

a thesis on covid 19

Nonacademic Factors in College Searches

Sarah Wood May 28, 2024

a thesis on covid 19

Takeaways From the NCAA’s Settlement

Laura Mannweiler May 24, 2024

a thesis on covid 19

New Best Engineering Rankings June 18

Robert Morse and Eric Brooks May 24, 2024

a thesis on covid 19

Premedical Programs: What to Know

Sarah Wood May 21, 2024

a thesis on covid 19

How Geography Affects College Admissions

Cole Claybourn May 21, 2024

a thesis on covid 19

Q&A: College Alumni Engagement

LaMont Jones, Jr. May 20, 2024

a thesis on covid 19

10 Destination West Coast College Towns

Cole Claybourn May 16, 2024

a thesis on covid 19

Scholarships for Lesser-Known Sports

Sarah Wood May 15, 2024

a thesis on covid 19

Read these 12 moving essays about life during coronavirus

Artists, novelists, critics, and essayists are writing the first draft of history.

by Alissa Wilkinson

A woman wearing a face mask in Miami.

The world is grappling with an invisible, deadly enemy, trying to understand how to live with the threat posed by a virus . For some writers, the only way forward is to put pen to paper, trying to conceptualize and document what it feels like to continue living as countries are under lockdown and regular life seems to have ground to a halt.

So as the coronavirus pandemic has stretched around the world, it’s sparked a crop of diary entries and essays that describe how life has changed. Novelists, critics, artists, and journalists have put words to the feelings many are experiencing. The result is a first draft of how we’ll someday remember this time, filled with uncertainty and pain and fear as well as small moments of hope and humanity.

  • The Vox guide to navigating the coronavirus crisis

At the New York Review of Books, Ali Bhutto writes that in Karachi, Pakistan, the government-imposed curfew due to the virus is “eerily reminiscent of past military clampdowns”:

Beneath the quiet calm lies a sense that society has been unhinged and that the usual rules no longer apply. Small groups of pedestrians look on from the shadows, like an audience watching a spectacle slowly unfolding. People pause on street corners and in the shade of trees, under the watchful gaze of the paramilitary forces and the police.

His essay concludes with the sobering note that “in the minds of many, Covid-19 is just another life-threatening hazard in a city that stumbles from one crisis to another.”

Writing from Chattanooga, novelist Jamie Quatro documents the mixed ways her neighbors have been responding to the threat, and the frustration of conflicting direction, or no direction at all, from local, state, and federal leaders:

Whiplash, trying to keep up with who’s ordering what. We’re already experiencing enough chaos without this back-and-forth. Why didn’t the federal government issue a nationwide shelter-in-place at the get-go, the way other countries did? What happens when one state’s shelter-in-place ends, while others continue? Do states still under quarantine close their borders? We  are  still one nation, not fifty individual countries. Right?
  • A syllabus for the end of the world

Award-winning photojournalist Alessio Mamo, quarantined with his partner Marta in Sicily after she tested positive for the virus, accompanies his photographs in the Guardian of their confinement with a reflection on being confined :

The doctors asked me to take a second test, but again I tested negative. Perhaps I’m immune? The days dragged on in my apartment, in black and white, like my photos. Sometimes we tried to smile, imagining that I was asymptomatic, because I was the virus. Our smiles seemed to bring good news. My mother left hospital, but I won’t be able to see her for weeks. Marta started breathing well again, and so did I. I would have liked to photograph my country in the midst of this emergency, the battles that the doctors wage on the frontline, the hospitals pushed to their limits, Italy on its knees fighting an invisible enemy. That enemy, a day in March, knocked on my door instead.

In the New York Times Magazine, deputy editor Jessica Lustig writes with devastating clarity about her family’s life in Brooklyn while her husband battled the virus, weeks before most people began taking the threat seriously:

At the door of the clinic, we stand looking out at two older women chatting outside the doorway, oblivious. Do I wave them away? Call out that they should get far away, go home, wash their hands, stay inside? Instead we just stand there, awkwardly, until they move on. Only then do we step outside to begin the long three-block walk home. I point out the early magnolia, the forsythia. T says he is cold. The untrimmed hairs on his neck, under his beard, are white. The few people walking past us on the sidewalk don’t know that we are visitors from the future. A vision, a premonition, a walking visitation. This will be them: Either T, in the mask, or — if they’re lucky — me, tending to him.

Essayist Leslie Jamison writes in the New York Review of Books about being shut away alone in her New York City apartment with her 2-year-old daughter since she became sick:

The virus.  Its sinewy, intimate name. What does it feel like in my body today? Shivering under blankets. A hot itch behind the eyes. Three sweatshirts in the middle of the day. My daughter trying to pull another blanket over my body with her tiny arms. An ache in the muscles that somehow makes it hard to lie still. This loss of taste has become a kind of sensory quarantine. It’s as if the quarantine keeps inching closer and closer to my insides. First I lost the touch of other bodies; then I lost the air; now I’ve lost the taste of bananas. Nothing about any of these losses is particularly unique. I’ve made a schedule so I won’t go insane with the toddler. Five days ago, I wrote  Walk/Adventure!  on it, next to a cut-out illustration of a tiger—as if we’d see tigers on our walks. It was good to keep possibility alive.

At Literary Hub, novelist Heidi Pitlor writes about the elastic nature of time during her family’s quarantine in Massachusetts:

During a shutdown, the things that mark our days—commuting to work, sending our kids to school, having a drink with friends—vanish and time takes on a flat, seamless quality. Without some self-imposed structure, it’s easy to feel a little untethered. A friend recently posted on Facebook: “For those who have lost track, today is Blursday the fortyteenth of Maprilay.” ... Giving shape to time is especially important now, when the future is so shapeless. We do not know whether the virus will continue to rage for weeks or months or, lord help us, on and off for years. We do not know when we will feel safe again. And so many of us, minus those who are gifted at compartmentalization or denial, remain largely captive to fear. We may stay this way if we do not create at least the illusion of movement in our lives, our long days spent with ourselves or partners or families.
  • What day is it today?

Novelist Lauren Groff writes at the New York Review of Books about trying to escape the prison of her fears while sequestered at home in Gainesville, Florida:

Some people have imaginations sparked only by what they can see; I blame this blinkered empiricism for the parks overwhelmed with people, the bars, until a few nights ago, thickly thronged. My imagination is the opposite. I fear everything invisible to me. From the enclosure of my house, I am afraid of the suffering that isn’t present before me, the people running out of money and food or drowning in the fluid in their lungs, the deaths of health-care workers now growing ill while performing their duties. I fear the federal government, which the right wing has so—intentionally—weakened that not only is it insufficient to help its people, it is actively standing in help’s way. I fear we won’t sufficiently punish the right. I fear leaving the house and spreading the disease. I fear what this time of fear is doing to my children, their imaginations, and their souls.

At ArtForum , Berlin-based critic and writer Kristian Vistrup Madsen reflects on martinis, melancholia, and Finnish artist Jaakko Pallasvuo’s 2018 graphic novel  Retreat , in which three young people exile themselves in the woods:

In melancholia, the shape of what is ending, and its temporality, is sprawling and incomprehensible. The ambivalence makes it hard to bear. The world of  Retreat  is rendered in lush pink and purple watercolors, which dissolve into wild and messy abstractions. In apocalypse, the divisions established in genesis bleed back out. My own Corona-retreat is similarly soft, color-field like, each day a blurred succession of quarantinis, YouTube–yoga, and televized press conferences. As restrictions mount, so does abstraction. For now, I’m still rooting for love to save the world.

At the Paris Review , Matt Levin writes about reading Virginia Woolf’s novel The Waves during quarantine:

A retreat, a quarantine, a sickness—they simultaneously distort and clarify, curtail and expand. It is an ideal state in which to read literature with a reputation for difficulty and inaccessibility, those hermetic books shorn of the handholds of conventional plot or characterization or description. A novel like Virginia Woolf’s  The Waves  is perfect for the state of interiority induced by quarantine—a story of three men and three women, meeting after the death of a mutual friend, told entirely in the overlapping internal monologues of the six, interspersed only with sections of pure, achingly beautiful descriptions of the natural world, a day’s procession and recession of light and waves. The novel is, in my mind’s eye, a perfectly spherical object. It is translucent and shimmering and infinitely fragile, prone to shatter at the slightest disturbance. It is not a book that can be read in snatches on the subway—it demands total absorption. Though it revels in a stark emotional nakedness, the book remains aloof, remote in its own deep self-absorption.
  • Vox is starting a book club. Come read with us!

In an essay for the Financial Times, novelist Arundhati Roy writes with anger about Indian Prime Minister Narendra Modi’s anemic response to the threat, but also offers a glimmer of hope for the future:

Historically, pandemics have forced humans to break with the past and imagine their world anew. This one is no different. It is a portal, a gateway between one world and the next. We can choose to walk through it, dragging the carcasses of our prejudice and hatred, our avarice, our data banks and dead ideas, our dead rivers and smoky skies behind us. Or we can walk through lightly, with little luggage, ready to imagine another world. And ready to fight for it. 

From Boston, Nora Caplan-Bricker writes in The Point about the strange contraction of space under quarantine, in which a friend in Beirut is as close as the one around the corner in the same city:

It’s a nice illusion—nice to feel like we’re in it together, even if my real world has shrunk to one person, my husband, who sits with his laptop in the other room. It’s nice in the same way as reading those essays that reframe social distancing as solidarity. “We must begin to see the negative space as clearly as the positive, to know what we  don’t do  is also brilliant and full of love,” the poet Anne Boyer wrote on March 10th, the day that Massachusetts declared a state of emergency. If you squint, you could almost make sense of this quarantine as an effort to flatten, along with the curve, the distinctions we make between our bonds with others. Right now, I care for my neighbor in the same way I demonstrate love for my mother: in all instances, I stay away. And in moments this month, I have loved strangers with an intensity that is new to me. On March 14th, the Saturday night after the end of life as we knew it, I went out with my dog and found the street silent: no lines for restaurants, no children on bicycles, no couples strolling with little cups of ice cream. It had taken the combined will of thousands of people to deliver such a sudden and complete emptiness. I felt so grateful, and so bereft.

And on his own website, musician and artist David Byrne writes about rediscovering the value of working for collective good , saying that “what is happening now is an opportunity to learn how to change our behavior”:

In emergencies, citizens can suddenly cooperate and collaborate. Change can happen. We’re going to need to work together as the effects of climate change ramp up. In order for capitalism to survive in any form, we will have to be a little more socialist. Here is an opportunity for us to see things differently — to see that we really are all connected — and adjust our behavior accordingly.  Are we willing to do this? Is this moment an opportunity to see how truly interdependent we all are? To live in a world that is different and better than the one we live in now? We might be too far down the road to test every asymptomatic person, but a change in our mindsets, in how we view our neighbors, could lay the groundwork for the collective action we’ll need to deal with other global crises. The time to see how connected we all are is now.

The portrait these writers paint of a world under quarantine is multifaceted. Our worlds have contracted to the confines of our homes, and yet in some ways we’re more connected than ever to one another. We feel fear and boredom, anger and gratitude, frustration and strange peace. Uncertainty drives us to find metaphors and images that will let us wrap our minds around what is happening.

Yet there’s no single “what” that is happening. Everyone is contending with the pandemic and its effects from different places and in different ways. Reading others’ experiences — even the most frightening ones — can help alleviate the loneliness and dread, a little, and remind us that what we’re going through is both unique and shared by all.

Most Popular

What to know about claudia sheinbaum, mexico’s likely next president, the best — and worst — criticisms of trump’s conviction, take a mental break with the newest vox crossword, what’s really happening to grocery prices right now, what trump really thinks about the war in gaza, today, explained.

Understand the world with a daily explainer plus the most compelling stories of the day.

More in Culture

20 years of Bennifer, explained

20 years of Bennifer, explained

Why the uncanny “All eyes on Rafah” image went so viral

Why the uncanny “All eyes on Rafah” image went so viral

Leaked video reveals the lie of Miss Universe’s empowerment promise

Leaked video reveals the lie of Miss Universe’s empowerment promise

The Sympathizer takes on Hollywood’s Vietnam War stories

The Sympathizer takes on Hollywood’s Vietnam War stories

The NCAA’s proposal to pay college athletes is fair. That's the problem.

The NCAA’s proposal to pay college athletes is fair. That's the problem.

Your favorite brand no longer cares about being woke

Your favorite brand no longer cares about being woke

20 years of Bennifer, explained

Why some wild animals are getting insomnia

What to know about Claudia Sheinbaum, Mexico’s likely next president

Billie Eilish vs. Taylor Swift: Is the feud real? Who’s dissing who?

What Trump really thinks about the war in Gaza

What ever happened to the war on terror?

The best — and worst — criticisms of Trump’s conviction

University of Illinois at Chicago

COVID-19, Food Insecurity, and Access to Oral Healthcare

Degree grantor, degree level, degree name, committee member, submitted date, thesis type, usage metrics.

  • Contributors
  • Mission and Values
  • Submissions
  • The Regulatory Review In Depth

The Regulatory Review

Lessons Learned From COVID-19

Lee a. fleisher and matthew a. fleisher.

a thesis on covid 19

The COVID-19 response illustrates steps officials should take to ensure the effectiveness of vaccine mandates.

The COVID-19 pandemic was the worst public health emergency of the last century. Despite aggressive attempts to contain the virus by social isolation, masking, and medical management, over 1.1 million Americans died between January 31, 2020, when the U.S. Department of Health and Human Services (HHS) declared COVID-19 a public health emergency, and March 11, 2023, when HHS declared the public health emergency over. Of those that perished, there was a particularly tremendous loss among the elderly, immunocompromised, and those in nursing homes.

In December 2020, the U.S. Food and Drug Administration issued emergency use authorizations for the Pfizer-BioNTech and Moderna COVID-19 vaccines . Despite the widespread availability of the vaccines at no cost, their adoption varied considerably. For this reason, physicians and public health officials soon called for a COVID-19 vaccine mandate.

In August 2021, President Joseph R. Biden directed the Centers for Medicare and Medicaid Services (CMS) to require nursing homes to ensure their workers were fully vaccinated against COVID-19 as a condition of participating in the Medicare and Medicaid programs. The Social Security Act provides that facilities participating in Medicare must meet certain requirements and that the HHS Secretary may impose additional requirements deemed necessary to protect the health and safety of patients in hospitals, nursing homes, and other CMS-certified facilities.

HHS’s emergency declarations authorized its component agencies, such as CMS, to issue new health and safety regulations. In addition, outside of public health emergencies, CMS has the authority to oversee healthcare delivery systems. CMS issued its vaccine mandate based on substantial evidence demonstrating that the prevalence of nursing home COVID-19 cases was related to low levels of vaccination among care staff. Furthermore, evidence that many nursing homes were not implementing standard infection control practices accelerated vaccine mandate drafting and execution.

The Administrative Procedure Act requires that agencies that wish to forgo notice-and-comment rulemaking during a public health emergency must demonstrate that undergoing notice-and-comment would be “impracticable, unnecessary, or contrary to the public interest.” The Biden Administration concluded on this basis that it could create an emergency regulation to require vaccines in nursing homes. Nevertheless, as CMS was developing its emergency regulation, nursing homes expressed concern that the mandate could trigger widespread staff shortages because workers would refuse to receive the vaccine. The industry feared that a staffing shortage could lead to worse health outcomes for residents.

While developing the vaccine mandate, the CMS Center for Clinical Standards and Quality convened several listening sessions from all corners of the healthcare industry. During this feedback period, several states issued their own vaccine mandates in both nursing homes and hospitals, and individual nursing home chains and hospital systems also proposed vaccine mandates. This patchwork approach further complicated efforts to limit the spread of COVID-19.

Hospitals and nursing homes were concerned that the variation between states’ rules could lead staff to move to different states to avoid a vaccine mandate. Several providers pushed for a national mandate. A marked increase in the proportion of nurses who sought employment through traveling services during the public health emergency validated this concern. Several national leaders suggested that a national mandate would be useful to manage interstate variability.

Because of these concerns, CMS and HHS began to explore the medical benefits of a national mandate for all healthcare facilities that receive Medicare funding. Data from the National Healthcare Safety Network demonstrated that COVID-19 rates among long-term care facilities were higher in facilities with lower vaccination coverage among staff. The agencies also explored the legal basis for a mandate. Critically, they determined that systems for documenting medical and religious exemptions to the vaccine mandate would be needed.

Ultimately, CMS issued its regulation in November 2021. Shortly thereafter, 14 states challenged the regulation and argued that CMS had exceeded its statutory authority under the Social Security Act. In January 2022, the U.S. Supreme Court, in a 5–4 decision, upheld the mandate, explaining that:

The Secretary of Health and Human Services determined that a COVID-19 vaccine man­date will substantially reduce the likelihood that healthcare workers will contract the virus and transmit it to their patients. He accordingly concluded that a vaccine mandate is “necessary to promote and protect patient health and safety” in the face of the ongoing pandemic. The rule thus fits neatly within the language of the statute.

Importantly, the Court found that the HHS Secretary had examined sufficient evidence justifying the decision to “(1) impose the vaccine mandate instead of a testing mandate; (2) require vaccination of employees with ‘natural immunity’ from prior COVID-19 illness; and (3) depart from the agency’s prior approach of merely encouraging vaccination.”

After the Biden Administration declared the public health emergency over in March 2023, CMS ended its vaccine mandate in August. In the end, the mandate did not substantially disrupt the healthcare ecosystem, and staff resignations due to the mandate did not produce national adverse health outcomes.

It is difficult to analyze the precise effects of the vaccine mandate because there were many states and local facilities that had already mandated the vaccine. Nonetheless, there are at least three important lessons public health officials can learn for the future from CMS’s experience in imposing a COVID-19 vaccine mandate.

First, it will be important to address the non-uniform manner in which states and local healthcare facilities adopt a mandatory vaccination policy during any future pandemic. There should be a national vaccine for healthcare facilities as soon as a safe and effective vaccine is approved. Early adoption can ensure national uniformity, which can in turn help prevent localized staffing shortages. The federal government should also monitor and evaluate the impact of any such mandate and adjust the manner of implementation as needed.

Second, public health officials should proactively collect evidence to demonstrate the health and safety implications of unvaccinated staff in Medicare-certified facilities to justify the need to forgo notice and comment rulemaking. This evidence can also help justify a national vaccine mandate if challenged in the courts.

Finally, public health officials should develop and implement rigorous standards for determining who is exempt from the vaccine mandate by balancing civil rights with healthcare concerns. Rigorous standards will help ensure vaccines succeed in cutting community transmission.

The political debate around vaccination continues to this day but these three lessons can help public health officials prepare for future public health emergencies.

Lee A. Fleisher

Lee A. Fleisher is an emeritus professor of anesthesiology and critical care at the University of Pennsylvania Perelman School of Medicine . From July 2020 to July 2023, he served as the Chief Medical Officer and Director of the Center for Clinical Standards and Quality at the Centers for Medicare & Medicaid Services .

Matthew A. Fleisher

Matthew A. Fleisher is the chief operating officer and managing director of Rubrum Advising .

Related Essays

Risk-Based Regulatory Regimes

Risk-Based Regulatory Regimes

Julia Black explains how regulatory regimes focused on risk can lead to greater coherence.

Regulating the Great Indoors

Regulating the Great Indoors

Scholar argues that environmental law and policy should expand its scope to inside areas.

Cutting Corners on COVID-19 Treatments?

Cutting Corners on COVID-19 Treatments?

Scholars analyze FDA’s emergency use authorizations during the COVID-19 pandemic.

Carnegie Mellon University

Developing Technological Platforms for Targeted Cancer Therapies, Protein Drug Delivery, and Pathogen Detection

 Biomedical engineering has made remarkable progress in enhancing human healthcare, contributing significantly to the fight against human diseases. However, we still confront grand challenges in accurate disease diagnosis, efficient therapeutic delivery, and the development of targeted therapies. For example, the diagnosis of coronavirus disease (COVID-19) remains challenging in low-resource settings where access to specialized medical equipment and trained personnel is severely limited. Cystic fibrosis patients carrying cystic fibrosis transmembrane conductance regulator (CFTR) mutations that lead to non-functional CFTR protein production remain ineligible for CFTR modulator treatments. Traditional cancer chemotherapies, though effective, frequently encounter "on-target, off-tissue" cytotoxicity associated with target molecule prevalence on healthy tissue. 

To tackle the critical challenges in disease diagnosis, therapeutic delivery, and targeted therapies in various human disease, in this thesis, we engineered disease diagnostic device for COVID-19 detection in low-resource settings, efficient therapeutic delivery system for cystic fibrosis patients carrying CFTR mutations, and targeted therapy for cancer treatment. In chapter 1, we developed TASE (TArgeted Split Enzyme), an innovative cancer treatment strategy featuring an AND-gated dual-targeting mechanism. TASE effectively reduces off-tissue cytotoxicity by utilizing a tunable payload, leveraging a pair of split human simplex virus (HSV) thymidine kinase (TK). This enzyme converts the prodrug ganciclovir (GCV) into a cytotoxic form exclusively within cancer cells, thus enhancing targeted therapy efficacy. Chapter 2 developed an innovative extracellular vesicle-based protein drug delivery system for the direct transport of CFTR protein to the plasma membrane of human bronchial epithelial cells. It holds significant promise for treating cystic fibrosis patients with non-functional CFTR protein production. Chapter 3 developed a Surfactant-Infused Space-Domain RT-qPCR (SiSd-RT-qPCR) device for ultrafast, one-step SARS-CoV-2 virus detection in low-resource settings. 

Degree Type

  • Dissertation
  • Biomedical Engineering

Degree Name

  • Doctor of Philosophy (PhD)

Usage metrics

  • Biomedical Engineering not elsewhere classified

U.S. flag

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

  • Publications
  • Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

  • Advanced Search
  • Journal List
  • Wiley - PMC COVID-19 Collection

Logo of pheblackwell

Epidemiology of COVID‐19: A systematic review and meta‐analysis of clinical characteristics, risk factors, and outcomes

1 Department of Infectious Disease, Shandong Provincial Hospital affiliated to Shandong First Medical University, Jinan Shandong, China

2 Department of Infectious Disease, Cheeloo College of Medicine, Shandong Provincial Hospital, Shandong University, Jinan Shandong, China

Daniel Q. Huang

3 Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore

4 Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

5 Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford California

Hongli Yang

Natasha tang sook yee, chuanli liu, sanjna nilesh nerurkar, justin chua ying kai, margaret li peng teng.

6 Division of Infectious Disease, The Third People's Hospital of Shenzhen, Shenzhen Guangdong, China

7 Department of Internal Medicine, School of Medicine, Shenzhen University, Shenzhen Guangdong, China

John A. Borghi

8 Lane Medical Library, School of Medicine, Stanford University, Stanford California

Linda Henry

Ramsey cheung.

9 Division of Gastroenterology and Hepatology, Veterans Affairs Palo Alto Health Care System, Palo Alto California

Mindie H. Nguyen

Associated data.

The data that supports the findings of this study are available in the supplementary material of this article.

Coronavirus disease 2019 (COVID‐19) has become a pandemic, but its reported characteristics and outcomes vary greatly amongst studies. We determined pooled estimates for clinical characteristics and outcomes in COVID‐19 patients including subgroups by disease severity (based on World Health Organization Interim Guidance Report or Infectious Disease Society of America/American Thoracic Society criteria) and by country/region. We searched Pubmed, Embase, Scopus, Cochrane, Chinese Medical Journal, and preprint databases from 1 January 2020 to 6 April 2020. Studies of laboratory‐confirmed COVID‐19 patients with relevant data were included. Two reviewers independently performed study selection and data extraction. From 6007 articles, 212 studies from 11 countries/regions involving 281 461 individuals were analyzed. Overall, mean age was 46.7 years, 51.8% were male, 22.9% had severe disease, and mortality was 5.6%. Underlying immunosuppression, diabetes, and malignancy were most strongly associated with severe COVID‐19 (coefficient =  53.9, 23.4, 23.4, respectively, all P  < .0007), while older age, male gender, diabetes, and hypertension were also associated with higher mortality (coefficient = 0.05 per year, 5.1, 8.2, 6.99, respectively; P  = .006‐.0002). Gastrointestinal (nausea, vomiting, abdominal pain) and respiratory symptoms (shortness of breath, chest pain) were associated with severe COVID‐19, while pneumonia and end‐organ failure were associated with mortality. COVID‐19 is associated with a severe disease course in about 23% and mortality in about 6% of infected persons. Individuals with comorbidities and clinical features associated with severity should be monitored closely, and preventive efforts should especially target those with diabetes, malignancy, and immunosuppression.

An external file that holds a picture, illustration, etc.
Object name is JMV-93-1449-g002.jpg

  • 1. In this systematic review and meta‐analysis of 212 studies involving 281,461 individuals with COVID‐19 from 11 countries/regions, the overall mortality was 5.6%, and 22.9% had severe disease. Immunosuppression, diabetes, malignancy and abdominal pain were strongly associated with severe disease.
  • 2. Close to one‐quarter of individuals with COVID‐19 develop a severe disease course, and individuals with clinical features associated with severity should be monitored closely.


1. introduction.

On 11 March, the World Health Organization (WHO) declared the coronavirus disease 2019 (COVID‐19) outbreak caused by the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) a pandemic. 1 Currently, the deadly COVID‐19 has no effective therapy or vaccine. In addition, the signs of having COVID‐19 are nonspecific or can be absent, adding challenges to disease control and prevention. 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 As COVID‐19 rapidly spreads, many available data sources were based on case series or small cohorts, limiting their conclusions.

The current pandemic has highlighted the marked variation in patient demographics, access to healthcare, healthcare infrastructure, and preparedness among regions, and these, in turn, have significantly impacted outcomes. 10 These factors are important for health policy, not only for the current pandemic but for future global events. Therefore, the aim of this systematic review and meta‐analysis aims was to elucidate regional variations in baseline clinical characteristics, presentation, and factors associated with outcomes in COVID‐19 patients including subgroup analysis by country/region and by disease severity.

2.1. Search strategy and selection criteria

Following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses statement for the conduct of meta‐analyses of observational studies ( http://www.prisma-statement.org/ ), two researchers independently performed the literature search, extracted the data and assessed for study quality. This study protocol was submitted for PROSPERO registration.

We searched Pubmed, Embase, Scopus, the Cochrane Library, the Chinese Medical Journal as well as the BioRxiv, MedRxiv, Preprints databases from 1 January 2020 to 6 April 2020 using search strategy developed in collaboration with an experienced medical librarian (JAB). Detailed search strategy and selection criteria are described in the Appendix Methods section. Briefly, for Pubmed, we used the search term (2019‐nCoV OR 2019‐nCoV OR COVID‐19 OR SARS‐CoV‐2 OR [wuhan AND coronavirus] AND 2019/12[PDAT]:2030[PDAT]). Original research articles were included if they fulfilled the following criteria: (a) laboratory‐confirmed COVID‐19 and (b) if the study provided information about clinical features and outcomes of COVID‐19. We excluded animal studies, review articles, and consensus documents. Exclusion criteria were as follows: (a) the study was a review article, letters to the editor, clinical trial, animal study, comments, consensus documents; (b) the study did not focus on patients with COVID‐19 or diagnosis was unclear. If the patients came from the same hospital with overlapping cases, we only selected the publication containing greatest number of cases.

We developed a case report form to screen and extract data and a specific database to house all study data. Quality assessment was performed using the Newcastle‐Ottawa scale (NOS) which comprised of three domains: selection, comparability, and outcome. 11 The risk of bias was assessed based on a total score of nine stars such that studies with seven to nine stars had a low risk of bias, four to six stars had a moderate risk of bias, and one to three stars were considered as a high risk of bias. Articles were initially screened by titles and abstract, followed by full article review to identify eligible studies. Discordant results were resolved by discussion between the two reviewers and/or by consulting a third senior researcher.

2.2. Statistical analysis

We used a random‐effects model to estimate pooled means or proportions of relevant COVID‐19 clinical characteristics and/or outcomes such as demographic data, medical history, exposure history, underlying comorbidities, symptoms, signs, laboratory findings (complete blood count, blood chemistry, coagulation test, liver and renal function, electrolytes) and chest computed tomography (CT) scans, complications (eg, adult respiratory distress syndrome), and death in the overall and selected populations. We assessed for heterogeneity using the Cochran Q‐statistic and I 2 ‐statistic. Estimates with P value of less than .05 in Q‐statistic and I 2  ≥ 50% were considered to have significant heterogeneity. The following subgroup analyses were performed to determine the source of the observed heterogeneity: age, gender, country/region, sample size, and quality assessment score. We performed meta‐regression to assess factors associated with severe disease which is based on the WHO Interim Guidance Report criteria for severe pneumonia. 12 , 13 In addition, we identified studies that reported outcomes in special subgroups including the pediatric age group and pregnant women. However, the data from pediatric and pregnant individuals were included only in subgroup analysis and not in the main meta‐analysis or in the meta‐regression. We utilized Egger's test to assess for publication bias. As a sensitivity analysis, we performed analysis without data from preprints studies, low‐quality studies, or studies with less than 10 patients. In addition, to assess whether there is a relationship between one or more covariates with mortality proportion, the direction, and magnitude of the relationship, we performed meta‐regression with the dependent variable being the logit transformation of mortality proportion (formula: in (p/(1‐p) = intercept + coefficient × (the value of covariate). 14 A P value of less than .05 suggests the presence of statistically significant relationship between the covariate and mortality proportion, the positivity or negativity of the coefficient denotes the direction of the relationship, and the numerical value of the coefficient corresponds to the magnitude of the relationship. All statistical analyses were conducted using the meta‐packages in R statistical software (version 3.6.3).

A total of 6007 articles were retrieved and 5795 were excluded as per our exclusion criteria (Figure  1 ). We analyzed data from 212 studies conducted in 11 countries/regions (Mainland China: 180, United States: 8, South Korea: 6, Singapore: 3, Italy: 3, Taiwan: 3, UK: 2, Hong Kong: 2, Canada: 1, Japan: 1, Vietnam: 1, and more than one country/region 2). Of these 212 articles, 164 were peer‐reviewed publications, and 48 were in preprint form; 161 were in English, and 51 were in Chinese. The details of study characteristics for each of the included 212 studies are summarized in Table S1. A total of 188 studies were included in the overall analysis, while 258 studies that provided data exclusively for special populations (eg, pediatric, pregnant, severe COVID‐19 vs nonsevere COVID‐19) were included only in subgroup analyses (Figure  1 ). Some studies provided data for more than one analysis, hence the sum added up to be greater than 212.

An external file that holds a picture, illustration, etc.
Object name is JMV-93-1449-g003.jpg

Flow chart of systematic literature search and screening for studies of COVID‐19. COVID‐19, coronavirus disease 2019

The quality assessment for each paper is included in Table S1. The average NOS score was 7, with 122 studies being of high quality, 90 of medium quality, and none of low quality.

3.1. Geographic distribution and demographic characteristics

The majority of study patients came from the United States (n = 223 862; 79.5%) followed by Mainland China (n = 24 605; 8.7%), Italy (n = 24 105; 8.6%), and South Korea (n = 7848; 2.8%). The individual study sample sizes ranged from 1 to 149 082 (Table S1).

The pooled mean age in the overall cohort was 46.7 years (95% confidence interval [CI]: 42.8‐50.5) using data from 88 studies (n = 8908) (Table  1 ) and was similar between patients from Mainland China and outside Mainland China ( P  = .1) (Table S2A), and within Mainland China between those from Hubei vs outside Hubei ( P  = .08) (Table S2B).

Demographic and clinical characteristics of COVID‐19 patients

Abbreviations: CI, confidence interval; COVID‐19, coronavirus disease 2019.

The overall pooled proportion of males was 51.8% (95% CI: 50.4‐53.2) (168 studies, Table  1 ) and was similar when stratified by within vs outside Mainland China, within Mainland China Hubei vs outside Hubei, and within Hubei Wuhan vs outside Wuhan (all P  > .05) (Tables S2A and S2B).

3.2. Diagnosis method, incubation period, and mode of transmission

Of the 212 studies, 190 (89.6%) studies used polymerase chain reaction (PCR) alone to diagnose COVID‐19, one study (0.5%) used a serum antibody test alone, nine (4.3%) studies used a combination of chest CT and PCR tests, one study (0.5%) used a combination of chest CT and antibody tests, and one study (0.5%) used a combination of PCR, chest CT, and antibody tests. The remaining 10 (4.7%) studies did not specify how COVID‐19 was diagnosed. Studies from all countries apart from Mainland China relied on PCR alone to diagnose COVID‐19.

The pooled mean incubation period in the overall cohort was 5.3 days (95% CI: 4.5‐6.0) (seven studies, 746 patients, Table  1 ). The incubation period was shorter in studies outside Mainland China (4.0 days, 95% CI: 3.0‐5.1) vs 6.0 days (95% CI: 4.7‐7.3) in Mainland China ( P  = .02) (Table S2A). However, there was only one study that provided data for incubation period outside of Mainland China. Within Mainland China, there was no difference in the incubation period when stratified by Hubei vs outside Hubei ( P  = .4) (Table S2B).

A total of 161 studies (n = 17 648) provided data for mode of transmission. The most common mode of transmission was travel‐related (58.1%, 95% CI: 51.1‐64.8), followed by close contacts (43.1%, 95% CI: 37.2‐49.2), and finally community spread (27.4%, 95% CI: 18.4‐38.7).

3.3. Clinical symptoms, disease presentation, and course

The pooled mean time from illness onset to first hospitalization was 5.5 days (95% CI: 4.6‐6.4) (26 studies, 3508 patients, Table  1 ). This duration was shorter in studies outside Mainland China (3.3 days, 95% CI: 2.2‐4.5) compared to within Mainland China (5.7 days, 95% CI: 4.8‐6.7) (Table S2A) ( P  = .002). Within Mainland China, the time from illness onset to hospitalization was longer in Hubei province (7.5 days, 95% CI: 5.7‐9.2) compared with outside Hubei province (4.5 days, 95% CI: 3.8‐5.3) ( P  = .003) (Table S2B).

The most common symptom was fever (78.8%, 95% CI: 76.2‐81.3), followed by cough (53.9%, 95% CI: 50.0‐57.7) and malaise 37.9% (95% CI: 29.5‐47.1). In contrast to other respiratory viral infections, the proportion of individuals with rhinorrhea was low (7.5%, 95% CI, 5.7‐9.6). With regards to gastrointestinal symptoms, the proportion of individuals with diarrhea was 9.5% (95% CI: 7.8‐11.5), while abdominal pain and vomiting were less common (4.5%, 95% CI: 3.3‐6.2 and 4.7%, 95% CI: 3.8‐5.8, respectively).

The pooled proportion of patients admitted to intensive care unit (ICU) was 10.96% (95% CI: 6.6‐17.6) (39 studies, 80 487 patients, Figure  2A ), without significant differences among the included countries/regions ( P  = .3) (Figure  2A ). However, within Mainland China, there was a higher proportion of individuals admitted to ICU in Hubei province vs outside Hubei province (15.6%, 95% CI: 10.8‐21.95 vs 8.1%, 95% CI: 4.8‐13.4; P  = .04) (Figure  2A and Table S2B); and within Hubei province, there were more patients admitted to ICU in Wuhan vs outside Wuhan (16.6%, 95% CI: 10.96‐24.3 vs 8.8%, 95% CI: 5.7‐13.1; P  = .03).

An external file that holds a picture, illustration, etc.
Object name is JMV-93-1449-g001.jpg

A, Proportion of COVID‐19 patients requiring intensive care unit. B, Proportion of COVID‐19 patients requiring mechanical ventilation. C, Proportion of COVID‐19 patients with severe disease. D, COVID‐19 mortality. COVID‐19, coronavirus disease 2019

The pooled proportion of patients that required mechanical ventilation from 36 studies (6152 patients) was 7.1% (95% CI: 4.5‐11.0) (Figure  2B and Table  1 ). Within Mainland China, this proportion was higher in Hubei province compared with outside Hubei (10.8%, 95% CI: 6.5‐17.2 vs 4.5%, 95% CI: 3.0‐6.7; P  = .01) (Figure  2B and Table S2B). Within Hubei province, 10.8% (95% CI: 6.5‐17.2) of patients from Wuhan required mechanical ventilation compared to 4.4% (95% CI: 2.9‐6.5) in Hubei patients from outside Wuhan city ( P  = .01).

Overall, 22.9% (95% CI: 13.3‐36.5) of COVID‐19 patients had severe disease (35 studies, 79 170 patients) as defined by WHO Interim Guidance Report or Infectious Disease Society of America/American Thoracic Society criteria (Figure  2C ), 12 , 13  with no statistically significant difference between Mainland China vs outside Mainland China patients ( P  = .3). However, within Mainland China, the proportion of severe disease within Hubei was higher than that outside of Hubei (36.1%, 95% CI: 28.1‐44.9 vs 17.3%, 95% CI: 14.1‐21.1; P  < .0001).

3.4. Demographic characteristics and comorbidities

Individuals with severe disease were significantly older (60.4 years, 95% CI: 57.8‐63.1) compared to those without severe disease (44.6 years, 95% CI: 42.8‐46.3), P  < .0001 (Table S3B). There were significantly more males in the severe group (60.8%, 95% CI: 57.2‐64.2) compared with the nonsevere group (47.6%, 95% CI: 44.9‐50.4), P  < .0001. Compared to patients without severe disease, severe COVID‐19 patients were more likely to have hypertension (35.9%, 95% CI: 31.2‐40.7 vs 14.5%, 95% CI: 11.5‐18.1; P  < .0001), diabetes (20.1%, 95% CI: 16.6‐24.2 vs 6.2%, 95% CI: 3.2‐11.9; P  = .0005) as well as chronic renal disease ( P  = .01), chronic lung disease ( P  = .02), chronic heart disease ( P  = .002), and malignancy ( P  = .03).

3.5. Symptoms, signs, and laboratory characteristics

Shortness of breath was present in about half (48.96%, 95% CI: 39.3‐58.7) of severe cases compared with only 13.6% (95% CI: 9.8‐18.5) of nonsevere cases, P  < .000 (Table S3B). Chills ( P  < .0001), abdominal pain ( P  = .01) and dizziness ( P  = .02) were also more common among those with severe disease.

Pooled mean AST ( P  < .0001), ALT ( P  = .006), urea ( P  = .02), C‐reactive protein ( P  < .0001), neutrophil count ( P  = .0007) and white blood cell count ( P  = .003) were higher in severe disease compared with nonsevere disease (Table S3C). Conversely, lymphocyte count was lower in severe disease ( P  < .0001).

In general, shock and organ injuries were more common in severe cases compared to nonsevere ones (26.5%, 95% CI: 15.95‐40.7 vs 1.2%, 95% CI: 0.4‐3.1; P  < .000 for shock; 14.1%, 95% CI: 6.6‐27.8 vs 1.96%, 95% CI: 0.5‐7.5; P  = .01 for cardiac injury).

3.6. Meta‐regression: factors associated with severe COVID‐19

Meta‐regression of multiple study‐level clinical and laboratory characteristics showed statistically significant correlation between several factors and disease severity (Table  2 ). The clinical characteristics strongly associated with severity were immunosuppression (coefficient: 53.9, 95% CI: 31.3‐76.4; P  < .0001), abdominal pain (coefficient: 24.7, 95% CI: 17.4‐31.94; P  < .0001), malignancy (coefficient 23.4, 95% CI: 9.9‐36.94; P  = .0007) and diabetes (coefficient: 23.4, 95% CI: 14.99‐31.7; P  < .0001). The complete list of variables analyzed by meta‐regression is found in Table S4A.

Significant factors associated with severe COVID‐19 illness a

Abbreviations: ATS, American Thoracic Society; CI, confidence interval; COVID‐19, coronavirus disease 2019; IDSA, Infectious Disease Society of America; WHO, World Health Organization.

3.7. Mortality outcome

The overall pooled mortality was 5.6% (95% CI: 4.2‐7.5) (Figure  2D ) using data from 86 studies and 52 808 patients (number of studies: Mainland China: 73, Italy: 3, United States: 3, Singapore: 2, South Korea 2, UK 1, Vietnam 1, Global 1).

Mortality varied significantly amongst individual countries/regions, 5.3% (95% CI: 3.7‐7.6) in Mainland China, 14.3% (95% CI: 4.2‐39.2) in Italy, 4.4% (95% CI: 0.7‐23.6) in United States, and 0.9% (95% CI: 0.7‐1.1) in South Korea, P  < .0001. However, there was no significant mortality difference when stratified by Mainland China (5.3%, 95% CI: 3.7‐7.6) vs non‐Mainland China (5.6%, 95% CI: 2.6‐11.8), P  = .90.

3.8. Clinical characteristics of COVID‐19 survivors vs nonsurvivors

Nonsurvivors were almost 20 years older (68.9 years, 95% CI: 66.8‐71.0) than survivors (50.7 years, 95% CI: 46.6‐54.8), P  < .0001 (Table S3A), and there were no differences in the proportion of males ( P  = .3). Nonsurvivors compared to survivors were more likely to have hypertension (44.9%, 95% CI: 34.4‐55.8 vs 23.8%, 95% CI: 19.3‐29.0; P  = .0003) and diabetes (24.8%, 95% CI: 18.7‐32.0 vs 13.9%, 95% CI: 10.5‐18.1; P  = .003), as well as malignancy ( P  = .01), chronic heart disease ( P  = .003), chronic renal disease ( P  = .03), and chronic lung disease ( P  = .04). However, there were no significant differences between the nonsurvivor and survivor group in terms of presenting symptoms or organ injuries except for kidney injury (29.98%, 95% CI: 20.6‐41.5 vs 4.5%, 95% CI: 0.8‐21.7; P  = .02) (Table S3A).

3.9. Meta‐regression: factors associated with COVID‐19 mortality

Meta‐regression of multiple study‐level clinical and laboratory characteristics showed statistically significant correlation between several clinical and laboratory factors and mortality (Table  3 ). Among baseline characteristics, age, male sex, hypertension, and diabetes were significantly associated with increased mortality. Clinical factors also significantly associated with mortality included pneumonia, kidney injury, shock, cardiac failure, and acute respiratory distress syndrome. Laboratory parameters significantly correlated with mortality included increased white cell count, neutrophil count, AST, ALT, creatinine, lactate dehydrogenase, procalcitonin, and C‐reactive protein (Table  3 ). Lymphocyte count and albumin were inversely correlated with mortality. The complete list of variables analyzed by meta‐regression is found in Table S4B.

Significant factors associated with COVID‐19 mortality

3.10. Pediatrics

A total of 14 studies involving 2786 patients aged 0.55 to 18 years provided data for this analysis. The pooled mean age was 4.6 years (95% CI: 1.1‐12.8), and 50.3% (95% CI: 43.99‐56.7) were male. Twelve studies (296 individuals) provided data for mortality. The pooled mortality was 3.8% (95% CI: 1.8‐8.1), 8.1% (95% CI: 2.8‐21.3) required admission to ICU, and 5.99% (95% CI: 2.5‐13.7) required mechanical ventilation.

3.11. Pregnant women

Analysis of nine studies comprising of 305 pregnant COVID‐19 patients demonstrated a pooled proportion of patients requiring ICU admission of 6.9% (95% CI: 2.5‐18.0). The pooled proportion of preterm delivery was 26.8% (95% CI: 13.99‐45.2) and of fetal loss was 4.6% (95% CI: 1.9‐10.5). Finally, among a small sample of 43 patients from six studies, the pooled proportion of obstetric complications (eg, pre‐eclampsia, premature rupture of membranes, gestational hypertension) was 51.7 (95% CI: 36.9‐66.3).

Sensitivity analyses were performed for the clinical characteristics and outcomes of COVID‐19 individuals, excluding studies that were (a) in preprint form and (b) studies with less than 10 individuals (Table S5A‐C). The results from the sensitivity analyses yielded similar results to the main analyses. As all included studies were of at least moderate quality, sensitivity analyses excluding low‐quality studies were not performed.

There was considerable heterogeneity among the studies for the overall and subgroup results (all I 2 statistic >98.00). Egger's test was not suggestive of significant publication bias in the analysis for mortality ( P  = .6) but was significant in the analysis for severity ( P  < .001).


In this large and comprehensive systematic review and meta‐analyses involving 212 studies and 281,461 individuals from 11 countries/regions, we found that COVID‐19 patients had a mean age of about mid 40's, equally distributed among the sexes, and without significant demographic differences among the countries/regions analyzed. We estimated a severe disease rate of about 23% and a mortality of about 6%, with the main variation toward the highest severe disease rate for Wuhan, China (38%), and highest mortality for Italy (14%) followed by Wuhan and Hubei (about 11%). Among those with severe disease, the pooled mean age was 60 years and more than half (61%) were male. In addition, severe COVID‐19 patients were more likely to have existing comorbidities such as diabetes, malignancy, immunosuppression, and hypertension, highlighting the special need for disease prevention and control in these high‐risk populations.

The pooled mean time from the onset of symptoms to hospitalization was 5.48 days and was notably longer in Mainland China compared to outside of Mainland China (about 6 vs 3 days). Within Hubei province, the time to hospitalization was 7.5 days compared to 4.5 days outside of Hubei, which may be related to the overwhelmed healthcare resources closer to the epicenter of the outbreak. We also noted significant differences in ICU admission within China with utilization rates being about 16% to 17% in Wuhan compared to 8% to 9% outside of Wuhan and Hubei. Wuhan and Hubei also had two times higher rates of mechanical ventilation than outside these areas (about 11% vs 5%). Together, these data suggest the presence of delayed diagnosis and care leading to more severe disease at presentation likely due to the overwhelmed healthcare resources at the onset of this pandemic, which advocates for local preparedness to prevent severe disease progression and mortality.

With regards to presenting symptoms as potential predictors for disease progression, abdominal pain, an infrequent symptom, were notably strongly associated with severe COVID‐19 disease. Those who present with abdominal pain should be more closely monitored for rapid decompensation. Similarly, patients with low lymphocyte and albumin levels may have a more severe course of disease. We hypothesize that people at most risk for dying may be the ones that are malnourished, as reflected in low albumin. This hypothesis is probable especially when we look at countries such as the United States where clusters of COVID‐19 cases appearing in elderly nursing homes carry a disproportionate number of deaths. 15 Therefore, this is an area that needs further research especially as the world's population continues to age 16 and as the pandemic marches to resource‐limited regions where malnutrition may be more common.

Among children, the mortality was nearly 4%, with 8% requiring ICU admission and 6% requiring mechanical ventilation. This pooled data may be limited by the small numbers of included patients, and we note that only 1.8% of patients in a recent study were admitted to the ICU. 17 Similarly, the pooled data show that among pregnant individuals, 7% were admitted to the ICU, fetal loss occurred in 5%, and half develop obstetric related complications. However, our pooled data were based on only 43 patients drawn from six studies and should be interpreted with caution, but these findings warrant further investigation.

Our study is not without its limitations. Due to the lack of age group studies, we were unable to perform any subanalyses by age groups other than the pediatric population. As the proportion of individuals with mild or asymptomatic COVID‐19 infection may be much higher than expected, the pooled data we report is likely to be an over‐estimate as most of the data comes from hospital‐based studies. With the pandemic constantly evolving, a recent study was published after our study completion showing a 21% mortality in New York City. 18 Another limitation of our study is the fact that we included case reports to avoid missing potentially important data for this new pandemic, but case report data may bias towards the extremes or atypical. However, we performed sensitivity analyses that excluded studies with less than 10 patients and found similar results. Part of the differences in death rates among the different studies and countries/regions could also be attributed to how COVID‐19 deaths are reported. Some countries may only be reporting deaths that are felt to be a direct cause of COVID‐19 and not just deaths occurring in COVID‐19 patients. Therefore, a universal definition of which deaths should be reported needs to be developed. Nonetheless, these data are important for each respective country to determine their death rate in comparison to others when developing their own policies addressing COVID‐19. In addition, the majority of studies included in our meta‐analysis are hospital‐based and/or tertiary care center‐based studies, so our data may not be generalizable to affected patients outside of this setting, and further studies focusing on less severe community patients are needed. Last, as the pandemic spreads across the globe, additional data have become available for other regions not well represented in this study; therefore, more updated review and meta‐analysis providing data for more regions of the world are needed.

In conclusion, we provide a large systemic review and regarding the clinical features and associations with severe COVID‐19 disease. These data can inform healthcare providers and policy decision‐makers as to how best to identify and monitor patients at most risk for the development of severe COVID‐19 as well as to identify vulnerable populations where special measures to prevent COVID‐19 transmission may be needed.


Guarantor of article: Mindie H. Nguyen; study concept and study supervision: Mindie H. Nguyen; study design: Jie Li, Daniel Q. Huang, Ramsey Cheung, and Mindie H. Nguyen; manuscript drafting: Jie Li, Daniel Q. Huang, Linda Henry, Ramsey Cheung, Mindie H. Nguyen; manuscript edition and final approval: all authors; data analysis: Biyao Zou, Jie Li, Daniel Q. Huang, and Mindie H. Nguyen; data collection and/or data interpretation: all authors.


Ramsey Cheung has received research support for Gilead Sciences. Mindie H. Nguyen has received research support from Gilead, BMS, and Janssen, and has served as an advisory board member or consultant for Dynavax, Gilead, Alnylam, BMS, Novartis, Spring Bank, and Janssen. Other authors have no disclosures.

Supporting information

Li J, Huang DQ, Zou B, et al. Epidemiology of COVID‐19: A systematic review and meta‐analysis of clinical characteristics, risk factors, and outcomes . J Med Virol . 2021; 93 :1449‐1458. 10.1002/jmv.26424 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Jie Li and Daniel Q. Huang contributed equally to this article.

[Correction added after online publication on 10 September 2020: Duplicate table 4 has been removed completely]


  • Erasmus School of Economics
  • Erasmus School of History, Culture and Communication
  • Erasmus School of Law
  • Erasmus School of Philosophy
  • Erasmus School of Social and Behavioural Sciences
  • Erasmus School of Health Policy & Management
  • International Institute of Social Studies
  • Rotterdam School of Management
  • Tinbergen Institute
  • Institute for Housing and Urban Development Studies
  • RSM Parttime Master Bedrijfskunde
  • Erasmus University Library
  • Thesis Repository.
  • Erasmus School of History, Culture and Communication /
  • Cultural Economics and Entrepreneurship /
  • Master Thesis
  • Search: Search

Carmen van 't Zelfden

What Am I Going to Wear?!


In recent years, the world has faced the Covid-19 pandemic where everyone’s lives turned upside down. This could have an influence on the way individuals behave and feel. Since daily habits changed, all kinds of changes happened in the minds of people, such as rethinking the way they dress. Especially for Generation Z, whose lives were supposed to be vibrant and lively, but did not have the incentive to get dressed up anymore. Now that the Covid-19 crisis has passed, this could have an influence on the current fashion trends, and to how Generation Z would dress now. This research aims to fill these gaps by answering the following research question: “What is the effect of the Covid-19 crisis, the economic crisis and the fashion industry on the clothing consumption behavior of Gen Z?”. Using a mixed method approach, a self-completion questionnaire, and focus groups, the impact of the Covid-19 crisis, the economic crisis and the fashion industry on the way Generation Z dresses has been researched. It is found that there are statistically significant relationships between the consequences of crises, the segments of the fashion industry, the bandwagon effect, and purchase intention. This has been supported by the qualitative results, showing evidence of changing consumption behavior, the need to follow others, and perceptions on comfortable clothing have been discovered. A contribution has been made through the discovery on new insight on the effects of crises, the changing consumption behavior, the development of fashion trends, and the definition of comfortable clothes.


Add Content


  1. A Chinese PhD Thesis Sheds Important New Light On The Origin of the

    a thesis on covid 19

  2. Fourth Grader Pens Essay About Coronavirus Anger and Fears

    a thesis on covid 19

  3. ≫ Nationalism and Covid-19 Pandemic Free Essay Sample on Samploon.com

    a thesis on covid 19

  4. Statement on COVID-19: ethical considerations from a global perspective

    a thesis on covid 19


    a thesis on covid 19

  6. A Chinese PhD Thesis Sheds Important New Light On The Origin of the

    a thesis on covid 19


  1. Muvhango actress Regina "Vho-Masindi" Nesengani receives her PhD from UNISA

  2. Motivated to finish my thesis!


  1. An Analysis of The Covid-19 Pandemic on The Students at The University

    This Honors Thesis is brought to you for free and open access by the Theses, Dissertations, and Student Projects ... COVID-19, and of those cases, 968,839, or 1.2%, resulted in death (Elflein, 2022). The South Dakota Department of Health recorded its first case of COVID-19 in South

  2. Coronavirus disease 2019 (COVID-19): A literature review

    Abstract. In early December 2019, an outbreak of coronavirus disease 2019 (COVID-19), caused by a novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), occurred in Wuhan City, Hubei Province, China. On January 30, 2020 the World Health Organization declared the outbreak as a Public Health Emergency of International Concern.

  3. A Literature Review on Impact of COVID-19 Pandemic on Teaching and

    The COVID-19 pandemic has created the largest disruption of education systems in human history, affecting nearly 1.6 billion learners in more than 200 countries. ... Designing a virtual reality-support for the thesis supervision meeting... Go to citation Crossref Google Scholar. A Solution-Focused Model: Integrating Counseling Concepts into ...

  4. COVID-19 pandemic and its impact on social relationships and health

    This essay examines key aspects of social relationships that were disrupted by the COVID-19 pandemic. It focuses explicitly on relational mechanisms of health and brings together theory and emerging evidence on the effects of the COVID-19 pandemic to make recommendations for future public health policy and recovery. We first provide an overview of the pandemic in the UK context, outlining the ...

  5. Coronavirus disease 2019 (COVID-19): A literature review

    In early December 2019, an outbreak of coronavirus disease 2019 (COVID-19), caused by a novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), occurred in Wuhan City, Hubei Province, China. On January 30, 2020 the World Health Organization declared the outbreak as a Public Health Emergency of International Concern. As of February ...

  6. PDF The Covid 19 Pandemic and Its Effects on Medication Usage

    A thesis submitted to the Johns Hopkins University in conformity with the requirements for the degree of Master of Science ... COVID‐19 could have had a variety of sources to help the spread in the beginning. So many changes have taken place throughout the world due to the pandemic, and behavior of ...

  7. PDF The Impact of Covid-19 on Student Experiences and Expectations ...

    COVID-19, we can back out the subjective treatment e ect of COVID-19 on academic performance. The credibility of our approach depends on: (1) students having well-formed beliefs about outcomes in the counterfactual scenario. This is a plausible assumption in our context since the counterfactual state is a

  8. The dissertation journey during the COVID-19 pandemic: Crisis or

    This study aims to fill the research gaps and integrate attribution and self-efficacy theories to understand how the COVID-19 pandemic influences students' decision-making and behaviours during the dissertation writing process. ... note that thesis advisors can empower students to explore novel ideas and identify new products or services for ...

  9. The challenges arising from the COVID-19 pandemic and the way ...

    The conducted qualitative research was aimed at capturing the biggest challenges related to the beginning of the COVID-19 pandemic. The interviews were carried out in March-June (five stages of the research) and in October (the 6th stage of the research). A total of 115 in-depth individual interviews were conducted online with 20 respondents, in 6 stages. The results of the analysis showed ...

  10. A comprehensive analysis of the efficacy and safety of COVID-19

    Many people are concerned about the efficacy and safety of the COVID-19 vaccines. We performed a comprehensive analysis of the published trials of COVID-19 vaccines and the real-world data from the Vaccine Adverse Event Reporting System. Globally, our research found that the efficacy of all vaccines exceeded 70%, and RNA-based vaccines had the ...

  11. COVID-19 vaccine rollout: Examining COVID-19 vaccination perceptions

    COVID-19 vaccine rollout: Examining COVID-19 vaccination perceptions and intention among nurses Emilee T. Austin Nurses' COVID-19 vaccination rates have been reportedly low for being among the first prioritized for vaccination. To understand and potentially explain uptake barriers, this thesis

  12. PDF Pandemic Economics: a Case Study of The Economic Effects of Covid-19

    An Abstract of the Thesis of. Lucy Hudson for the degree of Bachelor of Science in the Department of Economics to be taken June 2021. Title: Pandemic Economics: A Case Study of the Economic Effects of COVID-19 Mitigation Strategies in the United States and the European Union. Approved: Assistant Professor Keaton Miller, Ph.D.

  13. The impact of COVID-19 pandemic on physical and mental health of ...

    The coronavirus disease (COVID-19) pandemic has impacted the economy, livelihood, and physical and mental well-being of people worldwide. This study aimed to compare the mental health status during the pandemic in the general population of seven middle income countries (MICs) in Asia (China, Iran, Malaysia, Pakistan, Philippines, Thailand, and Vietnam). All the countries used the Impact of ...

  14. The complexity of managing COVID-19: How important is good ...

    This essay is part of "Reimagining the global economy: Building back better in a post-COVID-19 world," a collection of 12 essays presenting new ideas to guide policies and shape debates in a ...

  15. Mental Health Effects of the COVID-19 Pandemic on Older Adults

    Additionally, apart from the physical effects of. COVID-19, significant psychological effects such as anxiety, depression, and loneliness. are shown to affect individuals of all ages including the older adult population, individuals aged 65 years and older (Wang et al., 2020). In a prevalence study of the rates.

  16. How to Write About Coronavirus in a College Essay

    Writing About COVID-19 in College Essays. Experts say students should be honest and not limit themselves to merely their experiences with the pandemic. The global impact of COVID-19, the disease ...

  17. PDF Writing COVID-19 into your thesis

    Thinking about COVID-19 and your introduction The personal and professional context of your thesis is likely to have changed as a result of COVID-19. The changes implied are immediate and short-term, but there will also be long term implications (for example, online teaching, the role of the state, levels of unemployment, return to deepened

  18. PDF Research degree theses and the impact of Covid 19

    Introduction. 1.1. Where possible, research students should adapt their research activities to address disruptions caused by Covid-19 restrictions. 1.2. Students may choose to include a statement at the front of their thesis on the impact of disruptions on their work. Examiners will consider this statement as contextual information to support ...

  19. 12 moving essays about life during coronavirus

    Read these 12 moving essays about life during coronavirus. Artists, novelists, critics, and essayists are writing the first draft of history. A woman wearing a face mask in Miami. Alissa Wilkinson ...

  20. COVID-19, Food Insecurity, and Access to Oral Healthcare

    COVID-19, Food Insecurity, and Access to Oral Healthcare. Download (1.95 MB) thesis. posted on 2023-04-30, 17:00 authored by Pheba Abraham Abraham. The COVID-19 pandemic has led to dramatic shifts in employment rates and inflation, and will likely have long-ranging economic impacts, particularly on those who are already in lower SES groups.

  21. COVID-19 Thesis Impact Statement

    COVID-19 Thesis Impact Statement. The impact of the COVID-19 pandemic on all aspects of our lives is well known. Victoria experienced six lockdowns between March 2020 and October 2021 that collectively totalled 262 days. Deakin University sought to mitigate this impact on the research by higher degree by research students in various ways ...

  22. Lessons Learned From COVID-19

    The COVID-19 pandemic was the worst public health emergency of the last century. Despite aggressive attempts to contain the virus by social isolation, masking, and medical management, over 1.1 million Americans died between January 31, 2020, when the U.S. Department of Health and Human Services (HHS) declared COVID-19 a public health emergency, and March 11, 2023, when HHS declared the public ...

  23. An Introduction to COVID-19

    A novel coronavirus (CoV) named '2019-nCoV' or '2019 novel coronavirus' or 'COVID-19' by the World Health Organization (WHO) is in charge of the current outbreak of pneumonia that began at the beginning of December 2019 near in Wuhan City, Hubei Province, China [1-4]. COVID-19 is a pathogenic virus. From the phylogenetic analysis ...

  24. Developing Technological Platforms for Targeted Cancer Therapies

    Biomedical engineering has made remarkable progress in enhancing human healthcare, contributing significantly to the fight against human diseases. However, we still confront grand challenges in accurate disease diagnosis, efficient therapeutic delivery, and the development of targeted therapies. For example, the diagnosis of coronavirus disease (COVID-19) remains challenging in low-resource ...

  25. Epidemiology of COVID‐19: A systematic review and meta‐analysis of

    1. INTRODUCTION. On 11 March, the World Health Organization (WHO) declared the coronavirus disease 2019 (COVID‐19) outbreak caused by the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) a pandemic. 1 Currently, the deadly COVID‐19 has no effective therapy or vaccine. In addition, the signs of having COVID‐19 are nonspecific or can be absent, adding challenges to disease ...

  26. Erasmus University Thesis Repository: What Am I Going to Wear?!

    In recent years, the world has faced the Covid-19 pandemic where everyone's lives turned upside down. This could have an influence on the way individuals behave and feel. Since daily habits changed, all kinds of changes happened in the minds of people, such as rethinking the way they dress. Especially for Generation Z, whose lives were ...

  27. Ready, set, go!

    From a revolutionary new paper-drying technique to a new take on cancer therapy, the "3-minute thesis" competition offers a glimpse into outstanding graduate student research. ... New study reveals stark partisan differences in perceptions of COVID-19 disparities in the U.S.

  28. 24 THESES ON CORONA. By Rupert Read.

    10) Covid-19 is reminding us that we can be — that we are — good. 11) Covid-19 forces us to think like a community. 12) And forces us to reflect on what we usually take for granted.