Pandemic March: 2019 Coronavirus Disease’s First Wave Circumnavigates the Globe

Objective: March 2020 was a pivotal month for the worldwide geographic and numeric expansion of the first wave of Coronavirus Disease 2019 (COVID-19). We examined the major storylines that depicted this explosive spread of COVID-19 around the globe. Methods: A detailed review of World Health Organization (WHO) situation reports, surveillance summaries, and online resources allowed us to quantify the increases in cases and deaths by region and by country throughout the month of March 2020. Results: During March, COVID-19 was officially declared by the WHO to be a pandemic. COVID-19 emerged from a focalized outbreak in the Western Pacific Region and rapidly proliferated across all continents worldwide. Globally, cumulative numbers of confirmed cases increased by a factor of nine throughout the month. During the entire month, cases rose exponentially throughout Europe. Starting in mid-March, confirmed cases accelerated coast-to-coast throughout the United States and, on March 26, the United States surpassed all other nations to rank first in numbers of cases. COVID-19 mortality lagged several weeks behind but by month’s end, death tolls were also rising exponentially. Conclusion: March 2020 was a consequential month when the COVID-19 pandemic wrapped completely around the planet, with outbreaks erupting in most nations worldwide.

T he month of March 2020 was pivotal for the worldwide progression of coronavirus disease 2019 (COVID-19). COVID-19 was previously designated by the World Health Organization (WHO) as a Public Health Emergency of International Concern (PHEIC) on January 30, 2020. However, it was on March 11, 2020, when WHO Director General, Dr Tedros Adhanom Ghebreyesus, declared the outbreak to be a pandemic. March witnessed the total global wraparound of this highly transmissible disease.
By the month's end, the worldwide geographic distribution of cases had been dramatically reshaped. COVID-19's reach extended across 6 continents and all United Nations regions, with cases reported in 205 countries and territories. Although the tallies of confirmed cases and deaths will be eclipsed, and in fact dwarfed, in future months, it was during March 2020 that COVID-19 demonstrated its remarkable capacity to circumnavigate the planet. COVID-19 became a worldwide threat with breathtaking speed.
We examine patterns of confirmed cases globally, by United Nations regions and by country, drawing from WHO daily situation reports throughout the month of March 2020, with particular focus on the reports issued on March 1 and April 1, 2020. 1 In terms of known, confirmed cases, whether plotted on a map or depicted on an epidemic curve, COVID-19 appeared as a regional outbreak constrained primarily to the Western Pacific. However, as a faint but ominous sign of what March would bring, a total of 59 countries worldwide had reported cases to the WHO by February 29, including 50 countries outside of the Western Pacific Region. Yet among these 59 nations, 40 reported 4 cases or fewer.
During March 2020, all changed. Globally, confirmed case counts vaulted upward exponentially to 823 626 cases on March 31, 2020, representing more than a 9-fold increase in cases worldwide. Beyond the cumulative numbers, the global distribution of cases was fundamentally altered within a single month.
Three storylines emerged. First, extending throughout the entire month of March, COVID-19 engulfed the European Region, which would end the month with more cases than any other United Nations region. Second, continuously gaining momentum, COVID-19 swept generally west to east, and north to south throughout the continental United States, which would end the month with far more cases than any other nation. Third, by the end of March, as the COVID-19 pandemic spread broadly, 205 nation states and territories had reported cases -3.5 times more than the 59 states and entities reporting cases as of February 29, 2020.

Storyline 1: European Region
On February 29, The European Region had just 1457 COVID-19 cases, representing 1.7% of the global total. Fully 1128 (77.4%) of the European cases were reported in Italy. As a harbinger of things to come, 27 European countries had reported cases, yet 15 European nations had 3 cases or fewer.
During March, the European Region cases would increase to 464 212 (56.4% of total global cases), with cumulative cases rising by a factor of 319 over the month (Figure 1). The number of European Region nations reporting cases more than doubled from 27 to 60 countries and territories. Italy exceeded 100 000 cases. Italy and Spain both surpassed the numbers of cumulative cases reported in China. By the month's end, 24 European nations and territories had more than 1000 reported cases

Storyline 3: Worldwide Dispersion
The COVID-19 pandemic extended into 205 nation states and territories by the end of March compared with 59 entities reporting cases at the end of February. During that interval, the number of countries/territories with more than 100 cases had grown by a factor of 16, from 7 nations to 115. Two regions, in particular, witnessed monumental increases in nations reporting cases with the region of the Americas experiencing a 10-fold rise and the African Region experiencing a 22-fold increase.
As noted, Europe accounted for 56.4% of total global cases reported at the end of March, with case counts rising by a factor of 319. Yet this number, startling in its own right, was greatly exceeded by the more than 2000-fold increase in confirmed case numbers in both the region of the Americas and the African Region.

COVID-19 DEATHS AND CASE-FATALITY RATES Global Picture
At the beginning of March, China had recorded 2873 deaths, and just 104 deaths were reported worldwide from countries other than China. By the end of March, the global death toll had risen to 40 598. Among the 37 621 deaths occurring during March, only 448 deaths occurred inside China. Cumulative non-China deaths had increased by a factor of 358. The overall global case-fatality rate (CFR) was 4.9% but with remarkable disparities by region and by country within a region (Table 3).

European Region
On March 1, the European Region recorded 1457 cases and 31 deaths, with a CFR of 2.1%. By the month's end, those numbers had incremented to 464 212 cases and 30 089 deaths with a CFR of 6.5%. Cumulative deaths increased by a factor of 970. Several countries in the European Region had extremely high CFRs that were rising steadily over the month. On March 31, the CFR for Italy was 11.7% and for Spain, 8.7%.

United States
The first US death was announced on February 29, 2020, but it did not appear on the WHO situation reports until

CONCLUSION
The first wave of COVID-19 cases is on the move, rampantly extending its reach throughout the globe and erupting in new