By January 2022, a total of 66 COVID-19–themed games—23 (35%) analog and 43 (65%) digital—were identified. Detailed overviews of analog and digital games are provided in Multimedia Appendix 1 [47-52] and Multimedia Appendix 2 [53-70], respectively; Figures 1-10 show 10 game examples. The general findings are presented in the following sections.

The vast majority of the identified games were developed or launched in 2020 (41/66, 62%); the rest were developed or launched in 2021. The largest number of games originated in the United States (10/66, 15%), India (9/66, 14%), and the United Kingdom (7/66, 11%). The countries of origin of other games included Denmark, the Netherlands, and Switzerland (3/66, 5% of the games each); Canada, Czech Republic, Finland, Germany, Morocco, Portugal, and South Africa (2/66, 3% of the games each); and Australia, Bangladesh, Belgium, Brazil, China, France, Hungary, Indonesia, Poland, Saudi Arabia, Singapore, and Taiwan (1/66, 2% of the games each). For 8% (5/66) of the games, the country of origin could not be determined.

The lead developers were research institutions (31/66, 47% of the games), game development studios (17/66, 26% of the games), or private individuals (13/66, 20% of the games). A total of 9% (6/66) of the games were developed by children aged 10 to 17 years (Better than Hugo, Corona – Mit Eifer ins Geschäft, Corona Yuga, COVID-19: A Race to the Vaccine, Go Corona Go, and Infected!). Governmental and nongovernmental organizations (eg, ministries, educational institutes, the WHO, the Centers for Disease Control and Prevention [CDC], the United Nations Children’s Fund, and Médecins Sans Frontières) were involved in the development of 22% (5/23) of the analog games and 16% (7/43) of the digital games.

In total, 65% (15/23) of the analog games were commercial (price: US $6.54-33.77), 30% (7/23) were available for free (6/7, 86% of these as Print & Play games), and 9% (2/23) were Kickstarter prototypes. In contrast, the vast majority of digital games were free to play (20/43, 47%) or prototypes (20/43, 47%); 5% (2/43) were commercial (price: US $4.36-9.80), and 2% (1/43) were developed for internal use at a company.

Most games (38/66, 58%) targeted younger audiences, including children as young as 3 years old, teenagers, and university students. Analog games were often designed to be engaging for the entire family, whereas 36% (24/66) of all digital games did not have a defined target audience. Certain other games targeted very specific user groups, such as gamers, active social media users, health care workers, health enthusiasts, employees of certain enterprises, and the African population.

Practically all games identified were simulations of the COVID-19 pandemic. Some were set in the players’ immediate environment, such as the classroom (eg, Fighting COVID-19 at Purdue University), the office (eg, Social Distancing – The Game), or the supermarket (eg, Dino-Store), or more broadly in a village, town, or city (eg, Clinic Deluxe Edition: CoVid_19 variant [Figure 1], COVID Dodge, SurviveCovid-19, and VRS Fight Club); a country (eg, Better than Hugo and Korona hra); or the world (eg, Plague Inc.: The Cure; Figure 2), where the players were tasked with controlling the spread of the disease. Others were set in a microscopic environment of the human body, where the players assumed the role of immune cells in fighting off the infection (eg, Antidote COVID-19 [Figure 3] and Infekcja) or of the virus in spreading the disease (eg, Viruscape). Other interesting approaches were used in games such as At-Home Scavenger Hunt by the CDC (Figure 4), which required the players to find relevant physical items in their actual environment; the location-based game MeetDurian, where virtual items could be collected in the player’s physical environment (similar to Pokémon GO) if the player was wearing a face mask, the presence of which was detected by face recognition software; and GO VIRAL! (Figure 5), which was set in the environment of a simulated social media platform.

The vast majority of analog games were board games (15/23, 65%) or card games (6/23, 26%). The most common analog game types or genres were strategy games (11/23, 48%; eg, Lockdown!; Figure 7) and race-to-the-end games (6/23, 26%; eg, You Make Me Sick!; Figure 6), whereas most digital games were primarily strategy (15/43, 35%; eg, Plague Inc.: The Cure), action (14/43, 33%; eg, COVID Dodge), and trivia (12/43, 28%; eg, Corona Bee; Figure 8) games. Some less common game types such as meditation or Zen (CovidShield), hidden object (Help to stop the COVID-19 coronavirus and At-Home Scavenger Hunt by the CDC), memory (Heroes of Covid-19; Figure 9), and escape room–type puzzles (COVID-19 [CORONA VIRUS] and Destroy COVID; Figure 10) were also identified.

Most digital games (23/43, 53%) were web-based and playable on PCs, mobile devices, consoles, or a combination of these. An additional 21% (9/43) were deployed for mobile platforms, 7% (3/43) were deployed for desktop and mobile platforms, 2% (1/43) were deployed for desktop only, 2% (1/43) were deployed for desktop and consoles, and 2% (1/43) were deployed for consoles only. Analog games mainly took the form of physical objects (eg, game boards with figures and dice, play money or tokens, playing cards, and puzzle pieces) or free electronic files that were designed to be printed at home (Print & Play).

Of the 43 digital games, 37 (86%) were single-player, 4 (9%) were multiplayer (up to 7 players), and 2 (5%) were single- and multiplayer. Of the 6 multiplayer digital games, 5 (83%) were co-operative, and 1 (17%) was competitive. In contrast, all analog games (23/23, 100%) were multiplayer (up to 100 players), although single-player versions were also available in 26% (6/23) of the cases. Of these 23 games, 18 (78%) were competitive, 4 (17%) were co-operative, and 1 (4%) involved only teams or partnerships.

Information retrieved from 15 analog games showed that gameplay duration ranged from 5 to 180 minutes—3 (20%) games required up to 15 minutes, 5 (33%) games required up to 30 minutes, 2 (13%) games required up to 45 minutes, 2 (13%) games required up to 60 minutes, and 3 (20%) games required >1 hour. The estimated duration could only be retrieved for 7% (3/43) of the digital games, which were substantially shorter than most analog games and lasted 5 to 15 minutes.

A game only has an impact if it is played. It is noteworthy that we only became aware of the multitude of COVID-19–themed games when we started actively searching for them. Although our experience is anecdotal, it does suggest the importance of investing time and effort in the dissemination of serious games.

In the context of a pandemic, game developers should carefully consider their target audience. In many cases, this is probably the broadest audience possible, making it crucial to plan for the effective dissemination of the game. Most of the reviewed analog games (15/23, 65%) were commercially available physical objects, whereas most digital games (20/43, 47%) were freely accessible web-based applications. Each of the various forms of dissemination has advantages and disadvantages, but deployment strategy and cost may influence game accessibility to the greatest extent. Commercial games, for example, have an advantage in that they have access to professional dissemination channels and are often designed to be intriguing and esthetically appealing to attract people’s attention. However, the cost and effort necessary to obtain such games can preclude them from reaching a broader audience. For analog games, Print & Play games tend to be the most convenient to access, especially when freely available on the web. Such games have a relatively low threshold for access in that buying them is not necessary.

When social distancing is required, as was the case during the pandemic, playing analog games is typically only possible for members of the same household. In contrast, digital games are easy to obtain and play remotely provided that the users have access to electricity and the internet. To maximize reach, Hill et al [82] advised that COVID-19–themed games must be platform-independent and playable with minimal hardware.

Collaborating with health authorities, the media, nongovernmental organizations, educational institutions, (local) governments, and social media influencers can also help spread awareness of a game’s existence, although this may not always be the case. The designers of Escape COVID-19, for example, conducted a retrospective analysis to investigate the reasons for their limited success in recruiting participants for their study [104]. Specifically, they aimed to assess the effect of 3 different dissemination strategies on game account creation over a period of 6 months. In the first period (53 days), the game was disseminated by a part-time worker; following this was a press release (15 days); and in the final stage, the game was officially announced by the Swiss Federal Office of Public Health (15 days). Their findings suggested that the press release was the most successful and the official communication was the least successful. Nonetheless, the sequence and duration of communication interventions should also be considered.

For games that aim to inform and share recommendations during a pandemic, a prominent challenge is that such recommendations are inherently dynamic. Although some information might be fixed (eg, what a virus is), other information may likely change after a game is introduced. The use of reliable sources such as the WHO, the CDC, and local governments can assure people that the communicated knowledge is factual. Practically all the reviewed games based their learning objectives on such sources. However, as guidelines may differ among different institutions and game developers may have different opinions on which information is correct, it is recommended that players be explicitly informed about the sources of the communicated knowledge. In addition, the credibility of the aforementioned sources can be subject to change, as seen with the rapidly waning trust in the CDC in the United States.

Real-time updates can be especially helpful in tackling confusion when guidelines change rapidly owing to the evolving understanding of health crises. It is critical that pandemic games be designed in a way that prevents them from becoming outdated too quickly; this can be addressed by incorporating sufficient flexibility in game design to allow for changing guidelines or information. Although this tends to be more challenging for analog games, it is possible—the content of analog games can be updated via expansion packs, and hybrid games where physical game elements are complemented by a regularly updated mobile app can be developed.

All the analog games reviewed in this study (23/23, 100%) were multiplayer and mainly competitive, whereas only 14% (6/43) of the digital games supported a multiplayer mode, of which 83% (5/6) were co-operative. The main advantage of single-player games is that they can be played at any time independently of other people. However, most single-player games do not allow for socializing, sharing opinions, or discussing ideas. In contrast, multiplayer games allow for socializing, but the minimum number of players required can limit the number of opportunities to play the game as this may depend on other people’s interest, availability, or both. Optimally, a game should be designed to support both single- and multiplayer modes, as was the case for 26% (6/23) of the analog games and 5% (2/43) of the digital games studied in this review.

During the COVID-19 pandemic, collective action and compliance with safety guidelines were paramount in reducing the spread of the virus. Co-operative games can communicate this need to the players and support social bonding and collective decision-making that can be transferred from the in-game world to real-life situations. Previous studies have suggested that participation in co-operative—as opposed to competitive—multiplayer games can support team building [110-113] and increase real-world collaboration and prosocial behaviors among players [114-117]. In contrast, the motivation to win in competitive games may leave little room for bonding and the exchange of ideas, possibly limiting the encouragement of prosocial behavior. Nevertheless, competitive games tend to be more stimulating, whereas co-operative games may support passive participation when responsibilities are not equally distributed among the players. Therefore, it is advised to design for teams or partnerships, which combines both co-operation among team members and competition against the opposing team or teams.

Immersive simulations of realistic environments and experiences where acquired knowledge can be put to use without the serious consequences of a real disaster may facilitate players’ transfer of new knowledge to everyday life [29]; this is particularly important during pandemics, when rapid changes in attitudes and behavior are required. Presumably for this very reason, practically all the reviewed games were either literal or metaphorical simulations of the COVID-19 pandemic. However, as such games tend to emphasize educational goals, caution is necessary to adequately balance such education with entertainment so that games remain appealing to a broader audience.

To foster players’ motivation and consolidate their engagement, fun elements that are unrelated to the simulated domain (eg, avatar shape or a game within a game) can be used. For example, the authors of Escape COVID-19 found that attractive graphics that were adapted to fit the preferences of the target population were essential in increasing players’ engagement [92]. Nevertheless, the designers of Point of Contact [82] stressed that a game’s graphics and cross-player communication need to be lightweight to minimize players’ dependence on high-performance devices and high-speed networks. Similarly, it is important to avoid substantial hardware demands, which were present in 2 game prototypes that were included in this study: the Instructional remote multi-player VR game requires access to a VR headset, and participants need to own an Xbox 360 device for the Physical Fitness Training Program.

Most of the analog games reviewed in this study (9/15, 60%) were designed for longer durations of gameplay (up to 3 hours); we could only retrieve the predicted duration for 7% (3/43) of the digital games, but the time required to play these games was considerably shorter (up to 15 minutes). The main advantage of short game durations (a few minutes) is that they do not require high levels of commitment, so the games can be played without previous planning. However, they may fail to elicit a flow state, reflection, or both. In contrast, long game durations (several hours) may deter potential users, especially if the game is multiplayer and requires scheduling a time that is appropriate for all players. Moreover, players may lose interest if a game lasts too long. Therefore, it is important to carefully design pandemic-themed games for optimal duration, depending heavily on the target group, game type, and intended transfer effects.

To avoid cognitive overload, it is generally advised that games provide a clear distinction between the active and reflective phases of gameplay. Marne et al [105] suggested that intensive action phases that engage players emotionally and shift their focus toward a game’s goal can be used for practice and training, whereas less intensive phases should be provided for reflection and relief purposes. During reflective phases, games should provide feedback to players so that they can understand the consequences of their actions and keep track of their own progress. However, this information must be provided in a way that does not interfere with the player’s state of flow as this could cause them to lose interest in the game.

A possible solution proposed by Marne et al [105] is that individual items of obtainable knowledge or skills are represented as collectible virtual objects (rewards) that can be showcased or used as an asset later in the game. In addition to material rewards or achieving (publicly displayed) high scores, sensory stimulation (eg, sounds or graphics indicating an achievement) can also be rewarding, as can be messages of affirmation or commendation. For example, games such as Escape COVID-19 included a positive message at the end of each level to strengthen players’ motivation to comply with guidelines [92]. In such cases, simple, commonly used terminology can help a game more effectively reach broader target audiences.