The virus that causes COVID-19 is infecting people and spreading easily from person-to-person. Cases have been detected in most countries worldwide. Different parts of the world are seeing different levels of COVID-19 activity. Both the United States and Europe are in the acceleration phase of the pandemic.

1. YALE-TULANE ESF-8 SPECIAL REPORT
CORONAVIRUS (COVID-19)
AS OF 7 APRIL 2020
2300 HRS EDT
US FEDERAL GOVERMENT
• CORONAVIRUS.GOV
• USA.GOV
HHS
COVID-19
CDC
• CDC – COVID-19
NIH
• COVID-19
NIOSH
• NIOSH CORONAVISUS
FEMA
• FEMA
DOD
Coronavirus Response
USAF _ COVID-19
NEWS SOURCES
• New York Times
COVID-19 Coverage
• WASHINGTON POST
• Reuters
• CNN
• Xinhua
ASSOCIATION
• NACCHO
• AMERICAN HOSPITAL
ASSOCIATION
• NRHA
SITUATION - GLOBAL
PORTALS, BLOGS, AND RESOURCES
• YALE NEWHAVEN HEALTH – COVID-19
• YALE MEDICINE
• YALE NEWS _COVID 19
• JOHN HOPKINS UNIVERSITY COVID-19 GLOBAL CASES (CSSE)
• COVID-19 SURVEILLANCE DASHBOARD
• CIDRAP
• H5N1
• VIROLOGY DOWN UNDER BLOG
• CONTAGION LIVE
• WORLDOMETER
• 1POINT3ACRES
BACKGROUND WHO
• WHO –COVID-19
• ECHO
• PAHO
AFRO
• EMRO
• Western Pacific
OCHA
• ReliefWeb
ECDC
• European Centre for
Disease Prevention and
Control
CCDC
• China Center for Disease
Control and Prevention
INTERNATIONAL
JOUNALS AND ONLINE LIBRARIES
• BMJ
• Cambridge University Press
• Cochrane
• Elsevier
• JAMA Network
• The Lancet 2019-nCoV Resource Centre
• New England Journal of Medicine
• Oxford University Press
• Wiley
RESEARCH
SITUATION - US
The virus that causes COVID-19 is infecting people and
spreading easily from person-to-person. Cases have been
detected throughout the United States and its territories .
The United States is currently in the acceleration phase of
the pandemic.
RISK ASSESSMENT
RISK TO GENERAL
POPULATION
RISK TO ELDERLY
POPULATION
RISK TO HEATHCARE
SYSTEM CAPACITY
MODERATE VERY HIGH HIGH
GLOBAL
CONFIRMED CASES DEATHS RECOVERED
1,430,141 82,119 301,130
UNITED STATES
CONFIRMED CASES DEATHS RECOVERED
398,809 12,895 22,224
HEALTHCARE INNOVATIONS
COVID-19 PROJECTIONS
CASES IN US
WHERE CASES ARE RISING
TESTING
CLINICAL MANAGEMENT
EMERGING ISSUES

2. BACKGROUND
WHERE: WORLDWIDE
WHEN: DECEMBER 2019 - CURRENT
SITUATION PANDEMIC OUTBREAK – COVID-19
BACKGROUND:
At the end of December 2019, Chinese public health authorities reported several
cases of acute respiratory syndrome in Wuhan City, Hubei province, China. Chinese
scientists soon identified a novel coronavirus as the main causative agent. The
disease is now referred to as coronavirus disease 2019 (COVID-19), and the
causative virus is called severe acute respiratory syndrome coronavirus 2 (SARS-
CoV-2).
It is a new strain of coronavirus that has not been previously identified in humans.
The initial outbreak in Wuhan spread rapidly, affecting other parts of China.
The International Health Regulations (IHR) (2005) Emergency Committee on the
outbreak of COVID-19 was first convened on 22‒23 January 2020, and
subsequently reconvened on 30 January 2020.
PUBLIC HEALTH EMERGENCY OF INTERNATIONAL CONCERN (PHEIC)
The WHO Director General declared the COVID-19 outbreak to be a public health
emergency of international concern (PHEIC) on 30 January 2020.
The Emergency Committee provided recommendations to WHO, to China, to all
countries and to the global community, on measures to control the outbreak.
PANDEMIC
On 11 March 2020. WHO declared COVID-19 a pandemic because of the “alarming
levels of spread and severity, and by the alarming levels of inaction”. At that time,
there were large outbreaks of the virus in Italy, South Korea, and the United States.
In the US, the slow rollout of testing and limited testing capacity has crippled
response to the disease. The declaration came after a 13-fold rise in the number of
cases outside China in the two weeks prior to the declaration.
SOURCE: NATURE
WHAT IS COVID-19
Coronavirus disease (COVID-19) is a new strain that was discovered in 2019 and
has not been previously identified in humans. Coronaviruses are zoonotic,
meaning they are transmitted between animals and people.
HOW IS IT SPREAD?
People can catch COVID-19 from others who have the virus. The disease spreads
from person to person through small droplets from the nose or mouth when a
person with COVID-19 coughs or exhales. Droplets can land surfaces around the
infected person and other can catch COVID-19 by touching these objects or
surfaces, then touching their eyes, nose or mouth. People can also catch COVID-
19 if they breathe in droplets from the infected person. This is why it is
important to stay more than 3 feet away from a person who is sick. (WHO)
Time from exposure to onset of symptoms is generally between 2 and 14 days.
(CDC)
WHAT ARE THE SYMPTONS?
Common symptoms include fever, cough, and shortness of breath (CDC).
Complications may include pneumonia and acute respiratory distress syndrome.
PREVENTIVE MEASURES
Recommended preventive measures: hand washing, covering the mouth when
coughing, maintaining distance from other people, and monitoring and self-
isolation for people who suspect they are infected.
NOTE: Anecdotal evidence is rapidly accumulating from sites around the
world that anosmia (lack of smell) and dysgeusia (lack of taste) are significant
symptoms associated with the COVID-19 pandemic. Anosmia, in particular,
has been seen in patients ultimately testing positive for the coronavirus with
no other symptoms.

3. RISK ASSESSMENT
RISK TO GENERAL POPULATION RISK TO ELDERLY POPULATION RISK TO HEATHCARE SYSTEM
CAPACITY
MODERATE VERY HIGH VERY HIGH
SITUATION - GLOBAL
On 31 March 2020, WHO published a Medical Product Alert (Number 3/2020)
regarding falsified medical products, including in vitro diagnostics, that claim to
prevent, detect, treat or cure COVID-19. WHO has received reports regarding
falsified in vitro diagnostics and laboratory reagents for the detection of SARS-
CoV-2. Due diligence is required from all actors in the procurement, use and
administration of medical products, in particular those affected by the current
crisis of, or related to, COVID-19.
MEDICAL PRODUCT ALERT
AFFECTED COUNTRIES/AREAS /TERRITORIES WITH CASES : 211
CONFIRMED CASES: 1,430,141
DEATHS: 82,119
CURRENT EPI CENTER OF THE VIRUS: EUROPE (686,338)
COUNTRY WITH MOST CASES: UNITED STATES
Pandemic is continuing to spread globally and is accelerating. Cases are now
being reported in almost every county/territory.
There is evidence that countries are having success flattening the epi curve
where stay-at-home policies have been in place for two weeks or more.
NOTE: Flattening the curve does not necessarily mean seeing a decrease in total
cases right away; it first produces a decline in the number of new cases, which result
in fewer hospitalizations and death in the weeks that follow.
Testing remains problematic. There are not sufficient test kits to meet demand.
This makes interpretation of new case statistics problematic. though
death/mortality data may be most usable information available.
Almost every country in the world facing a shortages in personnel protective
gear
Emerging evidence suggest that asymptomatic cases could be drivers of
transmission
https://who.sprinklr.com/
OFF-LABEL USE OF MEDICINES FOR COVID-19
No pharmaceutical products have yet been shown to be safe and
effective for the treatment of COVID-19. However, a number of
medicines have been suggested as potential investigational therapies,
many of which are now being or will soon be studied in clinical trials,
including the SOLIDARITY trial co-sponsored by WHO and participating
countries.(WHO). The study treatments are remdesivir, chloroquine or
hydroxychloroquine, lopinavir plus ritonavir, and interferon-beta.(ISRCTN
Registry)
The risk of the virus continuing to spread globally remains high. Insufficient number of test kits, Personal Protective Equipment (PPE), and the lack of discipline in maintaining
social distancing will only make matters worse in the coming days. Globally, national health security is weak. Most countries are not fully prepared to deal with a pandemic.
Even the US, which is ranked first in the world, has shown it does not have the capacity yet to do wide spread testing or produce sufficient PPE.

4. DISTRIBUTION OF COVID-19 CASES WORLDWIDE
(AS OF 7 APRIL 2020)
SOURCE: WHO SITREP #77

5. SITUATION - UNITED STATES
• All 50 states have reported cases of COVID-19 (CDC)
• Case numbers are expected to continue rising through the coming weeks,
as more cases are identified through testing.
• Different parts of the country are seeing different levels of COVID-19
activity. The acceleration of the spread of the diseases, however, is slowing
down.
• In response, many states have closed schools and businesses; banned
gatherings, meetings and sporting events; and, in some places, residents
have been ordered to stay inside. Currently, the majority of cases have been
recorded in New York, New Jersey, Michigan, California, and Louisiana.
• All states except for North Dakota, South Dakota, Nebraska, and Arkansas.
have implemented statewide curfews; directed the closure of non essential
business and food operations restricted to carry out/delivery only.
• Louisiana announced 35 new deaths on Monday, for a total of 512, a
number that had more than doubled in a week., however, the curve is
flattening.
• All state Emergency Operations Centers are activated for COVID-19
RISK ASSESSMENT
RISK TO GENERAL
POPULATION
RISK TO ELDERLY
POPULATION
RISK TO HEATHCARE
SYSTEM CAPACITY
MODERATE VERY HIGH HIGH
UNITED STATES
CONFIRMED CASES DEATHS RECOVERED
398,809 12,895 22,224
HOSPITALIZATIONS
Cumulative COVID-19-associated hospitalization rates since March 1, 2020, will
be updated weekly. The overall cumulative hospitalization rate is 4.6 per
100,000, with the highest rates in persons 65 years and older (13.8 per 100,000)
and 50-64 years (7.4 per 100,000). (CDC)
The densely populated New York metro area has been hit the hardest so far, in
terms of a total count. And the area accounts for more than 40 percent of total
U.S. deaths from the virus, which had infected more than 365,000 U.S. residents,
as of Monday night, 7 April 2020. (NYT)
Although many European countries have more coronavirus deaths per
capita, the United States has the third-highest death toll in the world.
DEATH

6. CASES IN THE US
SOURCE: NYT
SOURCE:JOHN HOPKINS UNIVERSITY COVID-19 GLOBAL CASES (CSSE)
SOURCE: NYT
The number of known cases of the coronavirus in the United States has
surged.
As 07 April, 1000 hrs. EST, at least 368,449
people across every state, plus Washington, D.C., and three U.S. territories,
have tested positive for coronavirus, and at least 10,959 patients with the
virus have died and 19,843 have recovered.

7. WHERE CASES ARE RISING

8. NYT
STATES WITH A LOCKDOWN ORDER OR ADVISORY
STATE DATE ENACTED
Alabama April 4, 2020
Alaska March 28, 2020
Arizona March 31, 2020
California March 19, 2020
Colorado March 26, 2020
Connecticut March 23, 2020
Delaware March 24, 2020
Florida April 2, 2020
Hawaii March 25, 2020
Idaho March 25, 2020
Illinois March 21, 2020
Indiana March 24, 2020
Kansas March 30, 2020
Kentucky March 26, 2020
Louisiana March 23, 2020
Maine April 2, 2020
Maryland March 30, 2020
Massachusetts March 24, 2020
Michigan March 24, 2020
Minnesota March 27, 2020
Mississippi April 3, 2020
Missouri April 6, 2020
Montana March 28, 2020
Nevada April 2, 2020
New Hampshire March 27, 2020
New Jersey March 21, 2020
New Mexico March 24, 2020
New York March 22, 2020
North Carolina March 30, 2020
Ohio March 23, 2020
Oregon March 23, 2020
Pennsylvania April 2, 2020
Rhode Island March 28, 2020
Tennessee March 31, 2020
Texas April 2, 2020
Vermont March 25, 2020
Virginia March 30, 2020
Washington March 23, 2020
Washington, D.C. April 1, 2020
West Virginia March 24, 2020
Wisconsin March 25, 2020
The directives to keep people at home, which began in California in mid-March, have quickly swept the nation.
Today, a vast majority of states, the Navajo Nation and many cities and counties have instructed residents to stay
at home in a desperate race to stunt the spread of the coronavirus. This means at least 316 million people in at
least 42 states, three counties, nine cities, the District of Columbia and Puerto Rico are being urged to stay home.
A handful of more rural states — Arkansas, Iowa, Nebraska, North Dakota, and South Dakota — did not
have statewide stay-at-home orders in place as of 7 April 2020. A few others had only partial orders, issued
locally by cities or counties.

9. PROGRESS ON TESTING IN US
NOTE: Data during the gray period of graph are incomplete because of the lag in time between when
specimens are accessioned, testing is performed, and results are reported. The range was extended from 4
days to 7 days on March 26.
(SOURCE: CDC)
As of April 6th 2020, there have been
approximately 1,917,095 COVID-19 tests
administered in the United States.
• 361,331 were positive
• 1,555,764 were negative
• 17,292 are pending
CURRENT CDC TESTING PRIORITIES
PRIORITY 1: Hospitalized Patients and
Symptomatic Healthcare Workers
PRIORITY 2: Patients in long-term care
facilities with symptoms, patients 65+ with
symptoms, patients with comorbidities with
symptoms, first responders with symptoms
PRIORITY 3: critical infrastructure workers
with symptoms, any other individual with
symptoms, health care workers and first
responders, individuals with mild symptoms
in communities experiencing high COVID-19
hospitalizations
Non-Priority: Individuals without symptoms
(CDC; COVID TRACKING)
NUMBERS OF SPECIMENS TESTED FOR COVID-19 BY CDC LABS (N=4,904)
AND U.S. PUBLIC HEALTH LABORATORIES*(N=207,446)

10. TESTING
Doctors rely on a test called quantitative reverse-transcription
polymerase chain reaction (qRT-PCR) to determine whether a person is
infected with SARS-CoV-2. A team led by Nathan Grubaugh at Yale
School of Public Health in New Haven, Connecticut, compared nine
widely used versions of the test and found that all of them reliably
detect the virus (C. B. F. Vogels et al. Preprint at
medRxiv https://www.medrxiv.org/content/10.1101/2020.03.30.200481
08v1; 2020).
But the researchers also found that some tests — including one made by
the US Centers for Disease Control and Prevention, another developed at
Hong Kong University, and a third from Charité–Universitätsmedizin
Berlin — performed best when it came to detecting low levels of the
virus in samples.
Surgical face masks effectively block the spread of
seasonal coronaviruses in respiratory droplets, suggesting
that masks could prevent transmission of SARS-CoV-2.
Seasonal coronaviruses are one cause of the common
cold. Benjamin Cowling at the University of Hong Kong and
his colleagues had ill volunteers who were infected with
seasonal coronaviruses sit in an enclosed booth and place
their faces in a sampling device, called the Gesundheit-II,
that captures airborne particles (N. H. L. Leung et al. Nat.
Med. https://doi.org/10.1038/s41591-020-0843-2; 2020).
MASKS COULD CUT SPREAD OF COVID-19 VIRUS
RESEARCH
INTERSTATE TRANSMISSION OF COVID-19 IS NOW MOST
URGENT THREAT
Interstate transmission of the novel coronavirus that causes COVID-19 is now a
much greater public health threat in the United States than cases coming into
the country via international travel, a new study led by researchers at the Yale
School of Public Health finds.
The findings underscore a critical need for more widespread diagnostic testing for
COVID-19 at the state level as well as more intense tracking of individuals who may
have been exposed to SARS-CoV-2, the highly infectious virus that causes COVID-19.
The researchers based their findings on a genomic analysis of nine virus samples
collected from some of Connecticut’s first COVID-19 patients in mid-March. Using
genomic epidemiology, they sequenced the unique genetic code or ‘signature’ for
each sample. They then compared that Connecticut data to the known signatures of
168 sequenced genomes for SARS-CoV-2 from the United States and around the
world.
The study found that most of Connecticut’s virus samples were more closely linked to
outbreaks in other states than international locations such as Europe and China.
(Joseph R Fauver et al. Preprint at
medRxiv https://www.medrxiv.org/content/10.1101/2020.03.25.20043828v1; 2020

11. UPDATES ON CLINICAL MANAGEMENT WITH CO-MORBIDITY
Preexisting heart conditions (hypertension and coronary heart
disease) have been the most common category of comorbidity.
While the focus of the COVID-19 pandemic has been on respiratory
problems and securing enough ventilators, an initial study found
cardiac damage in 1 in 5 patients, leading to heart failure and death
even among those who show no signs of respiratory distress.
This will require a need for new precautions in people with
preexisting heart problems, new demands for equipment and, new
treatment plans for damaged hearts among those who survive.
The question of whether the emerging heart problems are caused by
the virus itself or are a by-product of the body’s reaction to it has
become one of the critical unknowns facing doctors.
If doctors in New York, Washington state and other hot spots can
start to tease out how the virus is affecting the heart, they may be
able to provide a risk score or other guidance to help clinicians
manage COVID-19 patients in other parts of the country.
RISK FACTORS
Source: NYT, NCBI
PREEXISTING HEART CONDITIONS
Comorbidities that have been associated with severe illness
and mortality include
• Cardiovascular disease
• Diabetes mellitus
• Hypertension
• Chronic lung disease
• Cancer
• Chronic kidney disease
In a subset of 355 patients who died with COVID-19 in Italy, the
mean number of pre-existing comorbidities was 2.7, and only 3
patients had no underlying conditions.
Source: NCBI
Hazard ratio for risk factors associated with admission to ICU,
ventilation or death:

12. EMERGING ISSUES
VENTILATORS
Somewhere between 10% and 25% of patients sick with COVID-19 eventually
require assistance to breathe. Roughly 5% of patients will develop acute
respiratory distress syndrome, at which point only a mechanical ventilator can
drive oxygen into their lungs and push fluid out.
Recognizing the difference between those whose survival depends on access to
a ventilator and those who can recover with less aggressive breathing assistance
has become a vital skill for doctors.
The United States has roughly 173,000 ventilators scattered across the country,
according to the Center for Health Security at Johns Hopkins University. It may
sound like a lot, but there could be 31 times as many patients who need one,
experts from Harvard Medical School predict.
Acute respiratory distress syndrome, or ARDS, is the endgame for the unluckiest
COVID-19 patients. By that point, the virus has begun to destroy the tiny
compartments in the lungs where blood normally collects oxygen. Roaring
inflammation, a response to infection, further deteriorates the lung’s ability to
draw in air. Without help, these patients could drown.
More than a dozen medications that were developed to treat other
diseases are now being tested on COVID-19 patients. Ideally, several of them
would allow patients with mild to moderate symptoms recover before their
illnesses reach the severe or critical stage.
REMDESIVIR
Remdesivir is an investigational intravenous drug with broad antiviral activity that
inhibits viral replication through premature termination of RNA transcription and
has in-vitro activity against SARS-CoV-2 and in-vitro and in-vivo activity against
related betacoronaviruses. Information about clinical trials of remdesivir is
available at ClinicalTrials.govexternal icon. Remdesivir is also available through an
expanded access programexternal icon from the manufacturer, Gilead Sciences.
HYDROXYCHLOROQUINE AND CHLOROQUINE
Hydroxychloroquine and chloroquine are oral prescription drugs that have been
used for treatment of malaria and certain inflammatory conditions.
Hydroxychloroquine and chloroquine are under investigation in clinical trials for
pre-exposure or post-exposure prophylaxis of SARS-CoV-2 infection, and
treatment of patients with mild, moderate, and severe COVID-19.
More information on clinical trials can be found at ClinicalTrials.govexternal icon.
FDA issued an Emergency Use Authorization (EUA) to authorize use of
chloroquine and hydroxychloroquineexternal icon from the Strategic National
Stockpile for treatment of hospitalized adults and adolescents (weight ≥50 kg)
with COVID-19 for whom a clinical trial is not available or participation is not
feasible.
OTHER DRUGS
Several other drugs (e.g., investigational antivirals, immunotherapeutic, host-
directed therapies) are under investigation in clinical trials or are being
considered for clinical trials of pre-exposure prophylaxis, post-exposure
prophylaxis, or treatment of COVID-19 in the United States and worldwide.
Information on registered clinical trials for COVID-19 in the United States is
available at ClinicalTrials.govexternal icon. FDA has issued guidance for
administering or studying use of convalescent plasma for treatmentexternal
icon of patients with COVID-19.
DRUGS

13. COVID-19 PROJECTIONS
HOSPITAL RESOURCE - US
8 DAYS
UNTIL PEAK RESOURCE
USE ON
APRIL 15, 2020
RESOURCES NEEDED FOR COVID-19 PATIENTS ON PEAK
DATE
All beds needed: 140,823bed Bed Shortage: 36,654beds
ICU beds needed: 140,823bed ICU Bed Shortage: 36,654beds
Invasive ventilators needed: 24,828
SOURCE: IHME
COVID-19 projections assuming full social distancing
through May 2020

14. VID-19 projections assuming full social distancing through May 2020
SOURCE: IHME

15. HEALTHCARE INNOVATIONS TO FIGHT COVID-19
(DIAGNOSTICS)
DIAGNOSTICS
SOURCE : https://www.av.co/covid-diagnostics
@vasudevbailey
@zoeguttendorf

16. HEALTHCARE INNOVATIONS TO FIGHT THE PANDEMIC
(TREATMENTS)
SOURCE : https://www.av.co/covid-diagnostics
@vasudevbailey
@zoeguttendorf

17. HEALTHCARE INNOVATIONS TO FIGHT THE PANDEMIC
(VACCINES)
SOURCE : https://www.av.co/covid-diagnostics
6
@vasudevbailey
@zoeguttendorf