1. YALE-TULANE ESF-8 SPECIAL REPORT
CORONAVIRUS (COVID-19)
AS OF 14 APRIL 2020
2200 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
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
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
1,980,003 126,557 485,917
UNITED STATES
CONFIRMED CASES DEATHS RECOVERED
608,458 25,992 48,224
HEALTHCARE INNOVATIONS
COVID-19 PROJECTIONS
CASES IN US
WHERE CASES ARE RISING
TESTING
UPDATES ON CLINICAL
MANAGEMENT WITH CO-MORBIDITY
EMERGING ISSUES
SOURCE: JOHNS HOPKINS COVID-19 DASHBOARD (AS OF 14 APRIL, 2133 HRS EDT)

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.
The first known case of COVID-19 in the U.S. was confirmed on January 21, 2020, in a
man in his 30s from Washington state, who traveled to Wuhan, is diagnosed with
novel coronavirus.
On 29 January 2020 the White House Coronavirus Task Force was established. On 31
January 2020 , Secretary azar declares a Public Health Emergency for United States
for COVID-19. Travel restriction were put into place for those traveling from China .
Later restriction were added for Iran and Europe (29 February 2020).
On 26 February 2020 the Centers for Disease Control and Prevention (CDC) confirms
the first case of COVID-19 in a patient in California with no travel history to an
outbreak area, nor contact with anyone diagnosed with the virus. It's suspected to
be the first instance of local transmission in the United States. Oregon, Washington
and New York soon report their own cases of possible community transmission.
The first COVID-19 death is reported in Washington state, after a man with no travel
history to China dies on 28 February 2020 at Evergreen Health Medical Center in
Kirkland, Washington. Two deaths that occurred 26 February 2020 at a nearby
nursing home would later be recorded as the first COVID-19 deaths to occur in the
United States.
President Donald Trump declares a U.S. national emergency, which he says will open
up $50 billion in federal funding to fight COVID-19 on 13 March 2020.
By 17 March 2020 COVID 19 was present in all 50 states.
COVID 19 IN THE UNITED STATES

3. SITUATION - UNITED STATES
JURISDICTIONS REPORTING CASES: 55 (50 states, District of Columbia, Guam,
Puerto Rico, the Northern Mariana Islands, and the U.S. Virgin Islands) (CDC)
EOC ACTIVATION: All State / Territory EOCs activated (FEMA)
42 states, D.C., 4 territories and 37 tribes issued shelter-in-place orders (FEMA)
Many states have closed schools and businesses; banned gatherings, meetings
and sporting events; and, in some places, residents have been ordered to stay
inside.
COVID-19 ACTIVITY
Different parts of the country are seeing different levels of COVID-19 activity.
The United States nationally is in the acceleration phase of the pandemic. The
duration and severity of each pandemic phase can vary depending on the
characteristics of the virus and the public health response. (CDC)
• The greatest number of cases have been recorded in New York, New
Jersey, Massachusetts, Michigan, Pennsylvania, California, Illinois, Florida
and Louisiana.
• There is early evidence that the epi curve is beginning to flatten
• Case numbers are expected to continue rising through the coming weeks,
as more cases are identified through testing.
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
608,458 25,992 48,224
HOSPITALIZATIONS
The overall cumulative hospitalization rate is 12.3 per 100,000, with the highest
rates in persons 65 years and older (38.7 per 100,000) and 50-64 years (20.7 per
100,000). (CDC)
SOURCE: JOHNS HOPKINS COVID-19 DASHBOARD (AS OF 14 APRIL, 2133 HRS EDT)
HEALTH CARE PROFESIONALS
The Centers for Disease Control and Prevention said on
Tuesday that 9,282 health care professionals had contracted the
coronavirus in the United States as of April 9, and that 27 had
died from it.
DEATH TOLL
New York City, already a center of the coronavirus outbreak, sharply increased
its death toll by more than 3,700 on Tuesday, 14 April 2020 after officials said
they were now including people who had never tested positive for the virus but
were presumed to have died because of it.
The new figures, released by the city’s Health Department, drove up the number
of people killed in New York City to more than 10,000 and appeared to increase
the overall United States fatality rate by 17 percent.

4. 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 14 APRIL, 2133 HRS EDT, at least 608,458 people across every state,
plus Washington, D.C., and three U.S. territories, have tested positive for
coronavirus, and at least 25,992 have died and 48,224 have recovered.
Approximately 3,081,620 have been tested in the US
Currently 101,017 are hospitalized

5. WHERE CASES ARE RISING
SOURCE: NYT (AS OF 14 APRIL 2020, 2000 HRS, EDT

6. 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)
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)
NUMBER OF SPECIMENS TESTED FOR SARS COV-2 BY CDC LABS
(N=5,038) AND U.S. PUBLIC HEALTH LABORATORIES* (N=310,434)†
TOTAL TESTED IN US
As of 14 April 2020, approximately
3,081,620 COVID-19 tests have been
administered in the United States.
• 605,193 were positive
• 2,459,268 were negative
• 17,159 arepending

7. 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.
Initial Data From China
In March, doctors from China published two studies that gave the first glimpse
at how prevalent cardiac problems were among patients with COVID-19
illness. The larger of the two studies looked at 416 hospitalized patients. The
researchers found that 19% showed signs of heart damage. And those who did
were significantly more likely to die: 51% of those with heart damage died
versus 4.5% who did not have it.
RISK FACTORS
Source: NYT, NCBI, JAMA
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
• Liver disease
Knowledge of these risk factors can be a resource for clinicians
in the early appropriate medical management of patients with
COVID-19.
In a study of 168 patients who died in Wuhan, 74.4% had 1 or
more comorbidities.
SOURCE:
MYSTERIOUS HEART DAMAGE, NOT JUST LUNG TROUBLES, BEFALLING COVID-19
PATIENTS
ASSOCIATION OF CARDIAC INJURY WITH MORTALITY IN HOSPITALIZED PATIENTS WITH
COVID-19 IN WUHAN, CHINA
Chronic comorbidities distribution among patients

8. EMERGING ISSUES
IMPACT ON GROUP HOMES & CARE FACILITIES FOR THE
DEVELOPMENTALLY DISABLED
Across the U.S., group homes and care facilities for the developmentally disabled
are experiencing disproportionately high numbers of COVID-19 cases and deaths
compared to the general population. Additionally, exposure to infected patients
has resulted in many staff/caregivers––the “direct care work force”––also
contracting the virus, making it difficult for facilities to maintain adequate staffing
levels.
Developmentally delayed residents of these facilities are a particularly vulnerable
group because, in addition to living in a congregate residential setting, many have
underlying health conditions that make them exponentially more likely to contract
and die from COVID-19.
In New York York state, 1,100 of the 140,000 developmentally disabled people
monitored by the state have tested positive, as well as 314 group home staff. As
of April 10th, 156 of the 1100 have died. In New York City, residents of group
homes and similar care facilities are 5.34 times more likely than the general
population to develop the virus and 4.86 times more likely to die from it.
Staff/caregivers have expressed concerns about facilities’ capacity to contain and
control infection control and containment, including:
• Staff lacking training on how to minimize infection transmission
when providing patient care
• Shortage of staff (due to infection or fear of getting infected)
• Difficulty enforcing recommended prevention measures like hand-
washing and social distancing among residents
• Difficulty obtaining tests
• Shortage of PPE and other critical supplies (e.g. oxygen)
The widespread challenge of overwhelmed hospitals has also contributed to the
increased toll of COVID-19 on group homes, with many facilities reporting that
their residents who displayed symptoms were turned away by the hospital if their
symptoms weren’t life threatening. As a result, these individuals returned to their
group homes, likely infecting other residents and staff.
SOURCE: NEW YORK TIMES
SOURCE: NBC NEW YORK
There is growing concern being expressed by caregivers, advocates and
policymakers about the potential deprioritization of developmentally delayed
COVID-19 patients for life saving treatments, namely ventilators.
On April 4th, Disability Rights New York, an oversight organization, filed a
federal complaint against Governor Cuomo’s administration, claiming that
state policies treat the developmentally disabled as second-class citizens who
will be deprioritized for access to ventilators, should there be a shortage.
Similar complaints were also filed by advocacy groups in Alabama, Kansas,
Tennessee, and Washington State.
In order to prevent discriminatory care of COVID-19 patients in healthcare
settings, leading advocates have proposed that [state] policy prohibiting
discriminatory allocation of ventilators, and healthcare at large, be enacted
immediately.
SOURCE: NEW YORK TIMES
PROTECTING COVID-19 PATIENTS WITH DEVELOPMENTAL
DISABILITIES FROM DISCIRIMINATORY HEALTH CARE

9. EMERGING ISSUES - CORONAVIRUS IN RURAL AMERICA
It’s common for viruses to trickle into rural communities after
hitting big cities first. COVID-19 outbreaks in rural communities are
becoming a concerning trend. When people are asked to
quarantine or shelter-in-place, people tend to move out of cities to
suburban and rural locations bunker down. (ABC News)
There is less coronavirus testing in rural areas. In Louisiana, around
70% of tests have been conducted in urban centers. (LA
Departrment of Health)
Rural Americans may be more likely to have COVID complications.
Rural populations are older on average, with more than 20 percent
above the age of 65. Rural Americans also tend to have higher rates
of cigarette smoking, higher blood pressure and higher obesity
rates. They also have higher rates of poverty, less access to
healthcare, and are less likely to have health insurance. (CDC)
(Washignton Post)
Rural counties have just 5,600 intensive care beds total, compared
with more than 50,000 in urban counties. Half of U.S. counties do
not have any ICU beds at all. (Washington Post)
(NY TIMES)
RURAL AMERICANS' HEALTH DEPENDS ON BROADBAND ACCESS
Apr 13, 2020 - Discusses the need for increased broadband access in rural areas,
especially with the healthcare access challenges posed by the COVID-19 pandemic.
Includes data that shows a large percentage of rural counties are designated as
medically underserved and highlights federal programs recently enacted to expand
broadband services through rural America.
Source: American Farm Bureau Federation
RESOURCES TO HELP RURAL HOSPITALS AND HEALTH SYSTEMS NAVIGATE COVID-19
Apr 9, 2020 - The American Hospital Association (AHA) compiled a list of case studies
highlighting strategies rural hospitals have taken to tackle the COVID-19 pandemic.
Includes additional resources to assist rural communities in implementing their own
solutions to help care for patients.
Source: American Hospital Association
CORONAVIRUS WAS SLOW TO SPREAD TO RURAL AMERICA. NOT ANYMORE
Apr 8, 2020 - Discusses the increasing rate at which coronavirus has spread in rural
areas of the country and the challenges these areas face combating the disease.
Includes an interactive map with a timeline of when coronavirus reached rural counties
across America.
Source: The New York Time
ONE-IN-FOUR U.S. RURAL HOSPITALS AT HIGH FINANCIAL RISK OF CLOSING AS
PATIENTS LEAVE COMMUNITIES FOR CARE
Apr 8, 2020 - Summarizes an analysis conducted before the coronavirus outbreak,
that found a quarter of rural hospitals are at high risk of closing due to financial
challenges. Describes how the migration of patients to care options outside the
community has contributed to the situation, includes advice for rural hospitals to
partner with other regional health systems and their communities.
Source: Guidehouse
SOURCE: RHIhub

10. EMERGING ISSUE
HOSPITALIZATION RATES AND CHARACTERISTICS OF
PATIENTS HOSPITALIZED WITH LABORATORY-
CONFIRMED CORONAVIRUS DISEASE 2019 — COVID-
NET, 14 STATES, MARCH 1–30, 2020
A new report presents age-stratified COVID-19–
associated hospitalization rates for patients admitted
during March 1–28, 2020, and clinical data on patients
admitted during March 1–30, 2020, the first month of
U.S. surveillance.
Among 1,482 patients hospitalized with COVID-19, 74.5%
were aged ≥50 years, and 54.4% were male. The
hospitalization rate among patients identified through
COVID-NET during this 4-week period was 4.6 per
100,000 population.
Rates were highest (13.8) among adults aged ≥65 years.
Among 178 (12%) adult patients with data on underlying
conditions as of March 30, 2020, 89.3% had one or more
underlying conditions; the most common were
hypertension (49.7%), obesity (48.3%), chronic lung
disease (34.6%), diabetes mellitus (28.3%), and
cardiovascular disease (27.8%).
These findings suggest that older adults have elevated
rates of COVID-19–associated hospitalization and the
majority of persons hospitalized with COVID-19 have
underlying medical conditions.
SOURCES:
Garg S, Kim L, Whitaker M, et al. Hospitalization Rates and Characteristics of Patients Hospitalized with Laboratory-Confirmed
Coronavirus Disease 2019 — COVID-NET, 14 States, March 1–30, 2020. MMWR Morb Mortal Wkly Rep. ePub: 8 April 2020.
CDC – DATA VISUALIZATION

11. EMERGING ISSUE
HOSPITALIZATION RATES AND CHARACTERISTICS OF
PATIENTS HOSPITALIZED WITH LABORATORY-
CONFIRMED CORONAVIRUS DISEASE 2019 — COVID-
NET, 14 STATES, MARCH 1–30, 2020
In the COVID-NET catchment population, approximately
49% of residents are male and 51% of residents are
female, whereas 54% of COVID-19-associated
hospitalizations occurred in males and 46% occurred in
females. These data suggest that males may be
disproportionately affected by COVID-19 compared with
females.
Similarly, in the COVID-NET catchment population,
approximately 59% of residents are white, 18% are
black, and 14% are Hispanic; however, among 580
hospitalized COVID-19 patients with race/ethnicity data,
approximately 45% were white, 33% were black, and 8%
were Hispanic, suggesting that black populations might
be disproportionately affected by COVID-19.
These findings, including the potential impact of both
sex and race on COVID-19-associated hospitalization
rates, need to be confirmed with additional data.
SOURCES:
Garg S, Kim L, Whitaker M, et al. Hospitalization Rates and Characteristics of Patients Hospitalized with
Laboratory-Confirmed Coronavirus Disease 2019 — COVID-NET, 14 States, March 1–30, 2020. MMWR
Morb Mortal Wkly Rep. ePub: 8 April 2020.
It's long been known that black Americans and Hispanic Americans are more likely to suffer from chronic health conditions that can detrimentally impact how
their bodies handle an additional illness. These minority communities also have less access to health care.
And early data suggest that a racial disparity has been playing out in the outcomes of coronavirus patients, with data from coronavirus deaths in Louisiana, Illinois,
Michigan and New Jersey showing African Americans make up a higher percentage of the victims.

12. COVID-19 PROJECTIONS
HOSPITAL RESOURCE - US
4 DAYS
SINCE PEAK RESOURCE
USE ON
APRIL 10, 2020
RESOURCES NEEDED FOR COVID-19 PATIENTS ON PEAK
DATE
All beds needed: 56,831bed Bed Shortage: 3,498beds
ICU beds needed: 140,823bed ICU Bed Shortage: 7,369
Invasive ventilators needed: 13,851
SOURCE: IHME
COVID-19 projections assuming full social distancing
through May 2020

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

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

15. HEALTHCARE INNOVATIONS TO FIGHT COVID-19

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

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