Day 1 - Background Module

COVID-19
Background
Developed with a grant from Project HOPE. Copyright © Brown

University, 2020. Released under Creative Commons license
Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-
ND 4.0)
2
Objectives
1. Understand how the SARS-CoV-2 relates to other coronaviruses such as

the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak.
2. Attain a basic understanding of how SARS-CoV-2 affects the body and the
organ systems most frequently impacted by infection.
3. Identify currently known transmission mechanisms for SARS-CoV-2.
4. Know the case definitions for COVID-19, including the associated
exposure risk factors, symptoms and signs, and clinical findings.
5. Understand the epidemiologic profile of the COVID-19 outbreak including
the initial outbreak setting and global transmission trends.
Developed with a grant from Project HOPE. Copyright © Brown

University, 2020. Released under Creative Commons license
Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-
ND 4.0)
3
Timeline
• Dec 2019 – first identified as a cluster of pneumonia cases in Wuhan, China
• Jan 30, 2020 – WHO declared the outbreak a “public health emergency of
international concern” under the International Health Regulations
• February 2020 – Outbreak spreads from initial epicenter in East Asia to the
Middle East, Europe, and North America
• Mar 11, 2020 – WHO determined that the outbreak reached pandemic
classification due to widespread community transmission across the world
• Current Situation – See COVID-19 Global Cases (Johns Hopkins University)
Developed with a grant from Project HOPE. Copyright © Brown University,

2020. Released under Creative Commons license Attribution-
NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0)
4
Coronaviruses
• Coronaviruses (CoV) are a large family of viruses that cause
illness ranging from the common cold to more severe illness.
• The Middle East Respiratory Syndrome (MERS-CoV) and Severe

Acute Respiratory Syndrome (SARS-CoV) are part of the
Coronavirus family.
• SARS-CoV-2, the name of the virus which causes the disease

known as COVID-19 is a new strain of coronavirus. It has not
been previously identified in humans.
• Coronaviruses are zoonotic, which means they are passed

between animals and people.

5
Components of a Coronavirus
 Spike proteins
 Envelope
 Core - RNA

6
SARS-CoV-2 Genome
January 10, 2020 – Complete viral genome sequenced and publicly

released by Fudan University in China
• Critical information for development of vaccines, treatments, and
prevention efforts.
• Comparison of the “spike proteins” (the glycoprotein responsible for
viral binding and entry) showed 75% similarity with SARS-CoV-1.
• SARS-CoV-1 and SARS-CoV-2 both use the ACE2 receptor to infect
human cells in the respiratory tract.
7
Source of COVID-19
• The novel SARS-CoV-2 likely originated from an animal

reservoir (possibly bats or pangolins), which first transmitted
it to humans directly or through an intermediate host
• The first human cases of COVID-19 were found in Wuhan,

Hubei Province, China in December 2019, many of whom
had visited or worked at a large animal market in the area.
• Importantly, since the initial transmission from animals to

humans, human-to-human spread has accounted for all new
cases of COVID-19.

8
Epidemiology of Disease Transmission

R is the replication rate of a disease, or the
average number of people infected by each person
with the disease. R is dynamic, depending on a
variety of factors, including public health measures
Ro is the inherent transmissibility of an infectious

agent, before any public health measures begin
The Ro for COVID-19 is not known for certain, but

it very likely falls between 1.5 and 3.5

9
Epidemiology of Disease Transmission
What determines R?
• % of population susceptible (without immunity)
• Mode of transmission – respiratory droplet vs. airborne
• Serial interval – amount of time between successive cases
in a chain of transmission
• Unique biological characteristics of pathogen
• Public health responses – isolation of ill patients,
quarantine of contacts, travel restrictions, use of PPE in
healthcare setting

10
Transmission of COVID-19
• Person-to-person transmission occurs mainly through the transfer of respiratory

droplets, similar to influenza and other respiratory pathogens.
• When someone infected with COVID-19 coughs or sneezes, respiratory droplets can
travel about 1-2 meters, landing on that person’s hands, other people’s bodies, or the
surface of nearby objects
• When other people touch those droplets and then touch their face, the virus can
enter their body through the mucous membranes of their eyes, nose or mouth
• SARS-CoV-2 is not generally spread through the air, like tuberculosis or measles (except
in the case of aerosolizing procedures done in a hospital, such as intubation)

11
Incubation Period
Incubation period = time from catching the virus to the time

when a person begins having symptoms from the infection.
• For COVID-19, the incubation period is from 2-14 days.
• Most commonly, people who become infected with the virus begin
feeling ill in about 5 days.

Epidemiological Comparison of Other Outbreaks 12
SARS MERS Seasonal Flu COVID-19
Unknown (possibly
Zoonotic reservoir Civet cats Camels Varies
bats or pangolins)
Ro
0.4-0.7 (community)
Control of pandemic 1.7-1.8 1.4-1.8 1.5-3.5
4-8 (nosocomial)
requires Ro to be < 1
Serial Interval 8-10 days 6.8 days 2-4 days ~7 days
Incubation period 4-6 days 5-6 days 2 days 2-14 days
Peak infectivity ~Day 10 Unknown Day 1-2 of illness Unknown
Case-fatality Ratio 11% 34% 0.1-0.2% 0.5-1%

13
Common Symptoms
• Fever
• Dry cough
• Shortness of breath
Other Associated Symptoms

• Feeling tired
• Aches and pains throughout the body
• Sore throat
• Congestion of the nose
• Runny nose
• Diarrhea (less common)

14
Severe Disease
• In some patients, the respiratory symptoms may be severe

and cause pneumonia.
• Some patients may need oxygen.
• When oxygen requirements become high, some patients with
COVID-19 will require ventilator support, intensive care and
monitoring.

15
Risk Factors for Severe Infection and Death
• Older age, > 50 years
• Underlying health problems
• High Blood Pressure
• Diabetes
• Heart Disease
• Lung Disease
Image: Chinese Center for Disease Control and Prevention

16
Special Populations: Pregnant Women
• Pregnant women may be at increased risk for severe illness or

mortality from COVID-19, though data is still limited.
• Pregnancy loss, including miscarriage and stillbirth, has been

seen in infection with other coronaviruses (SARS and MERS).
• We do not have definitive data on pregnancy outcomes in

patients with COVID-19.
• While there are some reports of mother to child transmission,

SARS-CoV-2 has not been detected in breastmilk to date.

17
Special Populations: Children
• Early reports from China suggest that children with

confirmed COVID-19 may present with mild symptoms.
• Serious complications (such as acute respiratory distress
syndrome or septic shock) and death appear to be very
uncommon in children with COVID-19.
• Most children can be treated at home and do not need to
be hospitalized for the disease.
• Certain populations of children, however, may be at
higher risk of severe disease, such as those with
underlying health conditions.

18
Profile of COVID-19 Disease

• Among patients who are symptomatic:
• 80% will have only mild to moderate symptoms, and can be managed as
outpatients.
• 15% will develop lower respiratory tract infection and may require
hospitalization.
• 3-5% will require intensive care and may need ventilator support.
• 0.5-1% of patients will die (based on data from South Korea, but case
fatality ratio may be higher in countries with less resources)
• 18% of patients infected with COVID-19 may never develop any symptoms,
but people without symptoms are unlikely to pass the disease on to others.

19
Vaccine and Drug Development
• Multiple vaccines are currently under development for COVID-19.
• However, it is estimated that it may take at least another 12-18 months before
we have a vaccine we can use.
• Many drug companies and universities around the world are also testing a
variety of new and old medications as treatments for COVID-19, though it will
likely be many months before any are proven to be effective.
• Despite the immediate need, it is very important that we take the time and go
through all the formal steps to develop vaccines and treatment that are both
effective and safe for the population, to avoid causing more harm than good.

Impact of the
Outbreak
Health Systems Strained Developed with a grant from Project HOPE.
Copyright © Brown University, 2020. Released
under Creative Commons license Attribution-
NonCommercial-NoDerivatives 4.0
International (CC BY-NC-ND 4.0)
Impact of the
Outbreak
Essential Supplies
Developed with a grant from Project HOPE. Copyright ©
Brown University, 2020. Released under Creative
Commons license Attribution-NonCommercial-
NoDerivatives 4.0 International (CC BY-NC-ND 4.0)
Impact of the
Outbreak
Global Economy Developed with a grant from Project HOPE. Copyright
© Brown University, 2020. Released under Creative
Commons license Attribution-NonCommercial-
Impact of the
Outbreak
Stigma and Developed with a grant from Project HOPE. Copyright
© Brown University, 2020. Released under Creative
Discrimination Commons license Attribution-NonCommercial-
24
Heroism in the Face of Fear and Danger

China's National Health Commission announced that 3,400 health workers had contracted the
new virus - at least 12 have died
• It is vital to protect healthcare workers for their safety and the safety of their patients. In times
like these, it is also important to recognize their heroism and to honor their sacrifices in
responding to the outbreak around the world.

25
Summary
• While Coronavirus is a sub-family of viruses familiar to humans, the SARS-CoV-2 virus
which causes COVID-19 is new and humans did not have any prior immunity to it.
• While many of those infected with the virus suffer from mild symptoms and do not
require hospitalization, the infection can be severe and even fatal, especially in elderly
patients or those who have underlying health conditions.
• While there are clinical trials for medications and vaccines underway, proper infection
control and prevention efforts are most important in controlling this pandemic.
• It is important for all of us to be well-informed with facts and educate the public to
reduce unnecessary anxiety, blame, and misinformation.

26
Resources
• CDC – Guidance and Updates
• https://www.cdc.gov/coronavirus/2019-nCoV/summary.html
• WHO – Situation Reports
• https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports
• Johns Hopkins University – Interactive Maps

• https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd402994234
67b48e9ecf6
• Local Ministries of Health

27
References
• Centers for Disease Control and Prevention, https://www.cdc.gov/coronavirus/2019-ncov/summary.html#source-spread
• UpToDate, https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19?topicRef=8298&source=see_link#H3504376427
• Sun et al. Journal of Medical Virology; 2020. https://onlinelibrary.wiley.com/doi/10.1002/jmv.25722
• Gralinski LE, Menachery VD. Return of the Coronavirus: 2019-nCoV. Viruses. 2020 Feb;12(2):135.
• World Health Organization, https://www.who.int/health-topics/coronavirus.
• Lipsich et al. NEJM; 2020. https://www.nejm.org/doi/full/10.1056/NEJMp2002125
• Wall Street Journal, https://www.wsj.com/articles/how-many-people-might-one-person-with-coronavirus-infect-11581676200?mod=article_inline
• Cauchemez et al. Proc Natl Acad Sci U S A; 2016.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4987807/
• Bai Y., Yao L., and Wei T. JAMA; 2020. https://jamanetwork.com/journals/jama/fullarticle/2762028
• World Health Organization, https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/patient-management
• Mayo Clinic, https://www.mayoclinic.org/diseases-conditions/coronavirus/symptoms-causes/syc-20479963
• Guan et al. NEJM; 2020. https://www.nejm.org/doi/full/10.1056/NEJMoa2002032
• Li Y. & Xia L. Am J Roentgenol; 2020. https://www.ajronline.org/doi/full/10.2214/AJR.20.22954
• Hosseiny et al. Am J Roentgenol; 2020. https://www.ajronline.org/doi/full/10.2214/AJR.20.22969
• Wei et al. Am J Roentgenol; 2020. https://www.ajronline.org/doi/10.2214/AJR.20.22976
• UpToDate: https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19#H1583795407
• Ellerin T. Harvard Health Publishing, https://www.health.harvard.edu/blog/as-coronavirus-spreads-many-questions-and-some-answers-2020022719004#q14
• Clinical Trials Arena, https://www.clinicaltrialsarena.com/analysis/covid-19-pharmaceutical-company-partnerships-for-coronavirus-vaccines-development/
• Ahmed SF., Quadeer A., & McKay MR. Viruses; 2020. https://www.sciencedaily.com/releases/2020/02/200226091227.htm
• Tang et al. National Science Review; 2020. https://academic.oup.com/nsr/advance-article/doi/10.1093/nsr/nwaa036/5775463#authorNotesSectionTitle
• The Atlantic, https://www.theatlantic.com/health/archive/2020/02/covid-vaccine/607000/
• CNBC, https://www.cnbc.com/2020/03/04/coronavirus-latest-updates-asia-china-south-korea.html
• Coronavirus 2019-nCoV Global Cases by Johns Hopkins CSSE. https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6
• Business Insider, https://www.businessinsider.com/healthcare-workers-getting-coronavirus-500-infected-2020-2
• The Lancet, https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30418-9/fulltext
• Riou J, et al. Pattern of early human-to-human transmission of Wuhan 2019 novel coronavirus (2019-nCoV), December 2019 to January 2020. Euro Surveill. 2020
• Zhang S, et al. Estimation of the reproductive number of novel coronavirus (COVID-19) and the probable outbreak size on the Diamond Princess cruise ship: A data-driven analysis. Int
J Infect Dis. 2020
• Shim E, et al. Transmission potential and severity of COVID-19 in South Korea. Int J Infect Dis. 2020
• Mizumoto K, et al. Estimating the asymptomatic proportion of coronavirus disease 2019 (COVID-19) cases on board the Diamond Princess cruise ship, Yokohama, Japan, 2020. Euro
Surveill. 2020

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COVID-19

Developed with a grant from Project HOPE. Copyright © Brown

1. Understand how the SARS-CoV-2 relates to other coronaviruses such as

Developed with a grant from Project HOPE. Copyright © Brown

• Dec 2019 – first identified as a cluster of pneumonia cases in Wuhan, China

• Current Situation – See COVID-19 Global Cases (Johns Hopkins University)

Developed with a grant from Project HOPE. Copyright © Brown University,

• The Middle East Respiratory Syndrome (MERS-CoV) and Severe

• SARS-CoV-2, the name of the virus which causes the disease

• Coronaviruses are zoonotic, which means they are passed

Developed with a grant from Project HOPE. Copyright © Brown University,

Developed with a grant from Project HOPE. Copyright © Brown University,

January 10, 2020 – Complete viral genome sequenced and publicly

• The novel SARS-CoV-2 likely originated from an animal

• The first human cases of COVID-19 were found in Wuhan,

• Importantly, since the initial transmission from animals to

Developed with a grant from Project HOPE. Copyright © Brown University,

Epidemiology of Disease Transmission

Ro is the inherent transmissibility of an infectious

The Ro for COVID-19 is not known for certain, but

Developed with a grant from Project HOPE. Copyright © Brown University,

Epidemiology of Disease Transmission

Developed with a grant from Project HOPE. Copyright © Brown University,

• Person-to-person transmission occurs mainly through the transfer of respiratory

Developed with a grant from Project HOPE. Copyright © Brown University,

Incubation period = time from catching the virus to the time

Developed with a grant from Project HOPE. Copyright © Brown University,

SARS MERS Seasonal Flu COVID-19

Serial Interval 8-10 days 6.8 days 2-4 days ~7 days

Incubation period 4-6 days 5-6 days 2 days 2-14 days

Peak infectivity ~Day 10 Unknown Day 1-2 of illness Unknown

Case-fatality Ratio 11% 34% 0.1-0.2% 0.5-1%

Developed with a grant from Project HOPE. Copyright © Brown University,

Other Associated Symptoms

Developed with a grant from Project HOPE. Copyright © Brown University,

• In some patients, the respiratory symptoms may be severe

Developed with a grant from Project HOPE. Copyright © Brown University,

Risk Factors for Severe Infection and Death

• Older age, > 50 years

• Underlying health problems

• High Blood Pressure

Image: Chinese Center for Disease Control and Prevention

Developed with a grant from Project HOPE. Copyright © Brown University,

Special Populations: Pregnant Women

• Pregnant women may be at increased risk for severe illness or

• Pregnancy loss, including miscarriage and stillbirth, has been

• We do not have definitive data on pregnancy outcomes in

• While there are some reports of mother to child transmission,

Developed with a grant from Project HOPE. Copyright © Brown University,

Special Populations: Children

• Early reports from China suggest that children with

Developed with a grant from Project HOPE. Copyright © Brown University,

Profile of COVID-19 Disease

Developed with a grant from Project HOPE. Copyright © Brown University,

Vaccine and Drug Development

• Multiple vaccines are currently under development for COVID-19.

Developed with a grant from Project HOPE. Copyright © Brown University,

Heroism in the Face of Fear and Danger

Developed with a grant from Project HOPE. Copyright © Brown University,

Developed with a grant from Project HOPE. Copyright © Brown University,

• WHO – Situation Reports

• Johns Hopkins University – Interactive Maps

• Local Ministries of Health