Overview of COVID-19: Epidemiology, Clinical Presentation, and Transmission
Last Updated: July 17, 2020
The COVID-19 pandemic has exploded since cases were first reported in China in December 2019. As of July 9, 2020, more than 12 million cases of COVID-19—caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection—have been reported globally, including more than 550,000 deaths. Cases have been reported in more than 180 countries, including all 50 states of the United States.1,2
Individuals of all ages are at risk for infection and severe disease. However, the probability of serious COVID-19 disease is higher in people aged ≥60 years, those living in a nursing home or long-term care facility, and those with chronic medical conditions. In a recent analysis of more than 1.3 million laboratory-confirmed cases that were reported in the United States between January and May 2020, 14% of patients required hospitalization, 2% were admitted to the intensive care unit, and 5% died.3 The percentage of patients who died was 12 times higher (19.5% vs. 1.6%) and the percentage of patients who were hospitalized was six times higher (45.4% vs. 7.6%) in those with reported medical conditions than in those without medical conditions. The mortality rate was highest in those aged >70 years, regardless of chronic medical conditions. Among those with available data on health conditions, 32% had cardiovascular disease, 30% had diabetes, and 18% had chronic lung disease. Other conditions that may lead to a high risk for severe COVID-19 include cancer, kidney disease, obesity, sickle cell disease, transplant recipients, and other immunocompromising conditions.2,4-9
Emerging data from the United States suggest that racial and ethnic minorities experience higher rates of COVID-19 and subsequent hospitalization and death.10-14 However, surveillance data that include race and ethnicity are not available for most reported cases of COVID-19 in the United States.2,15 Factors that contribute to the increased burden of COVID-19 in these populations may include over-representation in work environments that confer higher risks of exposure to COVID-19, economic inequality (which limits a person’s ability to protect against COVID-19 exposure), neighborhood disadvantage,16 and a lack of access to health care.15 Structural inequalities in society contribute to health disparities for racial and ethnic minority groups, including higher rates of comorbid conditions (e.g., cardiac disease, diabetes, hypertension, obesity, pulmonary diseases), which further increases the risk for severe illness from COVID-19.14
The estimated incubation period for COVID-19 is up to 14 days from the time of exposure, with a median incubation period of 4 to 5 days.6,17,18 The spectrum of illness can range from asymptomatic infection to severe pneumonia with acute respiratory distress syndrome (ARDS) and death. Among 72,314 persons with COVID-19 in China, 81% of cases were reported to be mild (defined in this study as no pneumonia or mild pneumonia), 14% were severe (defined as dyspnea, respiratory frequency ≥30 breaths/min, SpO2 ≤93%, PaO2/FiO2 <300 mmHg, and/or lung infiltrates >50% within 24 to 48 hours), and 5% were critical (defined as respiratory failure, septic shock, and/or multiple organ dysfunction or failure).19 In a report on more than 370,000 confirmed COVID-19 cases with reported symptoms in the United States, 70% of patients experienced fever, cough, or shortness of breath, 36% had muscle aches, and 34% reported headaches.3 Other reported symptoms have included, but are not limited to, diarrhea, dizziness, rhinorrhea, anosmia, dysgeusia, sore throat, abdominal pain, anorexia, and vomiting.
The abnormalities seen in chest X-rays vary, but bilateral multi-focal opacities are the most common. The abnormalities seen in computed tomography (CT) of the chest also vary, but the most common are bilateral peripheral ground-glass opacities, with areas of consolidation developing later in the clinical course.20 Imaging may be normal early in infection and can be abnormal in the absence of symptoms.20
Common laboratory findings of COVID-19 include leukopenia and lymphopenia. Other laboratory abnormalities have included elevated levels of aminotransferase, C-reactive protein, D-dimer, ferritin, and lactate dehydrogenase.
While COVID-19 is primarily a pulmonary disease, emerging data suggest that it also leads to cardiac,21,22 dermatologic,23 hematological,24 hepatic,25 neurological,26,27 renal,28,29 and other complications. Thromboembolic events also occur in patients with COVID-19, with the highest risk in critically ill patients.30 The long-term sequelae of COVID-19 survivors are currently unknown.
Recently, SARS-CoV-2 has been associated with a potentially severe inflammatory syndrome in children (multisystem inflammatory syndrome in children or MIS-C).31,32 Please see Special Considerations in Children for more information.
Routes of SARS-CoV-2 Transmission and Standard Means of Prevention
Transmission of SARS-CoV-2 occurs primarily through respiratory secretions, and, to a lesser extent, contact with contaminated surfaces. Most transmissions are thought to occur through droplets; covering coughs and sneezes and maintaining a distance of six feet from others can reduce the risk of transmission. When consistent distancing is not possible, face coverings may further reduce the spread of droplets from infectious individuals to others. Frequent handwashing is also effective in reducing acquisition.33 The onset and duration of viral shedding and the period of infectiousness are not completely defined. Viral RNA may be detected in upper respiratory specimens from asymptomatic or pre-symptomatic individuals with SARS-CoV-2.34 An increasing number of studies have described cases where asymptomatic individuals have transmitted SARS-CoV-2.35-37 The extent to which this occurs remains unknown, but this type of transmission may be contributing to a substantial amount of community transmission.
- World Health Organization. Coronavirus disease (COVID-2019) situation reports. 2020. Available at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/. Accessed June 9, 2020.
- Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): cases in U.S. 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html. Accessed April 9, 2020.
- Stokes EK, Zambrano LD, Anderson KN, et al. Coronavirus disease 2019 case surveillance—United States, January 22–May 30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69. Available at: https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6924e2-H.pdf.
- Cai Q, Chen F, Wang T, et al. Obesity and COVID-19 severity in a designated hospital in Shenzhen, China. Diabetes Care. 2020;43(7):1392-1398. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32409502.
- 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. 2020;69(15):458-464. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32298251.
- Guan WJ, Ni ZY, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020;382(18):1708-1720. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32109013.
- Wu C, Chen X, Cai Y, et al. Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 Pneumonia in Wuhan, China. JAMA Intern Med. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32167524.
- Palaiodimos L, Kokkinidis DG, Li W, et al. Severe obesity, increasing age and male sex are independently associated with worse in-hospital outcomes, and higher in-hospital mortality, in a cohort of patients with COVID-19 in the Bronx, New York. Metabolism. 2020;108:154262. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32422233.
- Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): people who are at increased risk for severe illness. 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-at-increased-risk.html. Accessed June 26, 2020.
- Azar KMJ, Shen Z, Romanelli RJ, et al. Disparities in outcomes among COVID-19 patients in a large health care system in California. Health Aff (Millwood). 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32437224.
- Gold JAW, Wong KK, Szablewski CM, et al. Characteristics and clinical outcomes of adult patients hospitalized with COVID-19—Georgia, March 2020. MMWR Morb Mortal Wkly Rep. 2020;69(18):545-550. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32379729.
- Gross CP, Essien UR, Pasha S, Gross JR, Wang S, Nunez-Smith M. Racial and ethnic disparities in population level COVID-19 mortality. medRxiv. 2020;Preprint. Available at: https://www.medrxiv.org/content/10.1101/2020.05.07.20094250v1.full.pdf.
- Nayak A, Islam SJ, Mehta A, et al. Impact of social vulnerability on COVID-19 incidence and outcomes in the United States. medRxiv. 2020;Preprint. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32511437.
- Price-Haywood EG, Burton J, Fort D, Seoane L. Hospitalization and mortality among black patients and white patients with COVID-19. N Engl J Med. 2020;382(26):2534-2543. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32459916.
- Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): COVID-19 in racial and minority groups. 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/racial-ethnic-minorities.html. Accessed June 26, 2020.
- Kind AJH, Buckingham WR. Making Neighborhood-disadvantage metrics accessible—the neighborhood atlas. N Engl J Med. 2018;378(26):2456-2458. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29949490.
- Li Q, Guan X, Wu P, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med. 2020;382(13):1199-1207. Available at: https://www.ncbi.nlm.nih.gov/pubmed/31995857.
- Lauer SA, Grantz KH, Bi Q, et al. The incubation period of coronavirus disease 2019 (COVID-19) from publicly reported confirmed cases: estimation and application. Ann Intern Med. 2020;172(9):577-582 Available at: https://www.ncbi.nlm.nih.gov/pubmed/32150748.
- Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72,314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32091533.
- Shi H, Han X, Jiang N, et al. Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: a descriptive study. Lancet Infect Dis. 2020;20(4):425-434. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32105637.
- Liu PP, Blet A, Smyth D, Li H. The science underlying COVID-19: implications for the cardiovascular system. Circulation. 2020;142(1):68-78. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32293910.
- Madjid M, Safavi-Naeini P, Solomon SD, Vardeny O. Potential effects of coronaviruses on the cardiovascular system: a review. JAMA Cardiol. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32219363.
- Sachdeva M, Gianotti R, Shah M, et al. Cutaneous manifestations of COVID-19: report of three cases and a review of literature. J Dermatol Sci. 2020;98(2):75-81. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32381430.
- Henry BM, de Oliveira MHS, Benoit S, Plebani M, Lippi G. Hematologic, biochemical and immune biomarker abnormalities associated with severe illness and mortality in coronavirus disease 2019 (COVID-19): a meta-analysis. Clin Chem Lab Med. 2020;58(7):1021-1028. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32286245.
- Agarwal A, Chen A, Ravindran N, To C, Thuluvath PJ. Gastrointestinal and liver manifestations of COVID-19. J Clin Exp Hepatol. 2020;10(3):263-265. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32405183.
- Whittaker A, Anson M, Harky A. Neurological manifestations of COVID-19: a systematic review and current update. Acta Neurol Scand. 2020;142(1):14-22. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32412088.
- Paniz-Mondolfi A, Bryce C, Grimes Z, et al. Central nervous system involvement by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). J Med Virol. 2020;92(7):699-702. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32314810.
- Pei G, Zhang Z, Peng J, et al. Renal involvement and early prognosis in patients with COVID-19 pneumonia. J Am Soc Nephrol. 2020;31(6):1157-1165. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32345702.
- Su H, Yang M, Wan C, et al. Renal histopathological analysis of 26 postmortem findings of patients with COVID-19 in China. Kidney Int. 2020;98(1):219-227. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32327202.
- Bikdeli B, Madhavan MV, Jimenez D, et al. COVID-19 and thrombotic or thromboembolic disease: Implications for prevention, antithrombotic therapy, and follow-up. J Am Coll Cardiol. 2020;75(23):2950-2973.. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32311448.
- Chiotos K, Bassiri H, Behrens EM, et al. Multisystem inflammatory syndrome in children during the COVID-19 pandemic: a case series. J Pediatric Infect Dis Soc. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32463092.
- Belhadjer Z, Meot M, Bajolle F, et al. Acute heart failure in multisystem inflammatory syndrome in children (MIS-C) in the context of global SARS-CoV-2 pandemic. Circulation. 2020. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32418446.
- Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19): How to Protect Yourself & Others. 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention-H.pdf. Accessed July 7, 2020.
- Pan Y, Zhang D, Yang P, Poon LLM, Wang Q. Viral load of SARS-CoV-2 in clinical samples. Lancet Infect Dis. 2020;20(4):411-412. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32105638.
- Rothe C, Schunk M, Sothmann P, et al. Transmission of 2019-nCoV infection from an asymptomatic contact in Germany. N Engl J Med. 2020;382(10):970-971. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32003551.
- Yu P, Zhu J, Zhang Z, Han Y, Huang L. A familial cluster of infection associated with the 2019 novel coronavirus indicating potential person-to-person transmission during the incubation period. J Infect Dis. 2020;221(11):1757-1761. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32067043.
- Bai Y, Yao L, Wei T, et al. Presumed asymptomatic carrier transmission of COVID-19. JAMA. 2020;323(14):1406-1407. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32083643.