For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 473. 23 July 2021

July 23

COVID-19 Situation Report 473

Centre for Infectious Disease Epidemiology and Research (CIDER) For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 473. 23 July 2021

s i. Background

In December, China notified the World Health Organization (WHO) of several cases of human respiratory illness, which appeared to be linked to an open seafood and livestock market in the city of Wuhan. The infecting agent has since been identified as a novel coronavirus, previously known as 2019-nCoV and now called SAR-CoV-2; The new name of the disease has also been termed COVID-19, as of 11th February 2020. Although the virus is presumed zoonotic in origin, person-to-person spread is evident. Screening of travellers, travel bans and quarantine measures are being implemented in many countries. Despite these precautions, it is anticipated that more cases will be seen both inside China and internationally. The WHO declared the outbreak of COVID-19 constitutes a Public Health Emergency of International Concern on 30 January. On 11 March, 2020, WHO declared the coronavirus outbreak a pandemic as the global death toll rose above 4,600 and the number of confirmed cases topped 125,000. This report aims to update Global Risk Assessment, Global Epidemiology, Quarantine Orders, Travel Ban/Advisory by countries, WHO’s and CDC’s Guidance and Protocols and Scientific publication on a daily basis. New updates in the tables are bolded.

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 473. 23 July 2021

ii. Global Risk Assessment

Table 1. Risk assessment of COVID-19 by WHO regions (Updated as of 23 July 2021, 1200H SGT) Severity of Availability of Treatment/ Overall Environmental Risk Transmissibility Disease Vaccination# Risk% Global (n=198 countries) High Limited

Globally, 189 (95.5%) countries (excluding Based on CDC Case The number of countries that have * territories ) have reported the outbreak. data, median R0 fatality rate commenced mass vaccination in each is estimated to is currently region are as follows: Combined WPRO Using an incidence >20 cases/100,000 be 5.8 (95% CI at 2.15% and SEARO (33 countries), EURO (53 people over the past 14-days as cut-off for 4.4–7.7), but globally. countries), EMRO (20 countries), a surge in cases, the number of countries the estimated Most cases Americas (34 countries), and Africa (43 reporting a surge in cases in each region effective present as countries).& are as follows: Combined WPRO and reproduction flu-like SEARO (19 countries), number in 177 illness. International clinical trials published on 2 EURO (42 countries), countries September confirm that cheap, widely EMRO (14 countries), Americas (29 ranged from available steroid drugs can help seriously countries), and Africa (17 countries). 0.13 to 2.3.$ ill patients survive Covid-19. The World Health Organization issued new Only 4 (2%) countries/territories have no treatment guidance, strongly reported restrictions on inbound arrivals, recommending steroids to treat severely while 147 (79%) countries/territories have and critically ill patients, but not to those partially reopened their borders – require with mild disease. [4] arrivals to produce a negative COVID-19 test result and/or undergo self-quarantine Researchers have found all regimens of upon arrival. 48 (26%) anticoagulants to be far superior to no countries/territories are totally closed to anticoagulants in COVID-19 patients. international arrivals. [1] More specifically, patients on both a High “therapeutic” or full dose and those on a On October 7, the Centers for Disease “prophylactic” or lower dose, showed Control and Prevention (CDC) confirmed about a 50% higher chance of survival airborne transmission of SARS-CoV-2. [2] and roughly a 30% lower chance of intubation, than those not on The U.S. CDC has revised its guidance on anticoagulants. It was observed that COVID-19 quarantine period from 14 days therapeutic and prophylactic to 7-10 days, based one's test results and subcutaneous low-molecular weight symptoms. Individuals without symptoms heparin and therapeutic oral apixaban only need quarantine for 10 days without may lead to better results. [3] testing; those tested negative can quarantine for 7 days. [14] A new strain known as B.1.525 containing the same E484K mutation The US Centers for Disease Control and found in the Brazilian and South African Prevention (CDC) on 10 Feb announced variants has been detected in Britain that fully vaccinated people did not need [18]. to quarantine if they received their last dose within three months and 14 days As of 6 July, the WHO recommended after their last shot, the time it takes to using arthritis drugs Actemra develop immunity. [16] (tocilizumab) and Kevzara (sarilumab) with corticosteroids for severe and critical COVID-19 patients. [27]

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 473. 23 July 2021

Western Pacific Region and South-East Asia Region (n=41 countries) Moderate High

33 (80.5%) countries have reported As of July 15, Case 33 countries have commenced outbreaks; but only 19 (46.3%) countries the estimated fatality rate vaccination as of 23 July 2021. Coverage are reporting a surge in cases. effective is 1.46%. was available for the following: i) at least reproduction 1 dose was at <50% for 27 countries; 51- 13 (31.7%) countries have either a no. of 25 70% for 3 countries; >70% for 2 countries constant decreasing change in incidence countries ii) full vaccination was at <50% for 18 & or no case in the last 14 days. ranged from countries; 51-70% for 3 countries. $ 0.55-1.3. Indonesia has approved Russian drug Highest incidence over the past 14 days Avifavir for emergency use. [22] were reported from Fiji, Indonesia, High Malaysia, Maldives and Mongolia and China has approved the use of 3 highest case numbers were reported from traditional chinese medicines, Qingfei Bangladesh, India, Indonesia, Malaysia Paidu Formula, Huashi Baidu Formula and Thailand. and Xuanfei Baidu Formula, for COVID-19 treatment. [20] At least 17 countries have closed their borders, 23 countries have opened their As of 4 June, India has approved a borders partially conditionally, and none is combination of monoclonal antibodies, allowing free travel. and etesevimab for restricted use in emergency situations in hospital settings in adults [24]. European Region (n=53 countries) High High

52 (98.1%) countries have reported with As of July 15, Case 53 countries have commenced outbreaks; 42 (79.3%) countries are the estimated fatality rate vaccination as of 23 July 2021. Coverage reporting a surge in cases. effective is 2.05%. was available for the following i) at least reproduction 1 dose was at <50% for 26 countries; 51- 1 (1.9%) countries have either a constant no. of 52 70% for 24 countries; >70% for 2 decreasing change in incidence or no case countries countries; ii) full vaccination was at <50% in the last 14 days. ranged from for 40 countries; 51-70% for 7 countries; 0.55-2.3$ >70% for 2 countries. & Highest incidence over the past 14 days High were reported from Andorra, Cyprus, On February 28, France authorized its Netherlands, Spain and United Kingdom, first ever use of synthetic monoclonal and highest case numbers were reported antibody, bamlanivab by Eli Lilly, for use from Netherlands, Russia, Spain, Turkey on severe COVID-19 patients. [19] and United Kingdom. As of February 14, Italy authorized the At least 6 countries have closed their use of the two monoclonal antibodies of borders, 46 countries have opened their companies Eli Lilly and Regeneron aimed borders partially conditionally, and only 1 mainly at more serious patients with country is allowing free travel. COVID-19 [17]. Eastern Mediterranean Region (n=22 countries) High High

22 (100%) countries have reported with As of July 15, Case 20 countries have commenced outbreak; 14 (63.6%) countries are the estimated fatality rate vaccination as of 23 July 2021. Coverage High reporting a surge in cases. effective is 1.91%. was available for the following: i) at least reproduction 1 dose was at <50% for 15 countries; 51- no. of 21 70% for 2 countries; >70% for 1 country; countries

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 473. 23 July 2021

1 (4.6%) country has either a constant ranged from ii) full vaccination was at <50% for 11 decreasing change in incidence or no case 0.13-1.4.$ countries; 51-70% for 2 countries. & in the last 14 days. As of June 25, the Abu Dhabi Stem Cell Highest incidence over the past 14 days Centre has treated more than 2,000 were reported from Iran, Kuwait, Libya, COVID-19 patients using UAECell19. Oman and Tunisia, and highest case 1,200 have fully recovered. [6] numbers were reported from Iran, Iraq, Kuwait, Pakistan and Tunisia. As of April, an Israeli firm is using placenta pluristem cells to treat COVID- At least 5 countries have closed their 19 patients on a compassionate use borders, 16 countries have opened their basis. [5] borders partially conditionally, and only 1 country is allowing free travel. As of June 4, UAE authorised the emergency use of , a kind of drug [25]. Region of the Americas (n=35 countries) High High

35 (100%) countries have reported with As of July 15, Case 34 countries have commenced outbreak; 29 (82.9%) countries are the estimated fatality rate vaccination as of 23 July 2021. Coverage reporting a surge in cases. effective is 2.62%. was available for the following: i) at least reproduction 1 dose was at <50% for 28 countries; 51- No country has either a constant no. of 34 70% for 3 countries; >70% for 2 decreasing change in incidence or no case countries countries ii) full vaccination was at <50% in the last 14 days. ranged from for 21 countries; 51-70% for 2 countries. 0.37-1.5.$ & Highest incidence over the past 14 days were reported from Argentina, Colombia, With the increase of multiple variants of Costa Rica, Cuba and Panama, and highest COVID-19, the U.S. FDA will limit the use case numbers were reported from of monoclonal antibody treatments Argentina, Brazil, Colombia, Mexico and developed by Regeneron and Eli Lilly due USA. to concerns the medications are not effective against these new strains. Eli At least 11 countries have closed their Lilly’s bamlanivimab will not be borders, 22 countries have opened their distributed to California, Arizona and borders partially conditionally, and 2 Nevada, where those variants are more High countries are allowing free travel. common. [21]

FDA has issued EUA to Eli Lilly’s combination antibody therapy of bamlanivimab and etesevimab to treat mild to moderate COVID-19 patients who are at risk of serious illness or hospitalization. [15]

The Food and Drug Administration has allowed the combination use of baricitinib and Remdesivir under emergency use authorization. The EUA covers dosing of patients (above the age of two) who are on supplemental oxygen, receiving invasive mechanical ventilation or extracorporeal membrane oxygenation. [12]

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 473. 23 July 2021

Health Canada has approved bamlanvimab, for the treatment of COVID-19 in patients 12 years and older with mild to moderate symptoms who are at risk of severe disease progression. [11]

FDA has allowed emergency use of Eli Lilly & Co’s bamlanivimab for non- hospitalized patients at risk of serious illness due to age or other conditions. [10]

FDA has issued emergency authorisation for convalescent plasma to treat COVID- 19. [9]

RLF-100 (aviptadil) by NeuroRx and Relief Therapeutics was approved for emergency use in COVID-19 patients who are too ill to participate in the trial. [8]

As of October 22, remdesivir is the first and only FDA-approved COVID-19 treatment in the U.S. [7].

FDA has issued emergency authorisation for sotrovimab to treat mild-to-moderate Covid-19 adults and paediatric patients (12 years old and older weighing at least 40kg) who are at risk of severe disease progression. [23]

As of 25 June, US FDA has issued emergency authorisation for Actemra/RoActemra (tocilizumab) to treat hospitalized adults and pediatric patients receiving corticosteroids and requiring supplemental oxygen, breathing support or ECMO. [26] African Region (n=47 countries) Moderate High

47 (100%) countries have reported with As of July 15, Case 43 countries have commenced outbreak; 17 (37.0%) countries are the estimated fatality rate vaccination as of 23 July 2021. Coverage reporting a surge in cases. effective is 2.37%. was available for the following: i) at least reproduction 1 dose was at <50% for 41 countries; 1 (2.1%) country has either a constant no. of 45 >70% for 1 country; ii) full vaccination High decreasing change in incidence or no case countries was at <50% for 14 countries; >70% for 1 in the last 14 days. ranged from country. & 0.29-1.7.$ Highest incidence over the past 14 days Ethiopia has approved the use of were reported from Botswana, Namibia, treatment for seriously Seychelles, South Africa and Zimbabwe, ill COVID-19 patients. [13] and highest case numbers were reported

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 473. 23 July 2021 from Mozambique, Namibia, South Africa, Zambia and Zimbabwe.

At least 9 countries have closed their borders, 38 countries have opened their borders partially conditionally, and no country is allowing free travel. *Only WHO member states are included. 30 territories that have reported cases (with the exception of Palestine) are excluded from the tabulation of total countries affected/imported/local cases and case fatality rate. Refer to WHO situation reports or table 4 for information. $ https://epiforecasts.io/covid/posts/global/ ^Differences between R0 and effective R can be found here https://www.coronavirustoday.com/r-number-refers- either-basic-or-effective-reproduction-number & https://www.bloomberg.com/graphics/covid-vaccine-tracker-global-distribution/; High vaccine coverage defined as >70% population with full vaccination % In view of the reduction in case fatality rate and effective reproduction number with increasing vaccination, the two metric are no longer conferred a risk level in our risk assessment matrix; overall risk of each region is compiled using risk of the environment and availability of treatment only.

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iii. Global Epidemiology

Table 2. Summary of COVID-19 cases & fatalities globally (Updated as of 23 July 2021, 1200H SGT) Case- No. of Total Cases Case- Fatality Countries/ Total Global Outside Total Fatality Rate (%) R0 Territories Cases Mainland Deaths Rate (%) [outside with Cases China [overall] China] 5.8 (95% CI 4.4– 220 193,423,973 193,331,511 4,151,699 2.15% 2.15% 7.7)^ ^Based on early release as of 10th April, 2020: https://wwwnc.cdc.gov/eid/article/26/7/20-0282_article

Table 3. Comparison with other viruses Virus Incubation Period (Days) Case Fatality Rate (%) R0 Median = 5.1$ SARS-CoV-2 2.15 5.8 (95% CI 4.4–7.7) ^ (2-14) or up to 24* SARS-CoV 2-7 9.6 2.0 <1 (higher in health care MERS-CoV 5 (2-14) 34 setting) Swine Flu 1-4 0.02 1.2-1.6 *Data on 1099 patients from 552 hospitals in 31 provinces of China ^https://wwwnc.cdc.gov/eid/article/26/7/20-0282_article $Data on 181 cases outside china

Figure 1. Growth Factor of Daily New Cases (Mainland China+ Other countries)

Growth Factor = every day’s cases/cases on previous day. A growth factor above 1 indicates an increase, whereas one between 0 and 1 is a sign of decline, with the quantity eventually becoming zero. A growth factor below 1 (or above 1 but trending downward) is a positive sign, whereas a growth factor constantly above 1 is the sign of exponential growth. *Huge jump in cases on Feb. 12 is attributed to the change in diagnostic criteria in China.

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Figure 2. Growth Factor excluding mainland China

Figure 3. Growth Factor of Novel Coronavirus Daily Deaths (Mainland China + Other Countries)

Growth Factor = every day’s cases/cases on previous day. A growth factor above 1 indicates an increase, whereas one between 0 and 1 is a sign of decline, with the quantity eventually becoming zero. A growth factor below 1 (or above 1 but trending downward) is a positive sign, whereas a growth factor constantly above 1 is the sign of exponential growth. Source: https://www.worldometers.info/coronavirus/coronavirus-cases/

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Case Breakdown by Countries Live update of COVID-19 global cases can be found at https://storymaps.arcgis.com/stories/a1746ada9bff48c09ef76e5a788b5910

Table 4. Breakdown of COVID-19 confirmed cases and deaths from 17 – 23 July 2021 (Updated as of 23 July 2021, 1200H SGT) Total Country Total Cases Change Total Deaths Change Region Recovered 1 USA 35,213,594 +326439 626,172 +1958 29,478,173 Americas

2 UK 5,602,321 +321223 128,980 +387 4,427,533 EURO 3 Indonesia 3,033,339 +306536 79,032 +8840 2,392,923 SEARO 4 India 31,293,062 +267187 419,502 +6939 30,468,079 SEARO 5 Brazil 19,524,092 +261574 547,134 +8084 18,259,711 Americas 6 Spain 4,249,258 +180096 81,194 +110 3,681,125 EURO 7 Russia 6,054,711 +172416 151,501 +5432 5,427,457 EURO 8 Iran 3,623,840 +159785 88,063 +1471 3,204,136 EMRO 9 Colombia 4,692,570 +109128 117,836 +3003 4,449,027 Americas 10 France 5,933,510 +100169 111,565 +136 5,669,083 EURO 11 Argentina 4,812,351 +92399 103,074 +2379 4,447,953 Americas 12 South Africa 2,342,330 +89090 68,625 +2653 2,109,820 Africa 13 Thailand 467,707 +85800 3,811 +712 320,152 SEARO 14 Malaysia 964,918 +84136 7,574 +961 815,293 WPRO 15 Mexico 2,709,739 +80091 237,626 +1886 2,112,815 Americas 16 Bangladesh 1,140,200 +68426 18,685 +1407 969,610 SEARO 17 Netherlands 1,827,273 +61171 17,789 +16 1,662,439 EURO 18 Iraq 1,526,943 +60414 18,101 +394 1,386,331 EMRO 19 Turkey 5,563,903 +56448 50,761 +346 5,405,339 EURO 20 Cuba 308,599 +45513 2,137 +411 270,757 Americas 21 Kazakhstan 516,117 +44011 5,244 +428 441,437 EURO 22 Myanmar 253,364 +40819 6,133 +1787 173,926 SEARO 23 Philippines 1,530,266 +39601 26,891 +577 1,452,813 WPRO 24 Vietnam 78,269 +35981 370 +163 13,421 WPRO 25 Tunisia 558,306 +31819 18,052 +1043 453,865 EMRO 26 Japan 852,517 +24745 15,097 +107 806,202 WPRO 27 Italy 4,302,393 +24074 127,920 +80 4,119,607 EURO 28 Portugal 943,244 +23044 17,248 +61 873,008 EURO 29 Greece 469,042 +18530 12,851 +56 422,175 EURO 30 Morocco 567,758 +17914 9,517 +99 538,370 EMRO 31 Guatemala 344,221 +16466 10,029 +195 299,752 Americas 32 Pakistan 1,000,034 +16315 22,939 +219 923,472 EMRO 33 Zimbabwe 93,421 +14549 2,870 +452 61,723 Africa 34 Georgia 395,621 +12887 5,636 +133 369,483 EURO 35 Libya 227,433 +12865 3,322 +73 184,852 EMRO

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36 Nepal 674,726 +12156 9,661 +198 637,690 SEARO 37 Botswana 97,657 +11524 1,375 +101 84,189 Africa 38 Peru 2,099,522 +11379 195,547 +702 N/A Americas 39 Mozambique 105,866 +11133 1,221 +164 80,773 Africa 40 Sri Lanka 291,298 +10755 3,959 +298 264,755 SEARO 41 UAE 667,080 +10726 1,910 +25 644,753 EMRO 42 S. Korea 185,733 +10687 2,066 +15 164,206 WPRO 43 Chile 1,604,713 +10217 34,792 +585 1,558,669 Americas 44 Kyrgyzstan 155,005 +10047 2,227 +84 132,138 EURO 45 Germany 3,758,406 +10039 91,990 +127 3,643,300 EURO 46 Rwanda 61,375 +9750 704 +88 43,924 Africa 47 Mongolia 153,782 +9290 761 +45 146,977 WPRO 48 Costa Rica 397,469 +9171 4,933 +76 321,048 Americas 49 Ireland 289,139 +8355 5,026 +20 264,469 EURO 50 Saudi Arabia 514,446 +8321 8,130 +95 495,650 EMRO 51 Algeria 158,213 +8307 4,008 +113 108,537 Africa 52 Kuwait 389,868 +7784 2,264 +90 372,358 EMRO 53 Israel 856,986 +7712 6,457 +14 840,712 EURO 54 Zambia 189,731 +7602 3,196 +205 177,419 Africa 55 Venezuela 296,863 +7501 3,443 +104 280,269 Americas 56 Fiji 21,361 +7475 161 +87 4,729 WPRO 57 Honduras 285,375 +7401 7,558 +167 97,200 Americas 58 Ecuador 479,784 +7062 30,777 +8905 443,880 Americas 59 Panama 426,849 +7020 6,730 +56 407,055 Americas 60 Cyprus 95,307 +6850 398 +15 75,466 EURO 61 Bolivia 466,318 +6739 17,576 +201 396,914 Americas 62 Cambodia 71,244 +6633 1,222 +197 63,474 WPRO 63 Belgium 1,108,675 +6606 25,213 +5 1,054,202 EURO 64 Belarus 437,664 +6552 3,365 +68 431,489 EURO 65 Senegal 54,820 +6550 1,256 +47 44,354 Africa 66 Denmark 309,420 +5951 2,542 +2 295,176 EURO 67 Paraguay 447,864 +5657 14,501 +381 408,973 Americas 68 Namibia 114,400 +5044 2,665 +395 90,448 Africa 69 Malawi 46,417 +4919 1,410 +109 35,792 Africa 70 Switzerland 711,877 +4520 10,903 +1 691,224 EURO 71 Afghanistan 143,439 +4388 6,357 +285 90,973 EMRO 72 Uzbekistan 122,048 +4146 814 +29 116,755 EURO 73 Kenya 195,111 +4091 3,826 +80 184,461 Africa 74 Ukraine 2,246,656 +3788 52,790 +105 2,183,003 EURO 75 Lebanon 552,871 +3444 7,889 +7 535,663 EMRO 76 Jordan 763,106 +3420 9,929 +57 745,551 EMRO 77 Canada 1,425,097 +2851 26,526 +54 1,394,060 Americas 78 Dominican Republic 338,902 +2758 3,931 +24 287,607 Americas 79 Austria 655,197 +2537 10,730 +3 640,202 EURO

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80 Sweden 1,096,341 +2418 14,615 +8 1,073,980 EURO 81 Finland 101,630 +2418 978 0 46,000 EURO 82 Uganda 91,355 +2275 2,483 +234 71,750 Africa 83 Martinique 15,612 +2241 99 0 104 Non 84 DRC 47,174 +1963 1,021 +37 29,389 Africa 85 Uruguay 379,911 +1870 5,913 +48 370,711 Americas 86 Channel Islands 8,240 +1857 86 0 5,022 Non 87 El Salvador 84,144 +1781 2,529 +59 75,608 Americas 88 Czechia 1,671,933 +1585 30,347 +12 1,638,500 EURO 89 Isle of Man 3,424 +1517 29 0 1,638 Non 90 Azerbaijan 339,274 +1473 4,999 +9 331,629 EURO 91 Trinidad and Tobago 36,884 +1456 1,018 +49 30,043 Americas 92 Serbia 719,462 +1369 7,095 +17 709,704 EURO 93 Malta 33,198 +1364 420 0 30,291 EURO 94 Norway 135,235 +1359 799 +3 88,952 EURO 95 Mauritius 3,181 +1323 19 +1 1,854 Africa 96 Réunion 34,615 +1320 266 +10 32,036 Non 97 Nigeria 170,306 +1232 2,130 +4 164,772 Africa 98 Armenia 228,161 +1212 4,575 +19 218,676 EURO 99 Eswatini 21,880 +1187 735 +37 19,392 Africa 100 Ghana 99,160 +1046 815 +9 95,221 Africa 101 Mauritania 23,223 +1036 517 +14 21,085 Africa 102 Laos 4,119 +1027 5 +1 2,174 WPRO 103 Cameroon 81,871 +1013 1,332 +8 78,224 Africa 104 Australia 32,588 +962 916 +4 29,743 WPRO 105 Singapore 63,791 +939 36 0 62,576 WPRO 106 Qatar 224,834 +923 600 +1 222,600 EMRO 107 Croatia 362,129 +911 8,245 +12 352,966 EURO 108 Angola 41,405 +875 977 +26 35,082 Africa 109 Maldives 76,454 +832 218 +3 73,637 SEARO 110 Lithuania 280,296 +808 4,408 +4 268,474 EURO 111 Seychelles 17,747 +742 89 +12 16,889 Africa 112 Suriname 24,573 +712 626 +24 20,846 Americas 113 French Guiana 29,419 +705 170 +7 9,995 Non 114 Poland 2,881,840 +689 75,231 +40 2,653,088 EURO 115 Luxembourg 73,309 +677 821 +2 70,989 EURO 116 Ethiopia 278,105 +662 4,363 +13 262,692 Africa 117 Bulgaria 423,440 +643 18,189 +26 397,900 EURO 118 Jamaica 51,542 +629 1,167 +31 46,773 Americas 119 British Virgin Islands 2,210 +608 23 +15 588 Non 120 Bahrain 268,225 +606 1,381 +2 266,036 EMRO 121 Moldova 258,365 +599 6,236 +17 251,242 EURO 122 Gambia 7,161 +551 197 +9 6,080 Africa 123 Lesotho 12,679 +526 357 +19 6,621 Africa

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124 Guinea 24,823 +525 195 +11 23,719 Africa 125 Bahamas 13,781 +507 274 +18 12,158 Americas 126 Curaçao 13,038 +501 126 0 12,302 Non 127 Estonia 132,179 +498 1,271 0 128,271 EURO 128 Romania 1,081,953 +486 34,264 +19 1,047,000 EURO 129 Guyana 21,733 +459 515 +9 20,009 Americas 130 Slovenia 258,468 +423 4,426 +1 253,200 EURO 131 Egypt 283,906 +416 16,470 +45 226,535 EMRO 132 Guadeloupe 17,779 +406 238 +2 2,250 Non 133 Haiti 19,762 +388 523 +36 13,332 Americas 134 Ivory Coast 49,386 +387 324 +5 48,655 Africa 135 Togo 14,801 +375 140 +6 13,907 Africa 136 Palestine 315,876 +372 3,591 +6 310,961 EMRO 137 Tajikistan 14,359 +359 116 +6 13,902 EURO 138 Hungary 809,016 +355 30,020 +7 744,714 EURO 139 Nicaragua 9,108 +341 194 +1 4,225 Americas 140 Latvia 138,344 +303 2,550 +8 135,262 EURO 141 Montenegro 100,865 +298 1,624 +3 98,761 EURO 142 China 92,462 +279 4,636 0 87,163 WPRO 143 Cabo Verde 33,452 +272 297 +3 32,617 Africa 144 Burundi 6,018 +254 8 0 773 Africa 145 Belize 13,893 +249 332 0 13,201 Americas 146 Iceland 6,967 +249 30 0 6,652 EURO 147 Papua New Guinea 17,581 +241 192 +13 17,177 WPRO 148 Timor-Leste 10,227 +230 26 +1 9,484 SEARO 149 Andorra 14,464 +225 127 0 13,988 EURO 150 Slovakia 392,219 +219 12,534 +10 379,279 EURO 151 Gibraltar 4,728 +210 94 0 4,336 Non 152 French Polynesia 19,234 +176 145 +1 18,945 Non 153 Albania 132,797 +168 2,456 0 130,109 EURO 154 Taiwan 15,511 +165 782 +23 13,708 WPRO 155 Sudan 37,138 +152 2,776 +2 30,867 EMRO 156 Guinea-Bissau 4,117 +119 74 +4 3,756 Africa 157 Bosnia and Herzegovina 205,384 +117 9,673 +8 188,330 EURO 158 Congo 13,050 +117 176 +4 11,759 Africa 159 North Macedonia 155,981 +115 5,489 +2 150,251 EURO 160 Saint Martin 2,481 +108 38 0 1,399 Non 161 Eritrea 6,480 +98 32 +2 6,201 Africa 162 Aruba 11,293 +94 109 +1 11,054 Non 163 Liberia 5,396 +90 148 0 2,715 Africa 164 Barbados 4,319 +89 48 0 4,098 Americas 165 Monaco 2,744 +89 33 0 2,609 EURO 166 Sierra Leone 6,206 +84 117 +4 4,201 Africa 167 Madagascar 42,561 +82 937 +3 40,990 Africa

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 473. 23 July 2021

168 Somalia 15,162 +81 781 0 7,277 EMRO 169 Benin 8,324 +80 107 0 8,125 Africa 170 Bhutan 2,458 +78 2 0 2,181 SEARO 171 Gabon 25,309 +64 163 +1 25,050 Africa 172 Faeroe Islands 958 +53 1 0 877 Non 173 New Zealand 2,855 +52 26 0 2,749 WPRO 174 Saint Lucia 5,496 +41 87 0 5,304 Americas 175 Syria 25,853 +39 1,905 +3 21,933 EMRO 176 Niger 5,594 +39 195 +1 5,295 Africa 177 Sint Maarten 2,698 +39 34 0 2,622 Non 178 Yemen 7,001 +34 1,372 +6 4,162 EMRO 179 Mali 14,527 +31 530 +1 12,868 Africa 180 Caribbean Netherlands 1,690 +29 17 0 1,647 Non 181 Brunei 311 +29 3 0 269 WPRO 182 Equatorial Guinea 8,848 +20 123 0 8,591 Africa 183 Greenland 84 +19 0 0 58 Non 184 Sao Tome and Principe 2,417 +17 37 0 2,340 Africa 185 Hong Kong 11,972 +16 212 0 11,690 WPRO 186 Saint Kitts and Nevis 560 +16 3 0 519 Americas 187 Turks and Caicos 2,459 +15 18 0 2,404 Non 188 St. Vincent Grenadines 2,271 +13 12 0 2,199 Americas 189 Comoros 4,014 +12 147 +1 3,849 Africa 190 Liechtenstein 3,073 +12 59 0 2,995 Non 191 Mayotte 19,460 +10 174 0 2,964 Non 192 Bermuda 2,535 +10 33 0 2,487 Non 193 Antigua and Barbuda 1,277 +10 42 0 1,225 Americas 194 Dominica 209 +10 0 0 196 Americas 195 Burkina Faso 13,537 +7 169 0 13,350 Africa 196 Cayman Islands 627 +7 2 0 618 Non 197 Djibouti 11,628 +6 155 0 11,466 EMRO 198 Chad 4,965 +6 174 0 4,777 Africa 199 CAR 7,147 +5 98 0 6,859 Africa 200 San Marino 5,099 +5 90 0 5,002 EURO 201 Grenada 164 +3 1 0 161 Americas 202 New Caledonia 131 +2 0 0 58 Non 203 Anguilla 113 +2 0 0 111 Non 204 Macao 56 +1 0 0 53 WPRO 205 Oman 289,042 0 3,498 0 263,752 EMRO 206 South Sudan 10,917 0 117 0 10,514 Africa 207 St. Barth 1,005 0 1 0 462 Non 208 Diamond Princess 712 0 13 0 699 NA 209 Tanzania 509 0 21 0 183 Africa 210 Wallis and Futuna 445 0 7 0 438 Non 211 Falkland Islands 63 0 0 0 63 Non

13 | P a g e Centre for infectious di sease epidemiology and research

For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 473. 23 July 2021

212 Vatican City 27 0 0 0 27 Non 213 Saint Pierre Miquelon 26 0 0 0 26 Non 214 Montserrat 21 0 1 0 19 Non 215 Solomon Islands 20 0 0 0 20 WPRO 216 Western Sahara 10 0 1 0 8 Non 217 MS Zaandam 9 0 2 0 7 NA 218 Vanuatu 4 0 1 0 3 WPRO 219 Marshall Islands 4 0 0 0 4 WPRO 220 Samoa 3 0 0 0 3 WPRO 221 Saint Helena 2 0 0 0 2 Non 222 Micronesia 1 0 0 0 1 WPRO Total 193,423,973 +3685063 4,151,699 +68550 174,019,308

Figure 4. Areas with reported confirmed cases of COVID-19 (12 – 18 July 2021)

Source: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports

14 | P a g e Centre for infectious di sease epidemiology and research

For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 473. 23 July 2021

Table 5. COVID-19 cases and deaths reported by states/UT in India between 17 – 23 July, 2021 (Updated as of 23 July 2021, 1200H SGT) Name of State Total Change Total Change Total Change Total Change / UT Diagnosed from Active from Recovered from Deaths from Cases previous Cases previous previous previous week week week week Andaman and 7525 +33 19 +6 7377 +26 129 +1 Nicobar Islands Andhra 1948592 +34379 23571 -8279 1911812 +42395 13209 +263 Pradesh Arunachal 44708 +6026 4398 +938 40102 +5065 208 +23 Pradesh Assam 554221 +27021 16205 -6843 532940 +33552 5076 +312 Bihar 724230 +1265 597 -544 713998 +1788 9635 +21 Chandigarh 61916 +122 34 -66 61073 +188 809 0 Chhattisgarh 1000763 +3728 3241 -1673 984015 +5361 13507 +40 Dadra and 10624 +45 36 +3 10584 +42 4 0 Nagar Haveli and Daman and Diu Delhi 1435720 +847 585 -262 1410095 +1077 25040 +32 Goa 170199 +1989 1376 -589 165700 +2541 3123 +37 Gujarat 824608 +517 370 -1127 814162 +1640 10076 +4 Haryana 769665 +517 765 -269 759287 +698 9613 +88 Himachal 204800 +1555 935 -372 200356 +1904 3509 +23 Pradesh Jammu and 320340 +2317 1513 -1831 314454 +4128 4373 +20 Kashmir Jharkhand 346846 +678 305 -171 341419 +846 5122 +3 Karnataka 2889994 +25126 24718 -14034 2828983 +38530 36293 +630 Kerala 3218015 +192549 129381 +18765 3072895 +172295 15739 +1489 Ladakh 20284 +129 83 -52 19995 +180 206 +1 Lakshadweep 10100 +120 67 -169 9984 +289 49 0 Madhya 791721 +1625 185 -231 781024 +367 10512 +1489 Pradesh Maharashtra 6245057 +113081 97513 -20185 6016506 +126524 131038 +6742 Manipur 88978 +13798 10395 +3668 77147 +9935 1436 +195 Meghalaya 59346 +6102 4413 +22 53945 +5982 988 +98 Mizoram 30492 +7478 7744 +3838 22617 +3610 131 +30 Nagaland 27024 +1297 1237 +233 25251 +1033 536 +31 Odisha 961934 +29604 17466 -7271 939160 +35982 5308 +893 Puducherry 120003 +1432 955 -807 117265 +2223 1783 +16 Punjab 598590 +1395 811 -1116 581529 +2418 16250 +93 Rajasthan 953462 +506 360 -464 944150 +960 8952 +10 Sikkim 24341 +2546 2719 +575 21294 +1955 328 +16 Tamil Nadu 2543040 +32981 25526 -8139 2483676 +40535 33838 +585 Telangana 639369 +9584 9857 -1349 625738 +10873 3774 +60

15 | P a g e Centre for infectious di sease epidemiology and research

For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 473. 23 July 2021

Tripura 75608 +6058 4251 +76 70623 +5957 734 +25 Uttarakhand 341629 +606 649 -796 333621 +1381 7359 +21 Uttar Pradesh 1708057 +1013 1028 -761 1684286 +1707 22743 +67 West Bengal 1521261 +12043 12205 -3938 1491016 +15808 18040 +173 Total 43104 - 3881 -454846 38740 - 483 -405456 30709846 29849544 Source: https://www.mohfw.gov.in/

16 | P a g e Centre for infectious di sease epidemiology and research

For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 473. 23 July 2021

iv. Travel Bans/Advisories & Quarantine Orders

[1] Australia - Quarantine-free travel from all Australian states and territories to New Zealand will be suspended, New Zealand Prime Minister Jacinda Ardern and Covid-19 Response Minister Chris Hipkins announced on July 23.

[2] Belgium - "Travellers who are not fully vaccinated and plan to return to Belgium from countries considered highly affected by the Coronavirus will be obliged to take a PCR test on the first and seventh day after arrival, authorities in Belgium have confirmed. According to Belgium’s government, persons who test positive will be required to follow the ten-day mandatory quarantine rule. The day-one test can be avoided if travellers present a negative result of the PCR test, not older than 72 hours, upon their arrival in the Western European country. In addition, checks will be stricter at airports and train stations to ensure that citizens accurately complete Passenger Locator Forms (PLF)."

[3] Canada - If the virus progress continues, Canada will welcome all fully vaccinated international travellers by 7 September. All travellers will need to present a negative Covid-19 test before entry.

[4] Chile - Chile announced on Thursday 22 July that its citizens and foreign residents would be allowed to travel outside the country if they are fully inoculated against coronavirus, a fresh perk for Chileans participating in one of the world's fastest vaccination campaigns.

[5] Saudi Arabia - Saudi Arabia will allow citizens who have received two doses of COVID-19 vaccine to travel abroad from August 9, the Saudi Press Agency reported. The Saudi Interior Ministry's decision comes as part of precautionary measures against the virus and its new variants, it said. The decision excepts children below 12 who should have a valid health insurance policy, approved by the Saudi Central Bank (SAMA), to cover the risks of the COVID-19. It also doesn't apply to citizens who recovered from the virus in less than six months, and those who recovered and received one dose of the vaccine.

[6] United States - As of 20 July, the United States Centers for Disease Control and Prevention (CDC) has raised its COVID-19 warning level for the UK to 'level 4'. The CDC has advised people to avoid travelling to the United Kingdom. The agency in the advisory added that if people travel to the UK, they must ensure full vaccination.

17 | P a g e Centre for infectious di sease epidemiology and research

For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 473. 23 July 2021

v. Lockdowns

[1] Bangladesh - The government announced that from July 15-23, all restrictions would be lifted and everything would be reopened so people could celebrate the festival, which is normally a boon to the economy.

[2] Indoneasia - The Indonesian government has decided to extend the emergency community activity restrictions, known locally as PPKM Darurat, to July 25 as the country is still fighting the second wave of COVID-19. The emergency restrictions, which include a ban on dine-in services at restaurants and mandates to work from home for workers in nonessential sectors, were initially implemented on the country's most populated Island of Java and the resort Island of Bali from July 3 to July 20. The restrictions were later expanded to 15 other regions that saw surges in new cases of COVID-19.

[3] Iran - Iran on 20 July reported its highest daily case total of the pandemic, and health officials ordered a week-long lockdown for Tehran, the country's capital.

[4] Singapore - Three weeks after it outlined its much-publicised road map for living with COVID-19, Singapore is returning to a partial lockdown for a month from 22 July to 18 August. The country is reverting to the tight restrictions it had in place during May and June, shutting down dining in restaurants, closing indoor venues such as gyms and limiting gatherings to two people.

[5] South Korea - The South Korean government decided on Friday 23 July to extend the restrictions for two weeks beyond the originally scheduled end date of July 25. It will also consider imposing tighter measures if cases continue to surge. Curbs include a ban on private gatherings of more than two people after 6 p.m.

[6] Thailand - Officials in Thailand further tightened coronavirus restrictions on Monday 19 July in response to an alarming rise in cases and deaths that is stressing the country’s health care system. City officials in Bangkok, the capital, ordered a range of establishments to close completely from Tuesday for two weeks or until further notice. They include museums, cinemas, amusement parks, fitness centers and swimming pools. Beauty parlors and barber shops may operate but must limit the numbers of customers, and public parks can stay open until 8 p.m.

[7] United Kingdom - England has lifted most of its domestic COVID-19 restrictions on 19 July, marking a milestone as the country moves into a new phase of pandemic life. The move to phase four of the country's reopening plan means there are no limits on the size of social gatherings or events, and is no longer required. The government still recommends meeting outdoors when possible.

18 | P a g e Centre for infectious di sease epidemiology and research

For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 473. 23 July 2021

vi. Military Surveillance

[1] South Korea- South Korea surpassed its record of daily coronavirus cases Thursday 22 July after accounting for hundreds of infections from an outbreak aboard a navy destroyer. The latest tally includes more than 270 infected crew members from the South Korean destroyer Munmu the Great. The warship, which was patrolling the Gulf of Aden off East Africa, had its mission cut short after over 80% of its unvaccinated crew was infected. The crew members were airlifted back to South Korea on Tuesday 20 July and placed in quarantine.

[2] United States Forces Korea - Twelve people affiliated with U.S. Forces Korea (USFK) have tested positive for the new coronavirus across the country, while another six were confirmed to have contracted the virus upon their arrival here, the U.S. military said on 23 July. Eight service members at Camp Casey in Dongducheon, 40 kilometers north of Seoul; one at Camp Carroll in the southeastern city of Daegu; one each at Camp Humphreys in Pyeongtaek, 70 km south of the capital, and the nearby Osan Air Base; and a family member of a Department of Defense official at K-16 Air Base in Seongnam, just south of Seoul, were found to have contracted the virus Tuesday 20 July and Wednesday 21 July after developing symptoms or coming into contact with infected individuals, according to USFK. Earlier, USFK also said five American service members and a civilian worker have tested positive for the new coronavirus upon arrival here from the United States.

[3] South Korea - Three more newly enlisted soldiers at an Army boot camp have tested positive for the new coronavirus, bringing the total caseload recently reported at the base to 122, the defense ministry said Friday 23 July. The soldiers at the Korea Army Training Center in the central city of Nonsan were confirmed to have contracted COVID-19 while in quarantine following the mass outbreak at the base earlier this month, according to the ministry.

[4] United States Forces Korea - Sixteen people affiliated with U.S. Forces Korea (USFK) have recently tested positive for the new coronavirus, the U.S. military said Wednesday, amid the fourth wave of the pandemic across the country. The latest cases -- confirmed between July 15-19 -- raised the total number of infections reported among the USFK-affiliated population to 1,101. Of the newly added cases, Camp Casey in Dongducheon, 40 kilometers north of Seoul, and Osan Air Base in Pyeongtaek, 70 kilometers south of Seoul each reported six, while Camp Henry in Daegu confirmed two.

[5] South Korea - Two Army officers and an enlisted soldier have tested positive for the new coronavirus, the defense ministry said Wednesday 21 July, the latest in a series of COVID-19 infections among the military population. The officers, stationed in the northern city of Yangju and the eastern port city of Samcheok, respectively, were confirmed to have been infected after their family members tested positive earlier, according to the ministry. The soldier in Seoul contracted the virus while on vacation, it added. The latest cases raised the total number of infections reported among the military population to 1,203.

19 | P a g e Centre for infectious di sease epidemiology and research

For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 473. 23 July 2021 vii. WHO Guidance & Other Protocols

There are no updates published by the WHO from 17 July – 23 July:

viii. CDC Guidance & Protocols

US CDC

The following updates were published by the US CDC from 17 July – 23 July:

• Interim Public Health Recommendations for Fully Vaccinated People Available at: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/fully-vaccinated- guidance.html

EU CDC

The following updates were published by the EU CDC from 17 July – 23 July:

• Partial COVID-19 vaccination, vaccination following SARS-CoV-2 infection and heterologous vaccination schedule: summary of evidence Available at: https://www.ecdc.europa.eu/en/publications-data/partial-covid-19-vaccination- summary

20 | P a g e Centre for infectious di sease epidemiology and research

For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 473. 23 July 2021

ix. Vaccines/Therapeutics Development

Noteworthy reports are included to inform main developments of COVID-19 pharmaceutics. Past updates are available from situation report 211 onwards. A global map and registry of trials is also visualised & accessible at: https://www.covid-nma.com/dataviz/ and trial results are available at: https://covid- nma.com/living_data/index.php. A living systematic review of vaccine trials is also accessable at https://covid-nma.com/vaccines/ or https://covid-nma.com/ .

Vaccines

[1] China - On 20 July, Sinopharm's COVID-19 vaccine has been approved for emergency use for young people ages 3 to 17, after early and midstage clinical trials showed it is safe and can elicit strong immune responses in the age group, the company said in a recent statement. The approval was granted by the Joint Prevention and Control Mechanism of the State Council, which was set up to deal with the COVID-19 pandemic. It is the second domestic COVID-19 vaccine made available for children and teenagers in China.

[2] United States - Vivaldi Biosciences, a clinical-stage biotechnology company developing genetically engineered intranasal vaccines for viral respiratory diseases, on 20 July announced positive preclinical data supporting further development of Delta-19, its combination vaccine for protection against COVID-19 and all strains of influenza.

Therapeutics

[3] United States - Sorrento Therapeutics today announced that COVID-19 patients have been dosed in its Phase 2 efficacy trial. Approximately 350 outpatients with COVID-19 who are asymptomatic or have mild symptoms will be enrolled in this large double-blind, randomized clinical trial evaluating COVIDROPS doses of 10 mg or 20 mg against placebo. This study uses a novel decentralized design where subjects are assessed and treated in their homes and received a rapid review and clearance from the Medicines and Healthcare products Regulatory Agency (MHRA) in the UK.

Vaccine Approval Status

Table 6: Number of approving countries per vaccine as of 16 July 2021 Number of countries Developer Vaccine approving Anhui Zhifei Longcom RBD-Dimer 2 Bharat Biotech 9 CanSino Ad5-nCoV 8 Center for Genetic Engineering and CIGB-66 1 Biotechnology (CIGB) FBRI EpiVacCorona 2 Gamaleya 10

21 | P a g e Centre for infectious di sease epidemiology and research

For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 473. 23 July 2021

Gamaleya Sputnik V 70 Johnson & Johnson Ad26.COV2.S 55 Kazakhstan RIBSP QazVac 1 Minhai Biotechnology Co SARS-CoV-2 Vaccine (Vero Cells) 1 Moderna mRNA-1273 63 Oxford/AstraZeneca AZD1222 119 BioNTech/Pfizer BNT162b2 96 Serum Institute of India Covishield 44 Shifa Pharmed Industrial Co COVID-19 1 Sinopharm BBIBP-CorV 56 Sinopharm Inactivated 1 Sinovac CoronaVac 37 Source: https://covid19.trackvaccines.org/vaccines/

Adverse Reactions & Effects

[1] United States - The US Centers for Disease Control and Prevention (CDC) confirmed an increased number of deaths reported after a COVID-19 vaccination. Between December 14, 2020, through July 19, 2021, the Vaccine Adverse Event Reporting System (VAERS) received 6,207 reports of death among people who received a COVID-19 vaccine. Since more than 338 million doses of COVID-19 vaccines were administered in the USA, this data reflects a vaccination-death ratio of 0.0018%.

22 | P a g e Centre for infectious di sease epidemiology and research

For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 473. 23 July 2021

x. Scientific Publications with Epidemiology and Clinical Focus

Making Waves: Plausible Lead Time for Based Epidemiology as an Early Warning System for COVID-19 [1]

Wastewater-based epidemiology (WBE) has emerged as a useful tool in the fight to track and contain COVID-19 spread within communities. One of the motives behind COVID-19 WBE efforts is the potential for ‘early warning’ of either the onset of disease in a new setting or changes in trends in communities where disease is endemic. Many initial reports of the early warning potential of WBE have relied upon retrospective sample analysis, and delays in WBE analysis and reporting should be considered when evaluating the early warning potential of WBE that enable public health action. Our purpose in this manuscript is to establish a framework to critique the potential of WBE to serve as an early warning system, with special attention to the onset of viral shedding and the differential between results reporting for WBE and clinical testing. While many uncertainties remain regarding both COVID-19 clinical presentation and technical factors influencing WBE results, our analysis suggests at most a modest lead time interval ranging from six days for clinical testing to four days for WBE during community-level wastewater surveillance where clinical testing is accessible on-demand with a rapid time to results. This potential lead time for WBE subsequently increases in settings with limited clinical testing capacity or utilization. Care should be taken when reporting ‘early detection’ of COVID-19 disease trends via WBE to consider underlying causes (e.g., clinical testing lag or delayed result reporting) to avoid misrepresenting WBE potential.

SARS-CoV-2 test positivity rate in Reno, Nevada: association with PM2.5 during the 2020 wildfire smoke events in the western United States [2]

Background Air pollution has been linked to increased susceptibility to SARS-CoV-2. Thus, it has been suggested that wildfire smoke events may exacerbate the COVID-19 pandemic.

Objectives Our goal was to examine whether wildfire smoke from the 2020 wildfires in the western United States was associated with an increased rate of SARS-CoV-2 infections in Reno, Nevada.

Methods We conducted a time-series analysis using generalized additive models to examine the relationship between the SARS-CoV-2 test positivity rate at a large regional hospital in Reno and ambient PM2.5 from 15 May to 20 Oct 2020.

Results We found that a 10 µg/m3 increase in the 7-day average PM2.5 concentration was associated with a 6.3% relative increase in the SARS-CoV-2 test positivity rate, with a 95% confidence interval (CI) of 2.5 to 10.3%. This corresponded to an estimated 17.7% (CI: 14.4–20.1%) increase in the number of cases during the time period most affected by wildfire smoke, from 16 Aug to 10 Oct.

Significance Wildfire smoke may have greatly increased the number of COVID-19 cases in Reno. Thus, our results substantiate the role of air pollution in exacerbating the pandemic and can help guide the development of public preparedness policies in areas affected by wildfire smoke, as wildfires are likely to coincide with the COVID-19 pandemic in 2021.

23 | P a g e Centre for infectious di sease epidemiology and research

For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 473. 23 July 2021

Emergency Physician Twitter Use in the COVID-19 Pandemic as a Potential Predictor of Impending Surge: Retrospective Observational Study [3]

Background: The early conversations on social media by emergency physicians offer a window into the ongoing response to the COVID-19 pandemic. Objective: This retrospective observational study of emergency physician Twitter use details how the health care crisis has influenced emergency physician discourse online and how this discourse may have use as a harbinger of ensuing surge. Methods: Followers of the three main emergency physician professional organizations were identified using Twitter’s application programming interface. They and their followers were included in the study if they identified explicitly as US-based emergency physicians. Statuses, or tweets, were obtained between January 4, 2020, when the new disease was first reported, and December 14, 2020, when vaccination first began. Original tweets underwent sentiment analysis using the previously validated Valence Aware Dictionary and Sentiment Reasoner (VADER) tool as well as topic modeling using latent Dirichlet allocation unsupervised machine learning. Sentiment and topic trends were then correlated with daily change in new COVID-19 cases and inpatient bed utilization. Results: A total of 3463 emergency physicians produced 334,747 unique English-language tweets during the study period. Out of 3463 participants, 910 (26.3%) stated that they were in training, and 466 of 902 (51.7%) participants who provided their gender identified as men. Overall tweet volume went from a pre-March 2020 mean of 481.9 (SD 72.7) daily tweets to a mean of 1065.5 (SD 257.3) daily tweets thereafter. Parameter and topic number tuning led to 20 tweet topics, with a topic coherence of 0.49. Except for a week in June and 4 days in November, discourse was dominated by the health care system (45,570/334,747, 13.6%). Discussion of pandemic response, epidemiology, and clinical care were jointly found to moderately correlate with COVID-19 hospital bed utilization (Pearson r=0.41), as was the occurrence of “covid,” “coronavirus,” or “pandemic” in tweet texts (r=0.47). Momentum in COVID-19 tweets, as demonstrated by a sustained crossing of 7- and 28-day moving averages, was found to have occurred on an average of 45.0 (SD 12.7) days before peak COVID-19 hospital bed utilization across the country and in the four most contributory states. Conclusions: COVID-19 Twitter discussion among emergency physicians correlates with and may precede the rising of hospital burden. This study, therefore, begins to depict the extent to which the ongoing pandemic has affected the field of emergency medicine discourse online and suggests a potential avenue for understanding predictors of surge.

24 | P a g e Centre for infectious di sease epidemiology and research

For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 473. 23 July 2021

xi. Sources

Global Risk Assessment 1. https://www.trip.com/travel-restrictions-covid-19/ 2. https://losangeleno.com/coronavirus-los-angeles/october-1/ 3. https://www.europeanpharmaceuticalreview.com/news/126922/study-shows-anticoagulation- therapy-beneficial-for-covid-19-patients/ 4. https://www.nytimes.com/2020/09/02/health/coronavirus-steroids.html 5. https://news.abs-cbn.com/overseas/04/22/20/israeli-firm-treating-covid-19-patients-with-placenta- cells-reports 6. https://www.khaleejtimes.com/coronavirus-pandemic/uae-stem-cell-therapy-for-coronavirus-treats- over-2000-patients-1200-fully-recover- 7. https://www.dailytarheel.com/article/2020/11/university-baric-lab-researchers 8. https://www.todayonline.com/world/relief-neurorx-say-emergency-treatment-rlf-100-helps-critically- ill-covid-patients 9. https://www.channelnewsasia.com/news/world/us-plasma-treatment-covid-19-donald-trump-fda- 13046312 10. https://www.reuters.com/article/us-health-coronavirus-eli-lilly-fda-idUSKBN27P35L 11. https://bc.ctvnews.ca/vancouver-developed-covid-19-treatment-approved-for-use-1.5201168 12. https://www.outsourcing-pharma.com/Article/2020/11/23/FDA-grants-EUA-for-combo-COVID-19- treatment 13. https://tribune.com.pk/story/2246746/3-ethiopia-use-dexamethasone-covid-19-patients/ 14. http://www.xinhuanet.com/english/2020-12/03/c_139560671.htm 15. https://www.reuters.com/article/us-health-coronavirus-lilly-fda/eli-lillys-antibody-combination- receives-fda-emergency-use-authorization-for-covid-19-idUSKBN2AA02P 16. https://www.channelnewsasia.com/news/world/covid-19-vaccine-no-quarantine-14-days-exposure- us-cdc-14173034 17. https://www.explica.co/covid-19-italy-approves-two-new-monoclonal-antibody-drugs-against-covid/ 18. https://thenewdaily.com.au/news/2021/02/17/uk-new-covid-strain/ 19. https://www.rfi.fr/en/science-and-technology/20210228-france-authorises-first-synthetic-antibody- treatment-for-covid-19-monoclonal-eli-lilly-bamlanivimab 20. https://www.globaltimes.cn/page/202103/1217150.shtml 21. https://www.biospace.com/article/fda-suspends-use-of-monoclonal-antibody-cocktail-in-three- states-due-to-rise-of-california-covid-19-variant/ 22. https://en.antaranews.com/news/170926/bpom-approves-covid-19-drug-avifavir-for-emergency-use 23. https://www.globenewswire.com/news-release/2021/05/26/2236926/0/en/GSK-and-Vir- Biotechnology-Announce-Sotrovimab-VIR-7831-Receives-Emergency-Use-Authorization-from-the-US- FDA-for-Treatment-of-Mild-to-Moderate-COVID-19-in-High-Risk-Adults-and-Pedia.html 24. http://www.businessworld.in/article/Eli-Lilly-Gets-Indian-Emergency-Use-Nod-For-COVID-19- Antibody-Drug-Combination/02-06-2021-391665/ 25. https://gulfnews.com/special-reports/monoclonal-antibodies-will-they-help-end-covid-19- 1.1622392290149 26. https://www.roche.com/media/releases/med-cor-2021-06-25.htm 27. https://www.channelnewsasia.com/news/world/covid-19-arthritis-drugs-corticosteroids-treatment- death-who-15168240

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 473. 23 July 2021

Travel Bans/Advisories & Quarantine Orders 1. https://edition.cnn.com/travel/article/australia-new-zealand-travel-bubble-burst-intl-hnk/index.html 2. https://www.schengenvisainfo.com/news/belgium-imposes-new-rules-for-travellers-from-covid-19- high-risk-countries/ 3. https://www.bbc.com/news/world-us-canada-57896430 4. https://www.channelnewsasia.com/news/world/chileans-allowed-to-travel-abroad-again-as-covid- 19-vaccination-15272742 5. http://www.xinhuanet.com/english/2021-07/19/c_1310070939.htm 6. https://www.republicworld.com/world-news/us-news/covid-19-us-issues-do-not-travel-advisory-for- uk-amid-rise-in-cases.html

Lockdowns Refer to Situation Report 91 for all updates before 1st May 2020 1. https://thediplomat.com/2021/07/bangladesh-lifts-lockdown-to-celebrate-despite-warnings-from- health-experts/ 2. http://www.xinhuanet.com/english/asiapacific/2021-07/20/c_1310073110.htm 3. https://www.cidrap.umn.edu/news-perspective/2021/07/iran-covid-19-surge-triggers-tehran- lockdown 4. https://www.smh.com.au/world/asia/now-is-not-the-time-to-risk-it-all-singapore-returns-to- lockdown-20210720-p58bfn.html 5. https://www3.nhk.or.jp/nhkworld/en/news/20210723_12/ 6. https://dailyprogress.com/news/world/thailands-capital-tightens-restrictions-to-fight-covid- 19/article_1a9975f0-b09c-51fa-88d8-7e948ad5653c.html 7. https://www.opb.org/article/2021/07/19/england-has-lifted-most-of-its-covid-19-restrictions-even- as-uk-cases-up-41-percent/

Military Surveillance 1. https://www.stripes.com/theaters/asia_pacific/2021-07-22/south-korea-coronavirus-covid-19- warship-outbreak-2229177.html 2. https://en.yna.co.kr/view/AEN20210723000851325?section=national/defense 3. https://en.yna.co.kr/view/AEN20210723002800325?section=national/defense 4. https://en.yna.co.kr/view/AEN20210721008600320?section=national/defense 5. https://en.yna.co.kr/view/AEN20210721005300325?section=national/defense

Vaccine/Therapeutics Development 1. http://www.ecns.cn/news/2021-07-20/detail-ihaphzwf8857844.shtml 2. https://www.biospace.com/article/nasal-spray-combined-vaccine-for-covid-and-flu-shows- protection/ 3. https://pipelinereview.com/index.php/2021072278779/Antibodies/Sorrento-Announces-Dosing-of- COVID-19-Patients-in-Phase-2-Clinical-Trial-for-COVIDROPS-a-Highly-Potent-Neutralizing-Antibody- Against-SARS-CoV-2-Including-Delta-and-Alpha-Varia.html

Compilation of Adverse Reactions 1. https://www.precisionvaccinations.com/covid-19-vaccine-related-fatalities-exceed-12000-updated

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 473. 23 July 2021

Scientific Reports 1. Bibby, K., Bivins, A., Wu, Z., & North, D. (2021). Making Waves: Plausible Lead Time for Wastewater Based Epidemiology as an Early Warning System for COVID-19. Water Research, 117438. 2. Kiser, D., Elhanan, G., Metcalf, W. J., Schnieder, B., & Grzymski, J. J. (2021). SARS-CoV-2 test positivity rate in Reno, Nevada: association with PM2. 5 during the 2020 wildfire smoke events in the western United States. Journal of exposure science & environmental epidemiology, 1-7. 3. Margus, C., Brown, N., Hertelendy, A. J., Safferman, M. R., Hart, A., & Ciottone, G. R. (2021). Emergency Physician Twitter Use in the COVID-19 Pandemic as a Potential Predictor of Impending Surge: Retrospective Observational Study. Journal of Medical Internet Research, 23(7), e28615.

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 473. 23 July 2021

Acknowledgement:

Dr. Pang Junxiong, Vincent

Ms Chua Ee Yong Pearleen

Ms Chua Hui Lan

Ms Gwee Xiao Wei Sylvia

Ms Koh Jiayun

Ms Shah Shimoni Urvish

Ms Wang Min Xian

Mr Lau Wai Hong Nicholas

Any queries? Email Sylvia Gwee @ [email protected]

Centre for Infectious Disease Epidemiology and Research

Saw Swee Hock School of Public Health National University of Singapore Tahir Foundation Building 12 Science Drive 2 #10-01 Singapore 117549

For more information, please visit:

Our NUS website: https://sph.nus.edu.sg/partnerships/cider/ Our blog: https://blog.nus.edu.sg/nuscider/

28 | P a g e Centre for infectious di sease epidemiology and research