Issue 5, Surges in COVID-19 Incidence in Countries with High

COVID-19 Containment Measures, Issue 5 | Surges in COVID-19 incidence in countries with high vaccination coverage

COVID- CONTAINMENT MEASURES ANALYSIS, ISSUE Surges in COVID-19 incidence in countries with high vaccination coverage

Evidence-Based Public Health (ZIG 2) | Center for International Health Protection (ZIG)

Robert Koch Institute

1 COVID-19 Containment Measures Analysis, Issue 5 | Surges in COVID-19 incidence in countries with high vaccination coverage

Surges in COVID-19 incidence in countries with high vaccination coverage Robert Koch-Institute, 2021

Funding This report was developed under the project Analysis of international epidemiological data and response measures, a project funded by the German Federal Ministry of Health (BMG).

Authors Thurid Bahr, Evidence-Based Public Health, Centre for International Health Protection Nina Klein, Evidence-Based Public Health, Centre for International Health Protection Seth Kofi Abrokwa, Evidence-Based Public Health, Centre for International Health Protection Lothar H. Wieler, President Johanna Hanefeld, Centre for International Health Protection Charbel El-Bcheraoui, Evidence-Based Public Health, Centre for International Health Protection

Acknowledgements The authors gratefully acknowledge Luisa Denkel, Angela Fehr and the Public Health Intelligence team for their valuable input and feedback on this report.

The icons on pages 5, 7, 8, 10 and 15 stem from https://allthefreestock.com.

Suggested Citation Bahr, T., Klein, N., Abrokwa, S. K., Wieler, L. H., Hanefeld, J. and El-Bcheraoui, C., 2021. Surges in COVID-19 incidence in countries with high vaccination coverage. Report. COVID-19 Containment Measures Analysis, Issue 5, Robert Koch Institute, Berlin.

Disclaimer The content of this report expresses the opinions of its authors and does not necessarily represent the views of the Robert Koch Institute.

2 COVID-19 Containment Measures Analysis, Issue 5 | Surges in COVID-19 incidence in countries with high vaccination coverage

Summary Surges in incidence in countries with high vaccination coverage have concerned decision makers. This report covers five countries that have experienced such surges despite high vaccination coverage: Bahrain, Chile, Seychelles, the United Kingdom and Uruguay. Germany is included in the report to enable comparison. The report describes select epidemiological indicators, maps the COVID-19 containment measures in place and describes vaccination rollout in the countries between 1 March and 29 June 2021.

Reliable data on what drove or continues to drive surges is not available for most countries. In particular, the following kinds of data are not available for most of the five countries in sufficient quality:  Age distribution of COVID-19 cases.  Vaccination status of COVID-19 cases.  High-quality genomic surveillance data on variants of concern.

Surges are possibly due to a combination of factors. These include:  Premature loosening of COVID-19 containment measures.  Reduced compliance with physical distancing requirements, including by individuals with incomplete vaccination coverage.  Spread of variants of concern.

Surges in incidence provide important lessons in COVID-19 containment:  Unvaccinated population groups remain vulnerable even in countries with higher vaccination coverage.  COVID-19 containment measures should be upheld during vaccination campaigns, including to protect unvaccinated and vulnerable individuals.

The recent surges in incidence have also provided insights regarding vaccine effectiveness:  The effectiveness of distributed vaccines in the six countries is generally not significantly reduced by circulating variants of concern.  According to media reports, the majority of new cases during periods of surging incidence occurred in unvaccinated individuals or in those who were not yet fully vaccinated.

Germany co uld consider the following recommendations:  Countries experiencing surges in COVID-19 incidence should investigate the age distribution and vaccination status of cases. This could provide them with the evidence needed to adopt suitable countermeasures. Countries should also share these data internationally to inform decision-making.  National vaccination campaigns should strive to reach unvaccinated individuals. Continued high incidence worldwide entails a continued risk that further variants of concern may emerge and spread. Therefore, vaccination campaigns should also be considered a global effort.  If countries lack evidence on variants of concern due to low genomic surveillance capacities, these countries should be supported in building up that capacity.

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Zusammenfassung Ansteigende Fallzahlen in Ländern mit hohen Durchimpfungsraten werden von Entscheidungstragenden mit Besorgnis beobachtet. Dieser Bericht befasst sich mit fünf Ländern, die einen solchen Anstieg trotz hoher Durchimpfungsraten verzeichnen: Bahrain, Chile, die Seychellen, Uruguay und das Vereinigte Königreich. Über Deutschland wird ebenfalls berichtet, um einen Vergleich zu den anderen Ländern zu ermöglichen. Der Bericht beschreibt ausgewählte epidemiologische Indikatoren, COVID-19 Eindämmungsmaßnahmen und Impfkampagnen in den Ländern zwischen dem 1. März und 29. Juni 2021.

Verlässliche Daten dazu, was Fallanstiege hervorgerufen haben könnte, sind für die fünf Länder zumeist nicht verfügbar. Insbesondere fehlen die folgenden Daten in ausreichender Qualität:  Altersverteilung von COVID-19 Fällen.  Impfstatus von COVID-19 Fällen.  Surveillancedaten hoher Qualität zu besorgniserregenden Virusvarianten.

Ansteigende Fallzahlen sind vermutlich auf eine Kombination von Faktoren zurückzuführen. Diese beinhalten:  Verfrühte Lockerung von COVID-19 Eindämmungsmaßnahmen.  Verminderte Befolgung von Abstandsregeln, auch durch Personen mit unvollständigem Impfschutz.  Ausbreitung von Variants of Concern .

Ansteigende Fallzahlen vermitteln wichtige Lektionen für die Eindämmung von COVID-19:  Ungeimpfte Bevölkerungsgruppen sind selbst in Ländern mit hoher Durchimpfungsrate weiterhin Risiken ausgesetzt.  COVID-19 Eindämmungsmaßnahmen sollten während Impfkampagnen aufrechterhalten werden, um ungeimpfte Personen und solche aus Risikogruppen zu schützen.

Ansteigende Fallzahlen verweisen auch auf Erkenntnisse zur Impfstoffeffektivität:  Die Effektivität der in den sechs Ländern verimpften Impfstoffe wird durch die zirkulierenden Variants of Concern nicht signifikant reduziert.  Medienberichten zufolge war die Mehrheit der in den fünf Ländern kürzlich infizierten Personen entweder ungeimpft oder nicht vollständig geimpft.

Deutschland könnte die folgenden Empfehlungen in Erwägung ziehen:  Länder mit ansteigenden Fallzahlen und hohen Durchimpfungsraten sollten die Altersverteilung und den Impfstatus der auftretenden Fälle beobachten. Diese Daten können dazu genutzt werden, angemessene Eindämmungsmaßnahmen einzuleiten. Die Länder sollten diese Daten auch international teilen und so eine Berücksichtigung der Daten bei der Entscheidungsfindung ermöglichen.  Nationale Impfkampagnen sollten darauf abzielen, ungeimpfte Personen zu erreichen. Fortdauernde hohe Inzidenzen weltweit bergen das Risiko der Entstehung und Verbreitung weiterer besorgniserregender Virusvarianten. Der Erfolg von Impfkampagnen sollte daher auch als globales Anliegen gesehen werden.  Falls es Ländern aufgrund von geringer Surveillancekapazität an Daten zu zirkulierenden besorgniserregenden Virusvarianten mangelt, so sollten diese Länder beim Aufbau dieser Kapazität unterstützt werden.

4 COVID-19 Containment Measures Analysis, Issue 5 | Surges in COVID-19 incidence in countries with high vaccination coverage

1. Problem Statement Despite succeeding at vaccinating large parts of their population against the SARS-COV-2 virus in a short time, some countries have experienced surges in incidence. To understand this dynamic, this report tracks select epidemiological indicators, maps the COVID-19 containment measures in place, and describes vaccination rollout in Bahrain, Chile, Germany, Seychelles, the United Kingdom and Uruguay between 1 March and 29 June 2021. Germany is not currently experiencing a surge in incidence and is included in this report for comparison purposes. Looking at the context in which increases in incidence occurred despite high vaccination coverage can help guide decision makers on adapting their COVID-19 containment measures and de-escalation plans.

2. Weekly COVID-19 incidence, deaths and vaccination coverage (2 nd dose) in Bahrain, Chile, Germany, Seychelles, the United Kingdom and Uruguay, weeks 9 – 25, 2021 (Figure 1) As of late June 2021, Weekly COVID-19 incidence per 100,000 population is decreasing in Bahrain, Chile, Germany, Seychelles and Uruguay. Weekly death rates per 100,000 population are decreasing in Bahrain, Germany and Uruguay and increasing in Chile, Seychelles and the United Kingdom. Full vaccination coverage is at just under 40% and higher in the countries.

COVID-19 Containment Measures, Issue 5 | Surges in COVID-19 incidence in countries with high vaccination coverage

Figure 1: Weekly COVID -19 incidence, deaths and full vaccination coverage (2 nd dose) in Bahrain, Chile, Germany, Seychelles, the United Kingdom and Uruguay, weeks 9 -2021 – 25 -2021

COVID-19 Containment Measures, Issue 5 | Surges in COVID-19 incidence in countries with high vaccination coverage

3. Vaccination Coverage and National Vaccination Campaigns 3.1 Full Vaccination coverage in Bahrain, Chile, Germany, Seychelles, the United Kingdom and Uruguay, 1 March – 27 June 2021 (Figure 1):

2nd Dose – Between 1 March and 27 June 2021, the share of the population that received its second COVID-19 vaccine dose increased from 0 to 45% in Uruguay, from 2 to 48% in the United Kingdom, from 3 to 35% in Germany, from 3 to 50% in Chile (1 March to 20 June), from 12 to 57% in Bahrain and from 25 to 68% in Seychelles.[1, 2]

3.2 Vaccination access in Bahrain, Chi le, Germany, Seychelles, the United Kingdom and Uruguay, 1 March – 29 June 2021 (Table 1):

Administered vaccines – In three out of four countries experiencing surges in incidence and for which data on predominantly administered vaccine types was available, the Sinopharm and Sinovac vaccines were predominantly administered.

Vaccine effectiveness – The administered vaccine types mostly maintain their effectiveness against circulating virus variants against symptomatic disease, severe disease, hospitalization and death. There is emerging evidence on the effectiveness of vaccines against transmission.[3] However, effectiveness requires taking the full course of vaccine doses and requires some time to lapse between completion of the course for antibodies to build up. ECDC reports that receiving only a first dose of a two-dose vaccination course provides less protection against infection with variant of concern (VOC) Delta than against other VOCs. This holds regardless of vaccine type. Yet receiving both doses offers nearly the same level of protection against Delta as against other VOCs.[4] Scientific, publicly available evidence is scarce on the Sinovac and Sinopharm vaccines, in particular peer reviewed publication of data on phase 3 trials and evidence from population-based studies is lacking.[5, 6] The World Health Organization granted Emergency Use to the Sinopharm and Sinovac vaccines in early May and early July, based on evidence from vaccine trials. WHO holds Sinovac to be effective against infection and symptomatic disease caused by the Delta VOC (Table 1). [3, 7-9]. Study results from Chile showed that the Sinovac vaccine had little effectiveness immediately following just a single dose, with rising effectiveness after two and three weeks following a single dose.[10, 11]

Vaccine access – Currently, the six countries universally offer vaccinations to their populations. Bahrain vaccinates anyone aged 12 and older. Germany vaccinates adolescents aged 12 and older with specific comorbidities (e.g. chronic lung diseases with persisting impairment of lung function), work-related high risk of exposure as well as when living with people with a high risk who cannot be vaccinated themselves.[12] In addition, the country vaccinates all adults aged 18 and older. The remaining countries also vaccinate anyone aged 18 and older.

COVID-19 Containment Measures, Issue 5 | Surges in COVID-19 incidence in countries with high vaccination coverage

Table 1: COVID -19 Vaccination Campaigns in Bahrain, Chile, Germany, Seychelles, the United Kingdom and Uruguay, 1 March 2020 – 29 June 2021

Administered Vaccines Vaccine Effectiveness Vaccine Access Oxford/AstraZeneca - Currently no evidence on effectiveness of Sinopharm vaccine against circulating Anyone aged 12+[14]

Pfizer/BioNTech variants[8] Sinopharm/Beijing + Currently no evidence that effectiveness of other administered vaccines may be Pfizer/BioNTech “booster dose” for first responders, those

Bahrain Sputnik V[13] significantly reduced by predominantly circulating variants[3] aged 50 and over and those with comorbidities who received two doses of Sinopharm six months ago[15, 16] 79% Sinovac - Limited evidence of potentially very small effectiveness shortly after first Sinovac Anyone aged 18+[18]

18% Pfizer/BioNTech dose[6, 10] 2% Oxford/AstraZeneca + Currently no evidence that effectiveness of other administered vaccines may be Chile 1% CanSino[17] significantly reduced by predominantly circulating variants[3]

73% Pfizer/BioNTech + Currently no evidence that administered vaccines’ effectiveness is significantly Anyone aged 18+ [21] 16% Oxford/AstraZeneca reduced by circulating VOC, if full vaccination course is taken[3, 4] Adolescents aged 12-17 with comorbidities, work-related 8% Moderna high risk of exposure or when living with people with a

Germany 3% Johnson&Johnson[19, 20] high risk who cannot be vaccinated themselves[12] 57% Sinopharm/Beijing - Limited evidence of potentially very small effectiveness shortly after first Sinopharm Anyone aged 18+[23, 24]

43% Oxford/AstraZeneca.[13, 22] dose[5] + Currently no evidence that effectiveness of other administered vaccines may be significantly reduced by predominantly circulating variants[3] Seychelles

61% Oxford/AstraZeneca + Currently no evidence that administered vaccines’ effectiveness is significantly Anyone aged 18+[26]; 38% Pfizer/BioNTech reduced by circulating VOC, if full vaccination course is taken[3, 4] In Scotland anyone aged 30+[27] 1% Moderna[25] United Kingdom

75% Sinovac - Limited evidence of potentially very small effectiveness shortly after first Sinovac Anyone aged 18+[28] 24% Pfizer/BioNTech dose[6, 10] 1% Oxford/AstraZeneca[20] + Currently no evidence that effectiveness of other administered vaccines may be Uruguay significantly reduced by predominantly circulating variants[8, 9]

COVID-19 Containment Measures, Issue 5 | Surges in COVID-19 incidence in countries with high vaccination coverage

4. Potential Factors in Incidence Surges in Bahrain, Chile, Seychelles, the United Kingdom and Uruguay Bahrain – According to a media report only 6% of those infected since the beginning of the pandemic in the country had been vaccinated. More specifically, only 2% of those who had become infected had been fully vaccinated with two doses and had completed 14 days post-vaccination, reportedly none requiring treatment. According to the same report, in Bahrain, no difference in vaccine type received was observed among individuals infected post-vaccination. Between January and mid-May 2021, 6% of those who died of COVID-19 had been vaccinated with two doses and completed 14 days post-second dose.[16]

Chile – The surge in cases is attributed by some observers to loosened measures early on in the vaccination campaign, reduced compliance with COVID-19 containment measures, including masking and physical distancing, following the start of the vaccination campaign, as well as the spread of VOC P.1 (Gamma). Some observers also noted that risk communication by the government at the beginning of the vaccination campaign might have contributed to people taking less precautions. Media reports suggest that people with incomplete vaccination coverage may have complied less with protective behaviors. Results from a study in Chile on vaccine effectiveness showed that the Sinovac vaccine had little effectiveness immediately following just a single dose, with rising effectiveness after two and three weeks following the first dose.[5, 10, 11]

Seychelles – Writing in mid-May 2021, media cited the Seychelles Ministry of Health in saying that 37% of active cases were people who had been fully vaccinated. WHO was investigating some cases that had occurred shortly after a first or second dose. WHO was cited in the media as stating that most COVID-19 cases during the surge had occurred in those who were not vaccinated or not fully vaccinated.[15] The president of Seychelles reported in the media that in the age group 18 to 60, 80% of those who were hospitalized had not been vaccinated. Further results of WHO looking into the surge in Seychelles are pending. By early May, no deaths were reported in COVID-19 cases that had been fully vaccinated.[22, 29] The Seychelles Ministry of Health is now considering administering a booster dose to vulnerable individuals.[15]

United Kingdom – Sequencing data showed that the share of VOC B.1.617.2 (Delta) has increased to 91% of all cases in the country. According to Public Health England, incidence has increased in all age and ethnic groups, but test positivity has most notably increased in younger age groups.[30] It also reports increasing outbreaks in educational settings.[31] A study from 5 April to 16 May 2021 indicated that the predominantly used vaccines in the United Kingdom (Oxford/AstraZeneca and Pfizer/BioNTech) are effective against VOC B.1.617.2 (Delta), especially after 2 doses.[32] Therefore, the four UK nations are reducing the time span between the 1 st and 2 nd dose of any vaccine. For example, in England the time span has been reduced from 12 to 8 weeks.[27]

Uruguay – According to media reports, the surge in COVID-19 cases in Uruguay might be attributable to VOC P.1 (Gamma) and loosening of COVID-19 containment measures, such as physical distancing.[33, 34] Also, lacking compliance with physical distancing has been reported. A study published in March reported that only one out of three people in Uruguay thought they would get infected with SARS-CoV-2 in the next six months.[35] A newspaper article reported recently released results of a population-based study on the effectiveness of administered vaccines by the government in Uruguay. These results show that a full vaccination cycle of Sinovac reduced deaths by 95%, ICU admissions by 92% and infections with SARS-CoV-2 by 61%. The effectiveness of Pfizer/BioNTech was also studied and showed 94% effectiveness at preventing ICU admissions and 78% effectiveness in preventing infection.[36]

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5. COVID-19 containment measures in Bahrain, Chile, Germany, Seychelles, the United Kingdom and Uruguay, 1 March – 23 June 2021 This section only reports on COVID-19 containment measures regarding school closures, international travel and face coverings. For a full overview of COVID-19 containment measures in the countries between early March and late June 2021, see the heatmap in Figure 2. 1

School closures – were loosened slightly between April and May 2021 in Bahrain and more recently in Seychelles. However, both countries have tightened this measure since then. School closures have been loosened over time in Germany, the United Kingdom and Uruguay.

In ternational travel measures – remain strict in all countries, with no loosening trend over time.

Face coverings – remain strictly required, with no change over time, in Bahrain and the United Kingdom. In Germany and Uruguay, face coverings are required only in some public spaces, with no change in this measure over time. In Chile, face covering measures were tightened from 1 May 2021 onwards and in Seychelles from 1 June 2021 onwards, following a previous mix of loosening and tightening.

1 Due to the coding scheme applied by Our World in Data, the loosening and tightening of COVID-19 containment measures at the sub- national level does not fully display in Figure 2. In the case of Chile, that means lifting of measures in March 2021 is not displayed in the heatmap.

COVID-19 Containment Measures, Issue 5 | Surges in COVID-19 incidence in countries with high vaccination coverage

1 March 2021 1 April 2021 1 May 2021 1 June 2021 23 June 2021 School Closures Required (all levels) Recommended Required (some levels) Workplace Closures Required (some levels) Cancellation of Public Events Recommended cancellations Required cancellations Restrictions on Public Gatherings > 1000 people 10-100 people 100-1000 people <10 people

Stay-at-Home Requirements Recommended Face Coverings Required in all public spaces Bahrain Public Transport Closures Recommended closing (or reduced No measures volume) Restrictions on Internal Movement Recommend movement restriction International Travel Controls Screening Quarantine from high-risk regions

School Closures Required (all levels)

Workplace Closures Required (all levels) Cancellation of Public Events Required cancellations Restrictions on Public Gatherings <10 people

Stay-at-Home Requirements Required (few exceptions)

Face Coverings Required in some public spaces Required in all public

Chile spaces Public Transport Closures Recommended closing (or reduced Required closing volume) Restrictions on Internal Movement Restrict movement

International Travel Controls Ban on high-risk-regions Total border closure School Closures Required (all levels) Recommended Workplace Closures Required for some Cancellation of Public Events Required cancellations Restrictions on Public Gatherings <10 people Stay-at-Home Requirements Required (except essentials) Recommended

Face Coverings Required in some public spaces Public Transport Closures Recommended closing (or reduce Germany volume) Restrictions on Internal Movement Restrict movement Recommend movement restriction International Travel Controls Ban on high-risk-regions

School Closures Required (all levels) Required (some levels) No Measure Required (some levels)

Workplace Closures Required for some No Measures Recommended Cancellation of Public Events Required cancellations Recommended Required cancellations

cancellations Restrictions on Public Gatherings <10 people Seychelles Stay-at-Home Requirements Recommended Required (except essentials)

1 COVID-19 Containment Measures Analysis, Issue 5 | Surges in COVID-19 incidence in countries with high vaccination coverage

Face Coverings Required in some public spaces Required in all public Required in some public Required in all public spaces spaces spaces Public Transport Closures Recommended closing (or reduce No measure Recommended closing (or volume) reduced volume) Restrictions on Internal Movement Recommended movement No measures Recommend movement restrictions restriction International Travel Controls Ban on high-risk-regions Screening Ban on high-risk regions School Closures Required (all levels) Required (some levels) Recommended Workplace Closures Required (all levels) Required (some levels) Cancellation of Public Events Required cancellations Recommended

cancellations Restrictions on Public Gatherings <10 people Stay-at-Home Requirements Required (except essentials) No measures

Face Coverings Required in all public spaces Public Transport Closures Recommended closing (or reduced

United Kingdom United volume) Restrictions on Internal Movement Restrict movement Recommend movement Restrict movement No measures restrictions International Travel Controls Ban on high-risk-regions School Closures Required (some levels) Required (all levels) Required (some levels) Workplace Closures Required (some levels) Cancellation of Public Events Required cancellations Recommended cancellations

Restrictions on Public Gatherings <10 people 10-100 people Stay-at-Home Requirements Recommended Face Coverings Required in some public spaces

Uruguay Public Transport Closures Recommended closing (or reduced volume) Restrictions on Internal Movement No measures Recommend movement restriction International Travel Controls Total border closure

Figure 2: Heatmap COVID -19 Containment Measures in Bahrain, Chile, Germany, Seychelles, the United Kingdom and Uruguay, 1 March – 23 June 2021

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6. Synthesis Surges in incidence in countries with high vaccination coverage have concerned decision makers. They highlight the need for decision makers and publics to remain vigilant in spite of ongoing vaccination campaigns.

Reliable data on what drove or continues to drive surges is not available for most countries. In particular, the following kinds of data are lacking for most of the five countries or are not available in sufficient quality:  Age distribution of COVID-19 cases.  Vaccination status of COVID-19 cases.  High-quality genomic surveillance data on variants of concern.

Surges in incidence provide important lessons in COVID-19 containment:  Unvaccinated population groups remain vulnerable even in countries with higher vaccination coverage. This is indicated by Public Health England data on high incidence and increasing test positivity in younger age groups.  COVID-19 containment measures should be upheld during vaccination campaigns, including to protect unvaccinated and vulnerable individuals.

Germany could consider the following recommendations:  Countries experiencing surges in COVID-19 incidence should investigate the age distribution and vaccination status of cases. This could provide them with the evidence needed to adopt suitable countermeasures. Countries should also share these data internationally to inform decision-making.  National vaccination campaigns should strive to reach unvaccinated individuals. Continued high incidence worldwide entails a continued risk that further variants of concern may emerge and spread. Therefore, vaccination campaigns should also be considered a global effort.  If countries lack evidence on variants of concern due to low genomic surveillance capacities, these countries should be supported in building up that capacity.

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7. Methodology and Evidence Rating The epidemiological evidence presented in this report builds on public data collected from a variety of sources. Weekly incidence and new deaths per 100,000 population were calculated by the report authors on the basis of the dataset by Appel et al. from Our World in Data.[38] COVID-19 cases and deaths in the Our World in Data- dataset stem from the Center for Systems Science and Engineering at Johns Hopkins University. Vaccination coverage was calculated by the authors on the basis of the vaccination dataset from Our World in Data by Mathieu et al.[2] Data on the prevalence of COVID-19 virus variants stems from analyses of public sources conducted by the Public Health Intelligence Unit at Robert Koch Institute and was supplemented with government sources. Data on COVID-19 containment measures stems from the Oxford COVID-19 government response tracker by Hale et al.[24] Data on vaccine types administered and predominant vaccine types stems from Our World in Data and was supplemented with media reports where no data from Our World in Data was available. The percentage shares of administered vaccines types per country were calculated by the report authors. Data on vaccination status of COVID-19 cases during phases of increasing incidence in the countries mostly stems from media reports, due to a paucity of public government sources. Data on national vaccination campaigns’ priority groups stems from government sources. Data on COVID-19 vaccine efficacy and effectiveness stems from the World Health Organization’s Weekly Epidemiological Updates and other reports and scientific publications.

Data on COVID-19 incidence, deaths rates and vaccination coverage was available for all countries. Data on COVID-19 incidence stratified by age groups was only available for Germany and the United Kingdom. Data on VOC circulation was available for five out of six countries. The representativeness and validity of data on VOC is limited for Bahrain, Chile and Uruguay, good for Germany and very good for the United Kingdom (England respectively). Data on vaccine types administered was available for all countries. Data quality on vaccine effectiveness varies. Media reports were included in this report as data sources due to the lack of scientific literature and evidence regarding the currents surges in these countries. Data on COVID-19 containment measures was available for all countries. Due to the coding scheme applied by the Oxford COVID- 19 government response tracker, containment policies at the sub-national level may not be fully represented in the tracker’s data. It should be kept in mind that data from the Oxford COVID-19 government response tracker do not reflect actual implementation and adherence to measures at the population level.

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Appendix

A. Epidemiological Background A.1 Weekly new COVID -19 cases per 100,000 population in Bahrain, Chile, Germany, Seychel les, the United Kingdom, and Uruguay, 1 March – 29 June 2021 (Figure 1): Weekly new cases per 100,000 population have been decreasing in Bahrain, Chile, Germany and Uruguay, have been mostly stable in Seychelles and increasing in the United Kingdom. As of 27 June 2021, there are 5.21 weekly new COVID-19 cases per 100,000 population in Germany, 151.1 in the United Kingdom, 138.4 in Bahrain, 157.38 in Chile, 470.73 in Uruguay (as of 20 June 2021) and 1009.76 in Seychelles.

A.2 Weekly new COVID -19 deaths pe r 100,000 population in Bahrain, Chile, Germany, Seychelles, the United Kingdom, and Uruguay, 1 March – 29 June 2021 (Figure 1): Weekly new deaths per 100,000 population have been increasing in Bahrain throughout May and in Seychelles in June. In Germany, the rate has been declining through May and June and in Uruguay it began declining in June. In Chile and the United Kingdom, rates have been stable throughout May and June. As of 29 June 2021, weekly new deaths stand at 0.18 in the United Kingdom, 0.44 in Germany, 2.29 in Bahrain, 4.11 in Chile, 6.42 in Uruguay and 8.14 in Seychelles per 100,000 population.

A.3 Weekly incidence per 100,000 population by age group in Germany and England, 1 March - 29 June 2021 (Figure 3): In Germany, incidence is declining across all age groups. Incidence is lowest in the oldest age groups 60-80+. Incidence is rising in all age groups in England, but is highest in the age groups 10-39 (Figure 1). Public Health England also reports that test positivity is most notably rising in younger age groups. The agency also reports increasing outbreaks in educational settings.[30, 31]

A.4 Variants of concern: In Bahrain, VOC B.1.617.2 (Delta) comprises 33.33%, VOC B.1.1.7 (Alpha) 24% and VOC B.1.351 (Beta) 4% of sequenced cases. The country did not report any sequenced case of VOC P.1. (Gamma).[39] In Chile, VOCs comprise 46.7% of sequenced cases between 22 December 2020 and 11 June 2021. VOC P.1 (Gamma) accounts for 37.4% and VOC B.1.1.7 (Alpha) for 9.2% of all sequenced cases in this time frame.[40] In Germany, VOC B.1.1.7 (Alpha) is prevalent in 74%, VOC B.1.617.2 (Delta) in 15% and both VOC B.1.351 (Beta) and VOC P.1 (Gamma) in less than 1% of all sequenced samples. The share of VOC B.1.617.2 (Delta) shows an increasing trend.[41] In England, VOC B.1.617.2 (Delta) comprises 95% of sequenced cases.[42] In Uruguay, VOC P.1 (Gamma) comprises 99% of all sequenced cases.[43] No systematic data on circulating virus variants was available for Seychelles. 2

2 Data quality on COVID-19 variants varies greatly across countries. See “Methodology and Evidence Rating” in this report.

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Figure 3: Weekly Incidence per 100,000 population by age group in Germany and England, weeks 9 – 25, 2021

6 COVID-19 Containment Measures Analysis, Issue 5 | Surges in COVID-19 incidence in countries with high vaccination coverage

References

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7 COVID-19 Containment Measures Analysis, Issue 5 | Surges in COVID-19 incidence in countries with high vaccination coverage

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