For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 476. 13 August 2021

Aug 13 30

COVID-19 Situation Report 476

Centre for Infectious Disease Epidemiology and Research (CIDER) For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 476. 13 August 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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ii. Global Risk Assessment

Table 1. Risk assessment of COVID-19 by WHO regions (Updated as of 13 August 2021, 1230H 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 2.11% 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 (35 countries), and Africa (45 reporting a surge in cases in each region effective present as countries).& are as follows: Combined WPRO and reproduction flu-like SEARO (20 countries), number in 177 illness. International clinical trials published on 2 EURO (47 countries), countries September confirm that cheap, widely EMRO (15 countries), Americas (31 ranged from available steroid drugs can help seriously countries), and Africa (24 countries). 0.36 to 2.5.$ 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 146 (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. 49 (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 476. 13 August 2021

On 4 Aug, the WHO called for a moratorium on COVID-19 vaccine boosters until at least the end of September, to enable that at least 10% of the population of every country was vaccinated. [28] Western Pacific Region and South-East Asia Region (n=41 countries) Moderate High

33 (80.5%) countries have reported As of Aug 11, Case 33 countries have commenced outbreaks; but only 20 (48.8%) countries the estimated fatality rate vaccination as of 13 August 2021. are reporting a surge in cases. effective is 1.51%. Coverage was available for the following: reproduction i) at least 1 dose was at <50% for 24 13 (31.7%) countries have either a no. of 25 countries; 51-70% for 6 countries; >70% constant decreasing change in incidence countries for 3 countries ii) full vaccination was at or no case in the last 14 days. ranged from <50% for 24 countries; 51-70% for 3 & 0.36-1.2. $ countries; >70% for 2 countries.

Highest incidence over the past 14 days Indonesia has approved Russian drug were reported from Fiji, Malaysia, Avifavir for emergency use. [22] High Maldives, Mongolia and Thailand, and highest case numbers were reported from China has approved the use of 3 India, Indonesia, Japan, Malaysia and traditional chinese medicines, Qingfei Thailand. Paidu Formula, Huashi Baidu Formula and Xuanfei Baidu Formula, for COVID-19 At least 19 countries have closed their treatment. [20] borders, 21 countries have opened their borders partially conditionally, and none is As of 4 June, India has approved a allowing free travel. combination of monoclonal antibodies, bamlanivimab 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 Aug 11, Case 53 countries have commenced outbreaks; 47 (88.7%) countries are the estimated fatality rate vaccination as of 13 August 2021. reporting a surge in cases. effective is 1.99%. Coverage was available for the following reproduction i) at least 1 dose was at <50% for 24 1 (1.9%) countries have either a constant no. of 52 countries; 51-70% for 20 countries; >70% decreasing change in incidence or no case countries for 9 countries; ii) full vaccination was at in the last 14 days. ranged from <50% for 31 countries; 51-70% for 19 0.48-2.1$ countries; >70% for 2 countries. & Highest incidence over the past 14 days were reported from Cyprus, Gerogia, On February 28, France authorized its High Israel, Kazakhstan and United Kingdom, first ever use of synthetic monoclonal and highest case numbers were reported antibody, bamlanivab by Eli Lilly, for use from France, Russia, Spain, Turkey and on severe COVID-19 patients. [19] 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].

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Eastern Mediterranean Region (n=22 countries) High High

22 (100%) countries have reported with As of Aug 11, Case 20 countries have commenced outbreak; 15 (68.2%) countries are the estimated fatality rate vaccination as of 13 August 2021. reporting a surge in cases. effective is 1.84%. Coverage was available for the following: reproduction i) at least 1 dose was at <50% for 16 No country has either a constant no. of 21 countries; 51-70% for 1 country; >70% decreasing change in incidence or no case countries for 3 countries; ii) full vaccination was at in the last 14 days. ranged from <50% for 13 countries; 51-70% for 2 0.77-1.4.$ countries; >70% for 1 country. & Highest incidence over the past 14 days were reported from Iran, Iraq, Libya, As of June 25, the Abu Dhabi Stem Cell High Morocco and Tunisia, and highest case Centre has treated more than 2,000 numbers were reported from Iran, Iraq, COVID-19 patients using UAECell19. Morocco, Pakistan and Tunisia. 1,200 have fully recovered. [6]

At least 5 countries have closed their As of April, an Israeli firm is using borders, 16 countries have opened their placenta pluristem cells to treat COVID- borders partially conditionally, and only 1 19 patients on a compassionate use country is allowing free travel. basis. [5]

As of June 4, UAE authorised the emergency use of Sotrovimab, a kind of monoclonal antibody drug [25]. Region of the Americas (n=35 countries) High High

35 (100%) countries have reported with As of Aug 11, Case 35 countries have commenced outbreak; 31 (88.6%) countries are the estimated fatality rate vaccination as of 13 August 2021. reporting a surge in cases. effective is 2.56%. Coverage was available for the following: reproduction i) at least 1 dose was at <50% for 25 No country has either a constant no. of 34 countries; 51-70% for 7 countries; >70% decreasing change in incidence or no case countries for 3 countries ii) full vaccination was at in the last 14 days. ranged from <50% for 29 countries; 51-70% for 4 0.65-2.5.$ countries. & Highest incidence over the past 14 days were reported from Argentina, Bahamas, With the increase of multiple variants of Costa Rica, Cuba and USA, and highest COVID-19, the U.S. FDA will limit the use case numbers were reported from of monoclonal antibody treatments Argentina, Brazil, Cuba, Mexico and USA. developed by Regeneron and Eli Lilly due High to concerns the medications are not At least 10 countries have closed their effective against these new strains. Eli borders, 23 countries have opened their Lilly’s bamlanivimab will not be borders partially conditionally, and 2 distributed to California, Arizona and countries are allowing free travel. Nevada, where those variants are more 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]

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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]

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]

As of 5 Aug, FDA has expanded the use of antibody cocktail, REGEN-COV, updating its emergency use authorisation (EUA) to include those at high risk of developing

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 476. 13 August 2021

severe COVID-19 who have been exposed to the virus. [29]

As of Aug 11, Brazil has issued emergency authorisation to Celltrion’s regdanvimab for high-risk patients with mild and moderate Covid-19. [30] African Region (n=47 countries) High High

47 (100%) countries have reported with As of Aug 11, Case 45 countries have commenced outbreak; 24 (52.2%) countries are the estimated fatality rate vaccination as of 13 August 2021. reporting a surge in cases. effective is 2.40%. Coverage was available for the following: reproduction i) at least 1 dose was at <50% for 42 No country has either a constant no. of 45 countries; 51-70% for 1 country; >70% decreasing change in incidence or no case countries for 1 country; ii) full vaccination was at in the last 14 days. ranged from <50% for 32 countries; >70% for 1 0.49-1.5.$ country. & Highest incidence over the past 14 days High were reported from Botswana, Eswatini, Ethiopia has approved the use of Namibia, Seychelles and South Africa, and Dexamethasone treatment for seriously highest case numbers were reported from ill COVID-19 patients. [13] Algeria, Botswana, Kenya, Mozambique and South Africa.

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 13 August 2021, 1230H 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– 220 206,251,780 206,157,520 4,348,193 2.11% 2.11% 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 2.11 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 7 – 13 August 2021 (Updated as of 13 August 2021, 1230H SGT)

Change Change in Total Total No. Country Total Cases in Region Cases Deaths Recovered Deaths 1 USA 37,203,649 +901,905 636,298 +4,419 30,097,898 Americas 2 Iran 4,320,266 +262,508 96,215 +3,587 3,647,016 EMRO 3 India 32,117,826 +262,043 430,285 +3,500 31,302,345 SEARO 4 Brazil 20,285,067 +218,480 566,988 +6,187 19,151,021 Americas 5 Indonesia 3,774,155 +205,824 113,664 +11,289 3,247,715 SEARO 6 UK 6,179,506 +196,925 130,701 +615 4,746,302 EURO 7 Turkey 6,018,485 +171,701 52,703 +828 5,558,722 EURO 8 France 6,398,983 +165,107 112,487 +389 5,840,584 EURO 9 Russia 6,534,791 +154,887 168,049 +5,540 5,828,972 EURO 10 Thailand 863,189 +148,505 7,126 +1,272 643,884 SEARO 11 Malaysia 1,342,215 +138,509 11,691 +1,672 1,093,503 WPRO 12 Mexico 3,045,571 +122,908 246,811 +3,646 2,390,075 Americas 13 Spain 4,677,883 +111,312 82,407 +476 3,877,494 EURO 14 Japan 1,069,554 +99,094 15,330 +102 920,862 WPRO 15 Argentina 5,066,253 +76,851 108,569 +1,546 4,713,411 Americas 16 Bangladesh 1,396,868 +74,214 23,613 +1,711 1,262,065 SEARO 17 Philippines 1,700,363 +72,547 29,539 +1,112 1,583,161 WPRO 18 South Africa 2,568,511 +70,856 76,247 +2,374 2,344,896 Africa 19 Iraq 1,751,176 +66,221 19,466 +466 1,566,703 EMRO 20 Morocco 731,084 +65,759 10,711 +624 639,534 EMRO 21 Kazakhstan 672,322 +61,578 7,313 +911 554,178 EURO 22 Cuba 491,904 +60,891 3,757 +573 444,019 Americas 23 Vietnam 246,568 +57,502 4,813 +2,093 89,145 WPRO 24 Italy 4,420,429 +43,241 128,334 +171 4,170,810 EURO 25 Colombia 4,856,595 +34,992 123,097 +1,198 4,675,215 Americas 26 Israel 924,762 +34,561 6,604 +95 874,977 EURO 27 Pakistan 1,089,913 +31,508 24,266 +564 979,411 EMRO 28 Georgia 466,326 +29,753 6,279 +293 412,420 EURO 29 Myanmar 344,730 +25,480 12,667 +1,679 260,025 SEARO 30 Germany 3,814,316 +24,875 92,348 +93 3,675,800 EURO 31 Sri Lanka 345,118 +23,689 5,620 +799 302,455 SEARO 32 Guatemala 403,348 +21,834 10,960 +382 351,996 Americas 33 Greece 528,474 +21,802 13,126 +126 480,198 EURO 34 Nepal 725,769 +17,690 10,212 +218 677,377 SEARO 35 Netherlands 1,894,667 +16,453 17,894 +44 1,726,806 EURO 36 Portugal 995,949 +15,962 17,525 +103 934,017 EURO

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37 Tunisia 618,124 +15,367 21,310 +760 552,606 EMRO 38 Belgium 1,147,855 +14,921 25,285 +27 1,071,747 EURO 39 Botswana 136,758 +14,184 1,973 +269 121,987 Africa 40 Libya 276,739 +13,791 3,835 +172 203,045 EMRO 41 S. Korea 220,182 +12,776 2,144 +31 192,248 WPRO 42 Ireland 318,937 +11,918 5,059 +15 273,994 EURO 43 Costa Rica 426,474 +11,729 5,199 +91 348,388 Americas 44 Azerbaijan 359,732 +11,658 5,109 +66 337,021 EURO 45 Lebanon 578,367 +11,323 7,962 +36 540,493 EMRO 46 Canada 1,447,446 +11,264 26,692 +55 1,406,013 Americas 47 Switzerland 733,275 +10,474 10,918 +9 695,341 EURO 48 Honduras 314,351 +10,170 8,339 +287 103,969 Americas 49 UAE 698,166 +9,677 1,992 +25 675,566 EMRO 50 Kenya 217,276 +9,014 4,273 +216 199,998 Africa 51 Peru 2,130,018 +8,957 197,209 +449 N/A Americas 52 Mongolia 179,889 +8,792 871 +30 171,011 WPRO 53 Mozambique 136,566 +7,530 1,671 +133 115,931 Africa 54 Algeria 185,042 +7,029 4,695 +254 124,087 Africa 55 Belarus 457,422 +6,977 3,572 +69 451,598 EURO 56 Denmark 327,972 +6,818 2,555 +3 312,907 EURO 57 Venezuela 316,449 +6,468 3,764 +98 302,556 Americas 58 Uzbekistan 140,210 +6,358 956 +46 133,362 EURO 59 Chile 1,626,594 +6,205 36,243 +437 1,582,781 Americas 60 Ukraine 2,262,601 +6,204 53,173 +124 2,194,791 EURO 61 Panama 445,651 +6,052 6,932 +57 427,755 Americas 62 Saudi Arabia 536,693 +5,712 8,378 +81 518,911 EMRO 63 Sweden 1,109,112 +5,419 14,621 +1 1,078,954 EURO 64 Finland 115,305 +5,323 995 +11 46,000 EURO 65 Jordan 780,542 +5,291 10,173 +73 759,217 EMRO 66 French Polynesia 27,036 +5,231 184 +29 22,095 Non 67 Eswatini 34,585 +5,188 905 +78 25,134 Africa 68 Serbia 729,150 +5,053 7,152 +20 712,762 EURO 69 Ethiopia 287,184 +4,686 4,452 +46 264,935 Africa 70 Austria 665,885 +4,526 10,753 +8 647,883 EURO 71 Bulgaria 431,292 +4,360 18,321 +78 399,755 EURO 72 Zimbabwe 118,754 +4,265 4,047 +293 94,925 Africa 73 Senegal 69,576 +4,243 1,554 +113 52,498 Africa 74 Martinique 27,255 +4,226 166 +37 104 Non 75 Nigeria 180,661 +4,084 2,200 +22 166,560 Africa 76 CAR 11,195 +4,044 98 0 6,859 Africa 77 Rwanda 78,303 +3,939 930 +70 45,045 Africa 78 Fiji 38,812 +3,924 345 +62 14,301 WPRO 79 Kuwait 405,442 +3,745 2,380 +24 395,348 EMRO 80 Lithuania 288,173 +3,741 4,438 +14 271,957 EURO 81 Kyrgyzstan 170,770 +3,694 2,426 +54 160,794 EURO 82 Cambodia 83,839 +3,614 1,634 +127 78,431 WPRO

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83 Réunion 43,835 +3,590 298 +10 38,315 Non 84 Bolivia 480,229 +3,434 18,109 +174 418,580 Americas 85 Cyprus 107,887 +3,418 454 +21 90,755 EURO 86 Ecuador 493,767 +3,411 31,870 +116 443,880 Americas 87 Zambia 201,770 +3,315 3,512 +65 194,004 Africa 88 Norway 142,895 +3,117 807 +3 88,952 EURO 89 Ghana 109,428 +2,994 899 +45 101,984 Africa 90 North Macedonia 159,908 +2,982 5,527 +26 150,635 EURO 91 Malawi 57,273 +2,558 1,919 +171 42,199 Africa 92 Australia 38,168 +2,470 949 +16 30,735 WPRO 93 Jamaica 56,165 +2,326 1,268 +57 47,365 Americas 94 Montenegro 105,002 +2,123 1,640 +5 99,989 EURO 95 Paraguay 456,291 +2,097 15,383 +176 431,006 Americas 96 Armenia 233,400 +2,078 4,669 +37 221,919 EURO 97 Mauritania 29,307 +2,076 627 +44 25,136 Africa 98 Afghanistan 151,770 +1,964 7,000 +121 105,490 EMRO 99 Romania 1,086,109 +1,883 34,334 +34 1,049,156 EURO 100 Laos 9,363 +1,852 9 +2 4,240 WPRO 101 Dominican Republic 345,325 +1,813 3,975 +4 334,863 Americas 102 El Salvador 90,129 +1,758 2,759 +78 77,768 Americas 103 Estonia 136,228 +1,749 1,279 +3 130,165 EURO 104 Burundi 9,408 +1,694 38 0 773 Africa 105 Palestine 319,223 +1,689 3,621 +12 312,879 EMRO 106 Trinidad and Tobago 41,207 +1,630 1,159 +42 34,033 Americas 107 Oman 299,642 +1,622 3,974 +68 287,244 EMRO 108 Namibia 121,817 +1,596 3,244 +102 108,553 Africa 109 Croatia 366,049 +1,558 8,278 +8 356,219 EURO 110 Qatar 228,543 +1,488 601 0 225,566 EMRO 111 DRC 52,432 +1,384 1,050 +5 30,380 Africa 112 Moldova 261,524 +1,341 6,298 +28 253,503 EURO 113 Uganda 96,224 +1,320 2,832 +80 93,260 Africa 114 Albania 134,761 +1,319 2,460 +3 130,549 EURO 115 Guinea 27,507 +1,319 271 +33 25,031 Africa 116 Czechia 1,675,675 +1,265 30,372 +1 1,642,877 EURO 117 Togo 17,434 +1,202 163 +8 15,244 Africa 118 Poland 2,884,780 +1,156 75,291 +16 2,654,874 EURO 119 Slovenia 260,867 +1,103 4,433 +4 254,533 EURO 120 Ivory Coast 51,926 +1,033 354 +16 50,632 Africa 121 Bahamas 16,141 +950 311 +16 13,070 Americas 122 Aruba 12,929 +929 115 +4 11,761 Non 123 Angola 44,174 +905 1,070 +38 41,024 Africa 124 French Guiana 31,633 +877 197 +4 9,995 Non 125 Bahrain 270,590 +853 1,384 0 268,090 EMRO 126 Uruguay 382,997 +842 5,996 +14 375,488 Americas 127 Maldives 78,815 +816 222 0 76,491 SEARO 128 Bosnia and Herzegovina 206,835 +804 9,698 +9 192,034 EURO

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129 China 94,260 +762 4,636 0 87,740 WPRO 130 Mauritius 5,349 +757 21 +1 1,854 Africa 131 Iceland 9,246 +738 30 0 7,914 EURO 132 Timor-Leste 11,870 +645 29 +3 10,169 SEARO 133 Latvia 139,814 +610 2,561 +3 136,163 EURO 134 Suriname 26,318 +602 672 +14 22,509 Americas 135 Isle of Man 5,787 +552 36 +3 5,013 Non 136 Egypt 285,061 +538 16,604 +47 233,729 EMRO 137 Singapore 66,012 +504 43 +3 64,380 WPRO 138 Curaçao 14,396 +489 132 +2 13,629 Non 139 Somalia 16,195 +460 870 +33 7,888 EMRO 140 Benin 9,065 +457 113 +3 8,136 Africa 141 Guyana 23,244 +455 569 +16 21,848 Americas 142 Saint Lucia 6,112 +424 95 +5 5,497 Americas 143 Malta 35,091 +423 429 +5 33,525 EURO 144 Tajikistan 15,862 +422 123 +1 15,428 EURO 145 Gambia 8,920 +415 251 +13 8,038 Africa 146 Hungary 810,212 +409 30,037 +5 763,801 EURO 147 Sudan 37,543 +405 2,803 +27 31,473 EMRO 148 Slovakia 393,302 +404 12,544 +3 379,993 EURO 149 Nicaragua 10,251 +398 197 +1 4,225 Americas 150 Cameroon 82,454 +390 1,338 +4 80,433 Africa 151 Belize 14,738 +356 344 +6 13,831 Americas 152 Tanzania 1,367 +350 50 +29 183 Africa 153 Luxembourg 74,545 +333 827 +3 72,993 EURO 154 Seychelles 18,895 +313 98 +4 18,314 Africa 155 Guinea-Bissau 4,986 +307 84 +5 4,313 Africa 156 Cabo Verde 34,235 +294 298 0 33,402 Africa 157 Channel Islands 9,815 +260 92 +1 9,173 Non 158 Lesotho 13,862 +259 391 +14 6,711 Africa 159 Brunei 543 +204 3 0 322 WPRO 160 Sint Maarten 3,088 +197 38 +4 2,768 Non 161 Dominica 412 +194 0 0 209 Americas 162 Haiti 20,507 +181 576 +13 15,659 Americas 163 Syria 26,205 +146 1,930 +11 22,100 EMRO 164 St. Barth 1,336 +141 2 +1 462 Non 165 Congo 13,356 +140 179 +1 12,421 Africa 166 Saint Martin 2,713 +134 39 +1 1,399 Non 167 Yemen 7,233 +129 1,395 +12 4,438 EMRO 168 Madagascar 42,795 +110 950 +7 42,484 Africa 169 Andorra 14,908 +99 129 +1 14,579 EURO 170 Gibraltar 5,187 +98 95 0 4,885 Non 171 Gabon 25,529 +89 165 0 25,309 Africa 172 Monaco 3,040 +79 33 0 2,891 EURO 173 Greenland 221 +70 0 0 135 Non 174 Taiwan 15,820 +67 817 +26 14,375 WPRO

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175 Barbados 4,509 +66 48 0 4,354 Americas 176 Bermuda 2,645 +56 33 0 2,529 Non 177 Mali 14,669 +54 534 0 14,001 Africa 178 South Sudan 11,143 +53 120 0 10,514 Africa 179 British Virgin Islands 2,552 +52 37 +6 2,469 Non 180 Antigua and Barbuda 1,372 +52 43 0 1,255 Americas 181 Niger 5,716 +47 196 0 5,424 Africa 182 San Marino 5,194 +47 90 0 5,029 EURO 183 Turks and Caicos 2,546 +47 19 +1 2,461 Non 184 Burkina Faso 13,635 +36 170 +1 13,411 Africa 185 Liechtenstein 3,127 +35 59 0 3,028 Non 186 New Zealand 2,914 +34 26 0 2,844 WPRO 187 Papua New Guinea 17,806 +32 192 0 17,479 WPRO 188 Saint Kitts and Nevis 630 +30 3 0 578 Americas 189 Sierra Leone 6,332 +29 121 +1 4,324 Africa 190 Mayotte 19,546 +28 175 +1 2,964 Non 191 Caribbean Netherlands 1,738 +25 17 0 1,702 Non 192 Eritrea 6,597 +24 36 +1 6,525 Africa 193 Hong Kong 12,026 +23 212 0 11,733 WPRO 194 Equatorial Guinea 8,951 +23 123 0 8,757 Africa 195 Djibouti 11,672 +16 156 0 11,503 EMRO 196 Grenada 180 +16 1 0 167 Americas 197 Sao Tome and Principe 2,480 +15 37 0 2,379 Africa 198 Anguilla 127 +14 0 0 117 Non 199 Bhutan 2,553 +10 3 +1 2,518 SEARO 200 St. Vincent Grenadines 2,307 +9 12 0 2,252 Americas 201 Cayman Islands 651 +7 2 0 644 Non 202 Chad 4,981 +5 174 0 4,800 Africa 203 Comoros 4,035 +5 147 0 3,881 Africa 204 Saint Pierre Miquelon 30 +2 0 0 28 Non 205 Montserrat 22 +1 1 0 20 Non 206 Guadeloupe 23,821 0 247 0 2,250 Non 207 Liberia 5,459 0 148 0 2,715 Africa 208 Faeroe Islands 987 0 2 0 963 Non 209 Diamond Princess 712 0 13 0 699 NA 210 Wallis and Futuna 445 0 7 0 438 Non 211 New Caledonia 134 0 0 0 58 Non 212 Falkland Islands 66 0 0 0 63 Non 213 Macao 63 0 0 0 57 WPRO 214 Vatican City 27 0 0 0 27 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

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 476. 13 August 2021

221 Saint Helena 2 0 0 0 2 Non 222 Micronesia 1 0 0 0 1 WPRO Total 206,251,780 +4,548,336 4,348,193 +67,759 183,381,663

Figure 4. Areas with reported confirmed cases of COVID-19 ( 2– 8 August 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 476. 13 August 2021

Table 5. COVID-19 cases and deaths reported by states/UT in India between 7 – 13 August, 2021 (Updated as of 13 August 2021, 1230H SGT)

Change Change Change Change Total Total Name of State from from Total from Total from Diagnosed Active / UT previous previous Recovered previous Deaths previous Cases Cases week week week week Andaman and 7548 +7 6 +2 7413 +5 129 0 Nicobar Islands Andhra 1988910 +12769 18688 -1614 1956627 +14256 13595 +127 Pradesh Arunachal 50973 +1532 2395 -831 48327 +2348 251 +15 Pradesh Assam 577970 +6399 10427 -1597 562092 +7888 5451 +108 Bihar 725369 +302 273 -92 715450 +394 9646 0 Chandigarh 62009 +43 37 +9 61161 +34 811 0 Chhattisgarh 1003537 +688 1509 -321 988483 +997 13545 +12 Dadra and 10655 +3 5 -9 10646 +12 4 0 Nagar Haveli and Daman and Diu Delhi 1436938 +359 502 -16 1411368 +367 25068 +8 Goa 172276 +668 993 -36 168117 +694 3166 +10 Gujarat 825118 +140 182 -24 814858 +162 10078 +2 Haryana 770146 +119 672 -31 759820 +142 9654 +8 Himachal 209344 +2256 2668 +1058 203134 +1187 3542 +11 Pradesh Jammu and 323061 +919 1307 -51 317359 +961 4395 +9 Kashmir Jharkhand 347498 +194 211 -12 342157 +205 5130 +1 Karnataka 2924732 +11220 22754 -1685 2865067 +12699 36911 +206 Kerala 3631638 +138035 177040 -1401 3436318 +138484 18280 +952 Ladakh 20430 +61 87 +25 20136 +36 207 0 Lakshadweep 10274 +39 40 -36 10183 +74 51 +1 Madhya 791998 +79 131 -21 781353 +100 10514 0 Pradesh Maharashtra 6375390 +39170 65808 -12604 6175010 +50732 134572 +1042 Manipur 106707 +4560 6835 -1851 98189 +6342 1683 +69 Meghalaya 70661 +3069 4539 -1035 64922 +4037 1200 +67 Mizoram 47471 +4663 11620 -1481 35677 +6130 174 +14 Nagaland 28955 +620 1347 +2 27015 +606 593 +12 Odisha 991182 +7659 9729 -2188 974756 +9386 6697 +461 Puducherry 121989 +656 914 +26 119272 +625 1803 +5 Punjab 599758 +454 533 +69 582891 +352 16334 +33 Rajasthan 953887 +114 194 -37 944739 +151 8954 0 Sikkim 28275 +749 2398 -972 25517 +1712 360 +9

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 476. 13 August 2021

Tamil Nadu 2583036 +13638 20399 +261 2528209 +13179 34428 +198 Telangana 651288 +3477 7996 -748 639456 +4206 3836 +19 Tripura 80980 +1203 1953 -813 78252 +2003 775 +13 Uttarakhand 342526 +219 418 -115 334739 +331 7369 +3 Uttar Pradesh 1708851 +202 490 -169 1685581 +361 22780 +10 West Bengal 1536446 +4784 10127 -594 1508051 +5303 18268 +75 Total 32117826 +261069 385227 -28932 31302345 +286501 430254 +3500 Source: https://www.mohfw.gov.in/

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 476. 13 August 2021

iv. Travel Bans/Advisories & Quarantine Orders

[1,2] Canada  Flight ban from India has been extended until 21 Sept.  From 9 Aug, American citizens and permanent residents of US will be allowed to enter the country if they are residing and traveling from US, provide proof of being fully vaccinated and negative Covid-19 test taken before entry. Canada is also planning to reopen to all fully vaccinated travelers from 7 Sept.

[3] Cyprus- From 9 Aug, travelers from Croatia, Sweden and Serbia will be required to undergo testing upon arrival. Travelers from Estonia and Lebanon will be required to undergo additional entry requirement.

[4] Denmark- From 7 Aug, non-vaccinated and have not been infected with Covid-19 travelers from Switzerland, Greece, Belgium and France are required to show proof of negative test result and also get tested on arrival. Citizens are advised against travelling to Czechia, Estonia and Turkey.

[5] Germany- Netherlands has been removed from the list of high-risk area. Unvaccinated travelers will not be required to undergo quarantine upon arrival from 8 Aug.

[6] Malaysia- From 9 Aug, fully vaccinated returning citizens and residents will be allowed to serve quarantine at home instead of designated hotel.

[7] Netherlands- From 8 Aug, travelers from Georgia will be required to show proof of full vaccination, negative PCR test from the past 72 hours and undergo a 10-day mandatory quarantine.

[8] New Zealand- From the first quarter of 2022, New Zealand plans to allow vaccinated travelers from low risk countries to travel quarantine-free, travelers from medium and high risk countries will undergo combination of quarantine measures ranging from self-isolation to 14-days quarantine.

[9] Norway- From 9 Aug, travelers from Monaco will undergo double testing and quarantine at government designated facilities as Monaco moves to dark red category. Iceland and Estonia will move to red category while Croatia and Lithuania move to orange category where travelers in both categories will undergo double testing and quarantine.

[10] Philippines- Travel ban on traveler arriving from India, Pakistan, Bangladesh, Sri Lanka, Nepal, the United Arab Emirates, Oman, Thailand, Malaysia and Indonesia has been extended to 31 Aug.

[11] Russia- Flights to Egyptian resorts, Dominican Republic, Moldova, Bahrain will resume on 9 Aug while flights to Tanzania will remain suspended until 17 Aug.

[12, 13] Singapore  From 10 Aug, entry approvals for vaccinated work visa holders and dependents with travel history to higher risk countries will resume.  From 21 Aug, fully vaccinated travelers from Australia, Austria, Canada, Germany, Italy, Norway, South Korea and Switzerland will serve their 14-days stay home notice at their residential place instead of dedicated facilities.

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 476. 13 August 2021

[14] UK- From 9 Aug, fully vaccinated travelers from France has been exempted from quarantine. Travelers from Austria, Germany, Latvia, Norway, Romania, Slovakia and Slovenia will enter the country without restriction.

[15] USA- The CDC has added 7 countries, Aruba, Eswatini, France, French Polynesia, Iceland, Israel and Thailand to the level 4 (very high) risk level warning citizen against travelling to these countries.

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 476. 13 August 2021

v. Lockdowns

[1-6] Australia  New South Wales- A seven-day lockdown has been imposed on Tamworth and Byron Bay on 9 Aug and on Canberra on 12 Aug.  Queensland- Lockdown in Brisbane has been lifted on 8 Aug. Restriction on leaving city and gathering will be in place for at least 2 weeks. A three-day lockdown was imposed in a northern city of Cairns. Borders with ACT will be closed and anyone entering Queensland from 14 Aug 1pm will undergo mandatory hotel quarantine for 14 days.  Victoria- Lockdown in the regional Victoria has been lifted on 10 Aug while lockdown in Melbourne has been extended for another 7 days until 19 Aug. In the regional, private gathering at home will be banned while public gathering outdoor will be limited to 10 people. Hospitality and retail will reopen and community sports will resume. Wedding and funerals will be restricted to 50 people. Travel to Melbourne will be allowed for permitted reason. Mask will remain mandatory indoors and outdoors.

[7] Bangladesh- Lockdown has been lifted on 11 Aug with certain measures in place. Shops and malls will reopen and operate from 10am to 8pm. Public transport will resume with capacity limited to the available number of seats. Half of the buses will be in operation carrying full passenger capacity. Hotels and restaurant will operate with half capacity.

[8] Bhutan- A three-day lockdown has been imposed on Jomotshangkha and Langchenphu gewog. Schools, institutions and offices will be closed.

[9] Brunei- Tighter social distancing measures were introduced on 7 Aug for 2 weeks. Schools will move to online learning, dine-in for restaurants will be banned and religious places, cinemas and indoor and outdoor sports facilities leisure centers will be closed.

[10] Dominica- Night curfew has been extended until 17 Aug and run from 6pm to 5am for weekday and 3pm on Saturday to 5am Monday.

[11] France- French overseas territory of Martinique has entered a tougher lockdown on 10 Aug for three weeks. Beaches and shops selling non-essential items will be closed and movement will be restricted. Lockdown rule in overseas territory of Guadeloupe will also be strengthened.

[12-14] India  Tamil Nadu- Lockdown has been extended until 23 Aug. Religious places will be closed from Friday to Sunday. Schools will reopen with 50% capacity on 1 Sept for classes 9 to 12. Medical and nursing colleges will reopen from 16 Aug.  Kerala- Shops in malls have reopened from 11 Aug. All shops, banks, factories, tourist places are allowed to operate from Monday to Saturday 7am to 9pm. Lockdown will be imposed on Sunday. Public observation and mass gathering for Onam, Muharram, Janmashtami, Ganesh Chathurthi, and Durga Pooja will be banned. Special intensified stringent lockdown restrictions will be imposed in the Panchayats or urban wards from 12 Aug.  Maharashtra- From 15 Aug, shops, malls and restaurants will be allowed to operate till 10pm. Private offices will be allowed to operate 24 hours daily with staggered shift hours. Employees in shops, establishments and offices are required to be fully vaccinated. Religious places and theatres, multiplexes and auditoriums will remain close. Restaurants, gym and spas will operate

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 476. 13 August 2021

with 50% capacity. Outdoor wedding will be limited to 200 and 100 or 50% capacity for indoor. Indoor game will be allowed for fully vaccinated people up to 10pm.

[15] Indonesia- Measures in Jakarta, Bandung, Semarang and Surabay have eased from 10 Aug. Shopping malls has reopen to vaccinated individuals but limited to 25% capacity. Level four containment measures in some parts of Java and Bali has been extended until 16 Aug and 23 Aug for regions beyond the two islands.

[16] Jamaica- Curfew has been imposed from 11 Aug to 31 Aug. It will run from 7pm to 5am on weekdays, 6pm to 5am on Saturdays and 2pm to 5am on Sunday. Establishments will be closed one hour before the curfew. Beaches without management or control will be closed while the other beaches will open from 6am to 4am from Monday to Saturday and 6am to 1pm on Sunday. Places of worship with be limited to 50 people depending on the physical distance rule.

[17] Japan- Coronavirus quasi-emergency has been expanded to eight prefectures of Fukushima, Ibaraki, Tochigi, Gunma, Shizuoka, Aichi, Shiga and Kumamoto until 31 Aug. Restaurants and bars will close before 8pm and ban sales of alcohol. Establishments in areas with decrease of new cases will be allowed to sell alcohol until 7pm.

[18] Malaysia- Restrictions for fully vaccinated people will be relaxed in in states and federal territories under second and third phase of the National Recovery Plan. From 10 Aug, interstate travels will be allowed for fully vaccinated long-distance couples and parents visiting children below 18 years old. Dine-in with seating capacity of 50% per table, cross-district travel and intrastate tourism in homestays or hotel, practice non-contact sports from 6am to 10pm will be allowed while contact sports and group exercise as well as changing and shower in clubhouse premises are banned. Fully vaccinated resident will be allowed to enter houses of worship for prayers from 9 Aug.

[19] Nepal- Restriction measures in Kathmandu Valley have been extended until 24 Aug. New restrictions on the ban of non-essential vehicles after 8pm has been introduced from 12 Aug.

[20] North Macedonia- From 16 Aug, proof of at least one dose of vaccination will be required to attend outdoor events with more than 30 people and entering hospitality venues. Indoor events will be banned.

[21] Singapore- From 10 Aug, fully vaccinated individuals will be allowed to dine-in at restaurants in groups of 5 and gathering limit will increase to 5 people.

[22] Uganda- Passenger train service in the capital Kampala have resumed. Each coach will carry 50% of its capacity allowing space for 65 passenger and mask will be mandatory.

[23] Pakistan- From 1 Oct, unvaccinated individuals will be ban from travelling on train.

[24] Philippines- Manila has been placed under 2-week lockdown from 6 Aug.

[25] South Korea- Restrictions have been extended for another 2 weeks.

[26] UK- Social distancing rules and gathering limit in Wales have been lifted while face masks remain mandatory in many public places.

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 476. 13 August 2021

[27] USA- Chicago has added 12 states, Idaho, North Carolina, Washington, Oregon, California, New Mexico, Montana, Delaware, New York, Indiana, Wisconsin, and Iowa to its travel advisory where unvaccinated travelers entering the states are advised to undergo 10 days quarantine or produce a negative test result taken 72 hours prior to arrival.

vi. Military Surveillance

[1-6] South Korea – Between 7 to 13 Aug, 25 covid-19 cases were reported in the military bringing the total number of infection in the military to 1,545. Cases were reported from Paju (9), Nonsan (4), Incheon (2), Busan (1), Okcheon County (1), Jinhae (1) and Dongducheon (1). In addition, three Army soldiers, a Marine, a Seoul-based officer at South Korea- US Combined Forces Command and a military civilian employee were also identified.

As of 10 Aug, all infected service members from the 301-strong Cheonghae unit have recovered.

[7-11] United States Forces Korea – Between 6 to 13 Aug, the USFK reported 51 cases consisting of 47 service members and four family members. 15 service members were based in Osan Air Base including one who was identified before returning to US, two service members were from Camp Humphreys, and 30 service members were new arrivals to South Korea between 13 Jul and 10 Aug. The latest cases raised the total number of infections reported among the USFK-affiliated population to 1,210.

[12-16] United States Forces Japan –Between 6 to 12 Aug, the US military in Japan reported 107 new cases. Cases were reported from Yokosuka Naval Base (23), Naval Air Facility Atsugi (7), Yokota Air Base (7), Sasebo Naval Base (1), Marine Corps Air Station Iwakuni (4), US Army Japan Camp Zama (12), Kadena Air Base (17) and Marine Corps base in Okinawa (36).

[17, 18] United States – As of 11 Aug, there were a total of 326,604 cases consisting of 217,982 military, 31,580 dependents, 56,983 civilians and 20,059 Defense Department contractors reported. Among the military cases, there are 208,287 recoveries and 1,962 hospitalized. There are 29 deaths including a recent death of an Army officer who had passed away on 2 Aug. There are 76,917 cases in the Army, 24,710 in the Marine Corps, 42,048 in the Navy, 36,227 in the Air Force, 36,798 in the National Guard and 1,282 cases among other elements.

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 476. 13 August 2021 vii. WHO Guidance & Other Protocols

The following update was published by the WHO from 7 – 13 August:

 Training on handling, storing and transporting Pfizer BioNTech COVID-19 Vaccine COMIRNATY® (Tozinameran) Available at: https://www.who.int/publications/m/item/training-on-handling-storing-and- transporting-pfizer-biontech-covid-19-vaccine-comirnaty-(tozinameran)  Guidance for surveillance of SARS-CoV-2 variants: Interim guidance, 9 August 2021 Available at: https://www.who.int/publications/i/item/WHO_2019-nCoV_surveillance_variants

viii. CDC Guidance & Protocols

US CDC

The following updates were published by the US CDC from 7 – 13 August:

 CDC Diagnostic Tests for COVID-19 Available at: https://www.cdc.gov/coronavirus/2019-ncov/lab/testing.html  Resuming Business Toolkit Available at: https://www.cdc.gov/coronavirus/2019-ncov/community/resuming-business- toolkit.html  Safer Travel Tips for Families with Unvaccinated Children Available at: https://www.cdc.gov/coronavirus/2019-ncov/travelers/travel-risk.html  Construction COVID-19 Checklists for Employers and Employees Available at: https://www.cdc.gov/coronavirus/2019- ncov/community/organizations/construction-worker-checklists.html  COVID-19 Vaccines That Require 2 Shots Available at: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/second-shot.html  Considerations for Non-emergency Vehicle Transportation for Tribal Communities During COVID-19 Available at: https://www.cdc.gov/coronavirus/2019-ncov/community/tribal/non-ems- transportation.html  Engaging Community Health Workers to Support Home-based Care for People with COVID-19 in Low-Resource Non-U.S. Settings Available at: https://www.cdc.gov/coronavirus/2019-ncov/global-covid-19/home-based- care.html  COVID-19 Vaccines While Pregnant or Breastfeeding Available at: https://www.cdc.gov/coronavirus/2019- ncov/vaccines/recommendations/pregnancy.html  Pregnant and Recently Pregnant People Available at: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/pregnant- people.html  Families and COVID-19

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 476. 13 August 2021

Available at: https://www.cdc.gov/coronavirus/2019-ncov/groups/families-covid-19.html  How to Engage the Arts to Build COVID-19 Vaccine Confidence Available at: https://www.cdc.gov/vaccines/covid-19/vaccinate-with-confidence/art.html  Selected Adverse Events Reported after COVID-19 Vaccination Available at: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/adverse- events.html

EU CDC

No updates were published by the EU CDC from 7 – 13 August.

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 476. 13 August 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] Australia- Provisional approval has been given for Moderna vaccine making it the fourth vaccine to be approved. The vaccine will be administered to individuals 18 years old and above in 2 doses with 28 days apart. [2] France- Valneva SE has commenced a further phase 3 clinical trial (VLA2001-304) for its inactivated, adjuvanted Covid-19 vaccine, VLA2001. This study will complement the ongoing trial and support additional regulatory submission. It will be conducted in New Zealand and recruit about 150 subjects aged 56 years old and above. [3] Israel- BriLife™ vaccine developed by Israel Institute for Biological Research will commence phase 2b clinical trial in the Nation of Georgia. [4] Singapore- SingHealth's Investigational Medicine Unit will be conducting phase 1/2 clinical trial study on two new vaccines, ARCT-154 and ARCT-165 as well as the original ARCT-021 vaccine. A total of 72 participants will be involved in the study with 36 who are unvaccinated and another 36 who have been administered with second dose of Pfizer vaccine at least 6 months ago. Participants will receive two doses of any one of the three vaccines with one month apart while the vaccinated ones will receive one dose of the vaccine. [5] South Korea- Vaccination reservation for all adults above 18 will be opened on 9 Aug as vaccination runs from 26 Aug to 30 Sept. [6] USA- Majority of the individuals fully vaccinated with Moderna vaccine in a study had maintained detectable blinding and function antibodies against the SARS-CoV-2 variants supporting the durable efficacy of 93% through six months. [7] USA- The US Food and Drug Administration has permit the use of booster dose of Pfizer and Moderna vaccine for immunocompromised people on 12 Aug.

Therapeutics

[8] Global- Findings from three clinical trials, the Randomised, Embedded, Multi-factorial Adaptive Platform Trial for Community-Acquired Pneumonia (REMAP-CAP), Accelerating COVID-19 Therapeutic Interventions and Vaccines-4 (ACTIV-4), and Antithrombotic Therapy to Ameliorate Complications of COVID-19 (ATTACC) showed that anticoagulation with heparin could increase survival and decrease the need for organ support in hospitalized patients with moderate COVID- 19. There was a 98.6% probability that anticoagulation with heparin increased the number of organ support-free days when compare to usual care.

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 476. 13 August 2021

[9] Global- Solidarity PLUS trial will be studying the potential of three new drugs, artesunate, imatinib and infliximab in reducing the risk of death in hospitalized Covid-19 patients. The study will be conducted in 52 countries. [10] South Korea- Celltrion has obtained the EUA from Brazil’s Anvisa for its COVID-19 monoclonal antibody treatment, Regkirona (regdanvimab) to treat high-risk adult patients with mild and moderate Covid-19 symptoms on 11 Aug. [11] South Korea- Celltrion has obtained the approval from Therapeutic Goods Administration (TGA) of Australia to commence phase 1 clinical trial of its inhaled version of Regkirona. The study will recruit 24 healthy participants.

Vaccine Approval Status

Table 6: Number of approving countries per vaccine as of 6 August 2021 Number of countries Developer Vaccine approving Anhui Zhifei Longcom RBD-Dimer 2 Bharat Biotech Covaxin 9 CanSino Ad5-nCoV 8 Center for Genetic Engineering and CIGB-66 1 Biotechnology (CIGB) Chumakov Center KoviVac 1 FBRI EpiVacCorona 2 Gamaleya Sputnik Light 12 Gamaleya Sputnik V 70 Johnson & Johnson Ad26.COV2.S 59 Kazakhstan RIBSP QazVac 1 Medigen MVC-COV1901 1 Minhai Biotechnology Co SARS-CoV-2 Vaccine (Vero Cells) 1 Moderna mRNA-1273 65 Oxford/AstraZeneca AZD1222 121 BioNTech/Pfizer BNT162b2 97 Serum Institute of India Covishield 45 Shifa Pharmed Industrial Co COVID-19 Inactivated Vaccine 1 Sinopharm BBIBP-CorV 59 Sinopharm Inactivated 1 Sinovac CoronaVac 39 Takeda TAK-919 (Moderna formulation) 1 Source: https://covid19.trackvaccines.org/vaccines/

Adverse Reactions & Effects

[1] Australia- Between 2-8 Aug, 2075 adverse events were reported bringing the total cases reported to 48,143 among 13.7 million vaccine doses administered. Among 7.4 million doses of AstraZeneca vaccine administered, 104 (59 confirmed and 45 probable) cases of thrombosis with thrombocytopenia syndrome (TTS) were reported. Of the cases reported between 2-8 Aug, 10 were 60 years old and above. Of the new probable TTS cases, 5 might be related to the second dose. TTS had resulted in 6 deaths (5.75% case fatality). There were 149 cases of

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 476. 13 August 2021

myocarditis and pericarditis among the 6.3 million Pfizer doses administered with 38 new cases reported. [2] Barbados- More than 180,000 doses of vaccine had been administered. 442 adverse reactions were reported and three of them were moderate to severe. [3] EU- The European Medicines Agency (EMA) will be studying on three new possible side effects, erythema multiforme, glomerulonephritis and nephrotic syndrome which had been reported by small number of people after administered with Pfizer and Moderna. [4] Ireland- The Health Products Regulatory Authority had recorded 24 suspected side effects in vaccinated children under 17 years old. Common symptoms were dizziness, abdominal pain or nausea, headache, blurred vision, fainting and fever. A small number of cases had cardiac related symptom with possible link to anxiety and stress-related reaction due to vaccination. As of 3rd Aug, 13,529 suspected side effects were reported out of 3.14 million doses administered. Of the side effects reported, 5,850 cases had received AstraZeneca and Janssen and 7,589 cases had Pfizer and Moderna. There were 24 reports of myocarditis and pericarditis in people administered with Pfizer or Moderna vaccine and 10 reports in those with AstraZeneca or Janssen vaccines. [5] Japan- In a pre-print study, among 3,998 people who were vaccinated with the first dose of Moderna vaccine in the workplace vaccination program, 0.5% had adverse events at the vaccination site and an anaphylaxis case (0.03%) was reported in an individual with history of anaphylaxis to flu vaccine. Among 1877 subjects who had responded to the questionnaire survey and were included in the analysis, 82% had reported local adverse events after leaving the vaccination site with injection site pain the most common (71%). 48% had reported systemic adverse events with myalgia being the most common (34%). [6] Israel- A preliminary study observed similar side effects in Pfizer-BioNTech booster shot and the second dose. Approximately 4,500 participants aged 60 years and above were involved in the study. 84% had reported feeling similar or better as compared to the second dose, 31% had side effect with common symptoms being soreness at infection site, 0.4% had breathing difficult and 1% had received medical treatment due to side effects.

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 476. 13 August 2021

x. Scientific Publications with Epidemiology and Clinical Focus

Clinical Characteristics and Outcomes of COVID-19 Patients with Overweight and Obesity: Turkish Nationwide Cohort Study (TurCObesity) [1]

Purpose: While obesity is related to more severe outcomes of coronavirus disease 2019 (COVID-19), factors leading to poor prognosis still remain unclear. The present study evaluated the outcomes of COVID-19 patients who were overweight or obese and variables associated with severe disease in a large group of consecutive cases.

Methods: A nationwide retrospective cohort study was performed using the Turkish National Healthcare Database. Demographic characteristics, laboratory tests, comorbidities, and medications of patients registered between March 11 and May 30, 2020, were recorded.

Results: A total of 14, 625 patients (median age:42, IQR:26 years; female 57.4%) with normal weight (34.7%), overweight (35.6%), and obesity (29.7%) were included. Hospitalization, ICU admission, intubation/mechanical ventilation, pulmonary involvement, and mortality were significantly higher in patients who were overweight or obese. In adjusted analyses, both overweight (OR, 95% CI: 1.82, 1.04- 3.21; p=0.037) and obesity (OR, 95% CI: 2.69, 1.02-1.05; p<0.001) were associated with a higher intubation/mechanical ventilation rate but only obesity was associated with increased mortality (OR, 95% CI: 2.56, 1.40-4.67; p=0.002). Old age, male gender, chronic kidney disease, and high C reactive protein levels were independently associated with COVID-19 mortality in overweight or obese patients.

Conclusions: COVID-19 patients who were overweight or obese were more likely to have adverse outcomes but only obesity was a predictor of mortality. Such patients should receive urgent medical attention and active management, especially the elderly, men, and people with chronic kidney disease.

Vitamin D levels associate with blood glucose and BMI in COVID-19 patients predicting disease severity [2]

Context: High prevalence of Vitamin-D (VD) deficiency in COVID-19 patients was reported and hypothesized to increase COVID-19 severity likely due to its negative impact on immune and inflammatory responses. Furthermore, clear associations between hypovitaminosis-D and fat body-mass excess and diabetes, factors associated with COVID-19 severity, have been widely recognized.

Objective: The aim of this study was to evaluate in COVID-19 patients the relationship between VD levels and inflammatory response, BMI, blood glucose and disease severity.

Design: Patients admitted to San Raffaele-Hospital for COVID-19 were enrolled in this study, excluding those with comorbidities and therapies influencing VD-metabolism. 25(OH)VD levels, plasma glucose levels, BMI and inflammatory parameters were evaluated at admission.

Results: A total of 88 patients were included. Median VD level was 16.3 ng/mL and VD-deficiency was found in 68.2% of patients. VD-deficiency was found more frequently in male patients and in those affected by severe COVID-19. Regression analyses showed a positive correlation between VD and PaO2/FiO2 ratio, and negative correlations between VD and plasma glucose, BMI, Neutrophil/Lymphocyte ratio, CRP and IL-6.Patients with both hypovitaminosis-D and diabetes mellitus, as well those with hypovitaminosis-D and overweight, were more frequently affected by a severe

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 476. 13 August 2021 disease with worse inflammatory response and respiratory parameters, compared to those without or just one of these conditions.

Conclusions: We showed, for the first-time, a strict association of VD levels with blood glucose and BMI in COVID-19 patients. VD-deficiency might be a novel common pathophysiological mechanism involved in the detrimental effect of hyperglycemia and adiposity on disease severity.

Household transmission of SARS-CoV-2 in the United States: living density, viral load, and disproportionate impact on communities of color [3]

Background: Households are hotspots for SARS-CoV-2 transmission. In the US, the COVID-19 pandemic has had a disproportionate impact on communities of color.

Methods: Between April-October 2020, the CO-HOST prospective cohort study enrolled 100 COVID-19 cases and 208 of their household members in North Carolina, including 44% who identified as Hispanic or non-white. Households were enrolled a median of 6 days from symptom onset in the index case. Incident secondary cases within the household were detected by quantitative PCR of weekly nasal swabs (days 7, 14, 21) or by seroconversion at day 28.

Results: Excluding 73 household contacts who were PCR-positive at baseline, the secondary attack rate among household contacts was 32% (33/103, 95% CI 22%-44%). The majority of cases occurred by day 7, with later cases confirmed as household-acquired by viral sequencing. Infected persons in the same household had similar nasopharyngeal viral loads (ICC=0.45, 95% CI 0.23-0.62). Households with secondary transmission had index cases with a median viral load that was 1.4 log10 higher than households without transmission (p=0.03) as well as higher living density (>3 persons occupying <6 rooms) (OR 3.3, 95% CI 1.02-10.9). Minority households were more likely to experience high living density and had a higher risk of incident infection than did white households (SAR 51% vs. 19%, p=0.01).

Conclusions: Household crowding in the context of high-inoculum infections may amplify the spread of COVID-19, potentially contributing to disproportionate impact on communities of color.

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 476. 13 August 2021

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Scientific Reports 1. Sahin I, Haymana C, Demir T, Demirci I, Tasci I, Atmaca A, Cakal E, Ata N, Emral R, Unluturk U, Ertugrul D, Salman S, Sahin M, Dagdelen S, Celik O, Caglayan M, Satman I, Sonmez A. Clinical Characteristics and Outcomes of COVID-19 Patients with Overweight and Obesity: Turkish Nationwide Cohort Study (TurCObesity). Exp Clin Endocrinol Diabetes. 2021 Aug 12. doi: 10.1055/a-1552-4449. Epub ahead of print. PMID: 34384122. 2. di Filippo L, Allora A, Doga M, Formenti AM, Locatelli M, Rovere Querini P, Frara S, Giustina A. Vitamin D levels associate with blood glucose and BMI in COVID-19 patients predicting disease severity. J Clin Endocrinol Metab. 2021 Aug 12:dgab599. doi: 10.1210/clinem/dgab599. Epub ahead of print. PMID: 34383926. 3. Cerami C, Popkin-Hall ZR, Rapp T, Tompkins K, Zhang H, Muller MS, Basham C, Whittelsey M, Chhetri SB, Smith J, Litel C, Lin KD, Churiwal M, Khan S, Rubinstein R, Claman F, Mollan K, Wohl D, Premkumar L, Powers KA, Juliano JJ, Lin FC, Lin JT. Household transmission of SARS-CoV-2 in the United States: living density, viral load, and disproportionate impact on communities of color. Clin Infect Dis. 2021 Aug 12:ciab701. doi: 10.1093/cid/ciab701. Epub ahead of print. PMID: 34383889.

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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/

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