For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 474. 30 July 2021

July 30

COVID-19 Situation Report 474

Centre for Infectious Disease Epidemiology and Research (CIDER) For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 474. 30 July 2021

s i. Background

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

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ii. Global Risk Assessment

Table 1. Risk assessment of COVID-19 by WHO regions (Updated as of 30 July 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 2.14% and SEARO (33 countries), EURO (53 people over the past 14-days as cut-off for 4.4–7.7), but globally. countries), EMRO (20 countries), a surge in cases, the number of countries the estimated Most cases Americas (34 countries), and Africa (43 reporting a surge in cases in each region effective present as countries).& are as follows: Combined WPRO and reproduction flu-like SEARO (19 countries), number in 177 illness. International clinical trials published on 2 EURO (43 countries), countries September confirm that cheap, widely EMRO (13 countries), Americas (30 ranged from available steroid drugs can help seriously countries), and Africa (17 countries). 0.23 to 3.5.$ 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 147 (79%) countries/territories have and critically ill patients, but not to those partially reopened their borders – require with mild disease. [4] arrivals to produce a negative COVID-19 test result and/or undergo self-quarantine Researchers have found all regimens of upon arrival. 48 (26%) anticoagulants to be far superior to no countries/territories are totally closed to anticoagulants in COVID-19 patients. international arrivals. [1] More specifically, patients on both a High “therapeutic” or full dose and those on a On October 7, the Centers for Disease “prophylactic” or lower dose, showed Control and Prevention (CDC) confirmed about a 50% higher chance of survival airborne transmission of SARS-CoV-2. [2] and roughly a 30% lower chance of intubation, than those not on The U.S. CDC has revised its guidance on anticoagulants. It was observed that COVID-19 quarantine period from 14 days therapeutic and prophylactic to 7-10 days, based one's test results and subcutaneous low-molecular weight symptoms. Individuals without symptoms heparin and therapeutic oral apixaban only need quarantine for 10 days without may lead to better results. [3] testing; those tested negative can quarantine for 7 days. [14] A new strain known as B.1.525 containing the same E484K mutation The US Centers for Disease Control and found in the Brazilian and South African Prevention (CDC) on 10 Feb announced variants has been detected in Britain that fully vaccinated people did not need [18]. to quarantine if they received their last dose within three months and 14 days As of 6 July, the WHO recommended after their last shot, the time it takes to using arthritis drugs Actemra develop immunity. [16] (tocilizumab) and Kevzara (sarilumab) with corticosteroids for severe and critical COVID-19 patients. [27]

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

33 (80.5%) countries have reported As of July 28, Case 33 countries have commenced outbreaks; but only 19 (46.3%) countries the estimated fatality rate vaccination as of 30 July 2021. Coverage are reporting a surge in cases. effective is 1.76%. was available for the following: i) at least reproduction 1 dose was at <50% for 26 countries; 51- 13 (31.7%) countries have either a no. of 25 70% for 4 countries; >70% for 2 countries constant decreasing change in incidence countries ii) full vaccination was at <50% for 17 or no case in the last 14 days. ranged from countries; 51-70% for 3 countries; >70^ & 0.44-1.3. $ for 1 country.

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 Bangladesh, India, Indonesia, Malaysia traditional chinese medicines, Qingfei and Thailand. Paidu Formula, Huashi Baidu Formula and Xuanfei Baidu Formula, for COVID-19 At least 17 countries have closed their treatment. [20] borders, 23 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 July 28, Case 53 countries have commenced outbreaks; 43 (81.1%) countries are the estimated fatality rate vaccination as of 30 July 2021. Coverage reporting a surge in cases. effective is 2.03%. was available for the following i) at least reproduction 1 dose was at <50% for 26 countries; 51- 1 (1.9%) countries have either a constant no. of 52 70% for 23 countries; >70% for 3 decreasing change in incidence or no case countries countries; ii) full vaccination was at <50% in the last 14 days. ranged from for 34 countries; 51-70% for 13 0.41-3.4$ countries; >70% for 2 countries. & Highest incidence over the past 14 days High were reported from Cyprus, On February 28, France authorized its Gerogia,Netherlands, Spain and United first ever use of synthetic monoclonal Kingdom, and highest case numbers were antibody, bamlanivab by Eli Lilly, for use reported from France, Russia, Spain, on severe COVID-19 patients. [19] Turkey and United Kingdom. As of February 14, Italy authorized the At least 6 countries have closed their use of the two monoclonal antibodies of borders, 46 countries have opened their companies Eli Lilly and Regeneron aimed borders partially conditionally, and only 1 mainly at more serious patients with country is allowing free travel. COVID-19 [17]. Eastern Mediterranean Region (n=22 countries) High High

22 (100%) countries have reported with As of July 28 Case 20 countries have commenced outbreak; 13 (59.1%) countries are the estimated fatality rate vaccination as of 30 July 2021. Coverage High reporting a surge in cases. effective is 1.88%. was available for the following: i) at least reproduction 1 dose was at <50% for 15 countries; 51- no. of 21 70% for 1 country; >70% for 3 countries;

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1 (4.6%) country has either a constant countries ii) full vaccination was at <50% for 11 decreasing change in incidence or no case ranged from countries; 51-70% for 2 countries; >70% in the last 14 days. 0.42-3.5.$ for 1 country. &

Highest incidence over the past 14 days As of June 25, the Abu Dhabi Stem Cell were reported from Iran, Kuwait, Centre has treated more than 2,000 Morocco, Pakistan and Tunisia, and COVID-19 patients using UAECell19. highest case numbers were reported from 1,200 have fully recovered. [6] Iran, Iraq, Kuwait, Libya and Tunisia. As of April, an Israeli firm is using At least 5 countries have closed their placenta pluristem cells to treat COVID- borders, 16 countries have opened their 19 patients on a compassionate use borders partially conditionally, and only 1 basis. [5] country is allowing free travel. 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 July 28, Case 34 countries have commenced outbreak; 30 (85.7%) countries are the estimated fatality rate vaccination as of 30 July 2021. Coverage reporting a surge in cases. effective is 2.61%. was available for the following: i) at least reproduction 1 dose was at <50% for 28 countries; 51- No country has either a constant no. of 34 70% for 3 countries; >70% for 3 countries decreasing change in incidence or no case countries ii) full vaccination was at <50% for 21 in the last 14 days. ranged from countries; 51-70% for 3 countries. & 0.72-1.7.$ Highest incidence over the past 14 days With the increase of multiple variants of were reported from Argentina, Bahamas, COVID-19, the U.S. FDA will limit the use Colombia, Costa Rica and Cuba, and of monoclonal antibody treatments highest case numbers were reported from developed by Regeneron and Eli Lilly due Argentina, Brazil, Colombia, Mexico and to concerns the medications are not USA. effective against these new strains. Eli Lilly’s bamlanivimab will not be At least 11 countries have closed their distributed to California, Arizona and borders, 22 countries have opened their Nevada, where those variants are more High borders partially conditionally, and 2 common. [21] countries are allowing free travel. FDA has issued EUA to Eli Lilly’s combination antibody therapy of bamlanivimab and etesevimab to treat mild to moderate COVID-19 patients who are at risk of serious illness or hospitalization. [15]

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

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

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

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

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

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

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

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

47 (100%) countries have reported with As of July 28, Case 43 countries have commenced outbreak; 17 (37.0%) countries are the estimated fatality rate vaccination as of 30 July 2021. Coverage reporting a surge in cases. effective is 2.39%. was available for the following: i) at least reproduction 1 dose was at <50% for 42 countries; No country has either a constant no. of 45 >70% for 1 country; ii) full vaccination High decreasing change in incidence or no case countries was at <50% for 16 countries; >70% for 1 in the last 14 days. ranged from country. & 0.23-2.1.$ Highest incidence over the past 14 days Ethiopia has approved the use of were reported from Botswana, Eswatini, Dexamethasone treatment for seriously Namibia, Seychelles and South Africa, and ill COVID-19 patients. [13] highest case numbers were reported from

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Algeria, Botswana, Mozambique, South Africa and Zimbabwe.

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

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iii. Global Epidemiology

Table 2. Summary of COVID-19 cases & fatalities globally (Updated as of 30 July 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– 220 197,381,922 197,289,047 4,214,877 2.14% 2.13% 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 2.14 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 24 – 30 July 2021 (Updated as of 30 July 2021, 1230H SGT) Total Total Country Total Cases Change Change Region Deaths Recovered 1 USA 35,584,272 +370678 628,492 +2320 29,626,754 Americas 3 Brazil 19,839,369 +315277 554,626 +7492 18,569,991 Americas 14 Indonesia 3,331,206 +297867 90,552 +11520 2,686,170 SEARO 2 India 31,572,344 +279282 423,244 +3742 30,743,972 SEARO 12 Iran 3,826,447 +202607 90,074 +2011 3,329,065 EMRO 6 UK 5,801,561 +199240 129,515 +535 4,488,894 EURO 10 Spain 4,422,291 +173033 81,442 +248 3,707,914 EURO 4 Russia 6,218,502 +163791 156,977 +5476 5,568,363 EURO 5 France 6,079,239 +145729 111,764 +199 5,691,923 EURO 7 Turkey 5,682,630 +118727 51,184 +423 5,443,501 EURO 30 Malaysia 1,078,646 +113728 8,725 +1151 890,742 WPRO 44 Thailand 578,375 +110668 4,679 +868 381,170 SEARO 16 Mexico 2,810,097 +100358 239,997 +2371 2,192,477 Americas 8 Argentina 4,905,925 +93574 105,113 +2039 4,542,904 Americas 26 Bangladesh 1,226,253 +86053 20,255 +1570 1,050,220 SEARO 17 South Africa 2,422,151 +79821 71,431 +2806 2,194,762 Africa 23 Iraq 1,603,787 +76844 18,533 +432 1,447,160 EMRO 9 Colombia 4,766,829 +74259 120,126 +2290 4,557,829 Americas 60 Cuba 366,985 +58386 2,628 +491 320,242 Americas 94 Vietnam 133,405 +55136 1,022 +652 31,780 WPRO 45 Kazakhstan 564,885 +48768 5,780 +536 467,972 EURO 24 Philippines 1,572,287 +42021 27,577 +686 1,488,437 WPRO 33 Japan 892,293 +39776 15,160 +63 827,372 WPRO 42 Morocco 606,871 +39113 9,697 +180 552,983 EMRO 72 Myanmar 289,333 +35969 8,552 +2419 202,235 SEARO 11 Italy 4,336,906 +34513 128,029 +109 4,130,393 EURO 20 Netherlands 1,859,199 +31926 17,815 +26 1,666,551 EURO 31 Pakistan 1,024,861 +24827 23,295 +356 938,843 EMRO 43 Tunisia 582,638 +24332 19,336 +1284 499,664 EMRO 32 Portugal 963,446 +20202 17,330 +82 894,555 EURO 79 Libya 246,200 +18767 3,469 +147 189,964 EMRO 48 Greece 487,709 +18667 12,911 +60 440,313 EURO 55 Georgia 413,626 +18005 5,768 +132 379,685 EURO 62 Guatemala 362,134 +17913 10,248 +219 316,931 Americas 39 Nepal 690,642 +15916 9,807 +146 650,445 SEARO 27 Belgium 1,122,951 +14276 25,235 +22 1,058,072 EURO 13 Germany 3,772,307 +13901 92,131 +141 3,650,900 EURO 67 Sri Lanka 304,202 +12904 4,324 +365 273,496 SEARO

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101 Zimbabwe 105,656 +12235 3,421 +551 73,394 Africa 34 Israel 869,063 +12077 6,466 +9 847,076 EURO 99 Mozambique 117,660 +11794 1,388 +167 87,256 Africa 84 S. Korea 196,806 +11073 2,089 +23 172,757 WPRO 40 UAE 677,801 +10721 1,939 +29 655,183 EMRO 87 Algeria 168,668 +10455 4,189 +181 113,707 Africa 71 Honduras 294,561 +9186 7,793 +235 99,879 Americas 88 Mongolia 162,869 +9087 809 +48 162,788 WPRO 19 Peru 2,108,595 +9073 196,214 +667 N/A Americas 100 Botswana 106,690 +9033 1,569 +194 95,323 Africa 47 Saudi Arabia 523,397 +8951 8,212 +82 503,827 EMRO 69 Ireland 298,048 +8909 5,035 +9 266,896 EURO 22 Chile 1,613,288 +8575 35,295 +503 1,568,294 Americas 56 Costa Rica 405,206 +7737 5,013 +80 327,249 Americas 113 Rwanda 68,867 +7492 787 +83 44,814 Africa 68 Venezuela 303,797 +6934 3,558 +115 287,720 Americas 70 Oman 295,857 +6815 3,814 +316 278,195 EMRO 53 Panama 433,545 +6696 6,798 +68 414,118 Americas 46 Lebanon 559,473 +6602 7,900 +11 536,805 EMRO 57 Kuwait 396,332 +6464 2,309 +45 381,575 EMRO 36 Jordan 769,390 +6284 10,010 +81 749,676 EMRO 52 Belarus 443,864 +6200 3,434 +69 438,050 EURO 129 Fiji 27,497 +6136 227 +66 6,951 WPRO 89 Kyrgyzstan 161,015 +6010 2,301 +74 141,499 EURO 83 Kenya 201,009 +5898 3,910 +84 188,222 Africa 49 Ecuador 485,673 +5889 31,549 +772 443,880 Americas 50 Bolivia 471,958 +5640 17,784 +208 405,853 Americas 66 Denmark 314,983 +5563 2,548 +6 301,343 EURO 105 Cyprus 100,784 +5477 416 +18 80,178 EURO 97 Uzbekistan 127,506 +5458 859 +45 121,718 EURO 115 Senegal 60,170 +5350 1,318 +62 46,421 Africa 38 Switzerland 716,865 +4988 10,906 +3 691,972 EURO 117 Malawi 51,141 +4724 1,588 +178 37,491 Africa 111 Cambodia 75,917 +4673 1,350 +128 68,386 WPRO 25 Canada 1,429,579 +4482 26,575 +49 1,397,037 Americas 85 Zambia 194,140 +4409 3,355 +159 185,210 Africa 18 Ukraine 2,250,907 +4251 52,916 +126 2,185,849 EURO 103 Ghana 103,019 +3859 823 +8 97,213 Africa 51 Paraguay 451,695 +3831 14,876 +375 417,876 Americas 102 Finland 105,260 +3630 978 0 46,000 EURO 141 Martinique 19,149 +3537 111 +12 104 Non 98 Namibia 117,896 +3496 2,970 +305 94,412 Africa 63 Azerbaijan 342,548 +3274 5,019 +20 332,574 EURO 91 Afghanistan 146,523 +3084 6,677 +320 96,692 EMRO 28 Sweden 1,099,414 +3073 14,618 +3 1,075,469 EURO 135 Eswatini 24,848 +2968 772 +37 20,476 Africa

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41 Austria 658,004 +2807 10,737 +7 642,229 EURO 123 Réunion 37,231 +2616 275 +9 33,894 Non 86 Nigeria 172,821 +2515 2,141 +11 164,930 Africa 64 Dominican Republic 341,179 +2277 3,956 +25 317,127 Americas 119 DRC 49,251 +2077 1,023 +2 29,497 Africa 106 Uganda 93,282 +1927 2,632 +149 81,014 Africa 108 El Salvador 86,059 +1915 2,599 +70 76,056 Americas 93 Norway 137,127 +1892 799 0 88,952 EURO 134 Mauritania 25,063 +1840 553 +36 21,985 Africa 37 Serbia 721,267 +1805 7,110 +15 710,372 EURO 74 Lithuania 282,039 +1743 4,413 +5 268,947 EURO 139 Guadeloupe 19,503 +1724 242 +4 2,250 Non 172 Laos 5,675 +1556 6 +1 2,691 WPRO 75 Ethiopia 279,629 +1524 4,381 +18 263,392 Africa 80 Armenia 229,603 +1442 4,604 +29 219,502 EURO 122 Trinidad and Tobago 38,247 +1363 1,057 +39 31,341 Americas 126 Australia 33,909 +1321 923 +7 29,926 WPRO 21 Czechia 1,673,219 +1286 30,363 +16 1,639,849 EURO 59 Uruguay 381,187 +1276 5,953 +40 373,007 Americas 179 Isle of Man 4,525 +1101 29 0 2,732 Non 61 Croatia 363,227 +1098 8,250 +5 353,901 EURO 54 Bulgaria 424,526 +1086 18,208 +19 398,436 EURO 121 Angola 42,486 +1081 1,003 +26 36,025 Africa 81 Qatar 225,905 +1071 601 +1 223,494 EMRO 116 Jamaica 52,504 +962 1,182 +15 46,938 Americas 95 Estonia 133,111 +932 1,272 +1 128,698 EURO 114 Singapore 64,722 +931 37 +1 62,679 WPRO 29 Romania 1,082,880 +927 34,275 +11 1,047,528 EURO 125 Malta 34,090 +892 423 +3 31,211 EURO 162 Channel Islands 9,127 +887 86 0 6,277 Non 169 Burundi 6,865 +847 9 +1 773 Africa 77 Moldova 259,202 +837 6,253 +17 251,850 EURO 15 Poland 2,882,630 +790 75,257 +26 2,653,529 EURO 104 Montenegro 101,642 +777 1,629 +5 98,917 EURO 150 Bahamas 14,545 +764 286 +12 12,549 Americas 76 Bahrain 268,974 +749 1,384 +3 266,635 EMRO 110 Maldives 77,202 +748 220 +2 74,429 SEARO 183 Mauritius 3,913 +732 19 0 1,854 Africa 145 Togo 15,522 +721 150 +10 14,338 Africa 166 Iceland 7,676 +709 30 0 6,680 EURO 133 Suriname 25,218 +645 643 +17 21,527 Americas 138 French Polynesia 19,875 +641 148 +3 19,206 Non 136 Guyana 22,372 +639 535 +20 20,974 Americas 128 French Guiana 30,040 +621 185 +15 9,995 Non 65 Palestine 316,487 +611 3,601 +10 311,714 EMRO 131 Guinea 25,401 +578 211 +16 24,071 Africa

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147 Tajikistan 14,929 +570 121 +5 14,389 EURO 165 Gambia 7,709 +548 212 +15 6,600 Africa 118 Ivory Coast 49,911 +525 326 +2 49,117 Africa 197 Tanzania 1,017 +508 21 0 183 Africa 112 Luxembourg 73,816 +507 822 +1 71,744 EURO 78 Slovenia 258,963 +495 4,428 +2 253,619 EURO 160 Timor-Leste 10,695 +468 26 0 9,802 SEARO 153 Curaçao 13,493 +455 126 0 12,715 Non 142 Seychelles 18,189 +442 94 +5 17,538 Africa 107 China 92,875 +413 4,636 0 87,307 WPRO 35 Hungary 809,427 +411 30,025 +5 747,512 EURO 92 Latvia 138,717 +373 2,554 +4 135,463 EURO 161 Nicaragua 9,470 +362 195 +1 4,225 Americas 137 Haiti 20,116 +354 552 +29 14,042 Americas 58 Slovakia 392,537 +318 12,536 +2 379,464 EURO 158 Aruba 11,584 +291 110 +1 11,125 Non 190 British Virgin Islands 2,500 +290 31 +8 1,914 Non 180 Guinea-Bissau 4,387 +270 74 0 3,872 Africa 127 Cabo Verde 33,721 +269 298 +1 32,935 Africa 73 Egypt 284,170 +264 16,514 +44 229,167 EMRO 90 North Macedonia 156,225 +244 5,491 +2 150,333 EURO 155 Lesotho 12,908 +229 374 +17 6,649 Africa Bosnia and 82 205,610 +226 9,686 +13 189,348 EURO Herzegovina 151 Belize 14,114 +221 337 +5 13,349 Americas 96 Albania 132,999 +202 2,457 +1 130,187 EURO 146 Somalia 15,358 +196 809 +28 7,498 EMRO 178 Gibraltar 4,922 +194 94 0 4,471 Non 109 Cameroon 82,064 +193 1,334 +2 80,433 Africa 148 Andorra 14,655 +191 127 0 14,180 EURO 144 Taiwan 15,637 +126 787 +5 14,053 WPRO 186 Monaco 2,853 +109 33 0 2,685 EURO 154 Congo 13,156 +106 177 +1 11,759 Africa 159 South Sudan 11,014 +97 118 +1 10,514 Africa 143 Papua New Guinea 17,673 +92 192 0 17,274 WPRO 130 Syria 25,942 +89 1,912 +7 21,974 EMRO 120 Madagascar 42,645 +84 942 +5 41,109 Africa 174 Saint Lucia 5,567 +71 88 +1 5,354 Americas 164 Benin 8,394 +70 108 +1 8,136 Africa 170 Eritrea 6,544 +64 34 +2 6,416 Africa 171 Sierra Leone 6,268 +62 120 +3 4,258 Africa 187 Sint Maarten 2,760 +62 34 0 2,648 Non 132 Gabon 25,370 +61 163 0 25,143 Africa 189 Bhutan 2,506 +48 2 0 2,353 SEARO 181 Barbados 4,365 +46 48 0 4,167 Americas 168 Yemen 7,042 +41 1,374 +2 4,171 EMRO

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149 Mali 14,566 +39 531 +1 13,939 Africa 208 Greenland 117 +33 0 0 78 Non 163 Equatorial Guinea 8,880 +32 123 0 8,637 Africa 176 San Marino 5,130 +31 90 0 5,005 EURO 152 Burkina Faso 13,566 +29 169 0 13,363 Africa 199 Faeroe Islands 980 +22 1 0 918 Non 202 Saint Kitts and Nevis 582 +22 3 0 537 Americas 204 Brunei 333 +22 3 0 270 WPRO 157 Djibouti 11,649 +21 155 0 11,483 EMRO 192 Turks and Caicos 2,479 +20 18 0 2,431 Non 188 Bermuda 2,553 +18 33 0 2,495 Non 196 Antigua and Barbuda 1,295 +18 43 +1 1,235 Americas 194 St. Vincent Grenadines 2,288 +17 12 0 2,210 Americas 185 New Zealand 2,870 +15 26 0 2,799 WPRO 193 Sao Tome and Principe 2,432 +15 37 0 2,353 Africa 195 Caribbean Netherlands 1,705 +15 17 0 1,661 Non 140 Mayotte 19,474 +14 174 0 2,964 Non 173 Niger 5,607 +13 195 0 5,330 Africa 201 Cayman Islands 640 +13 2 0 628 Non 184 Liechtenstein 3,085 +12 59 0 3,005 Non 156 Hong Kong 11,983 +11 212 0 11,709 WPRO 182 Comoros 4,025 +11 147 0 3,864 Africa 177 Chad 4,972 +7 174 0 4,789 Africa 167 CAR 7,151 +4 98 0 6,859 Africa 211 Macao 59 +3 0 0 53 WPRO 207 New Caledonia 133 +2 0 0 58 Non 212 Saint Pierre Miquelon 28 +2 0 0 26 Non 205 Dominica 210 +1 0 0 200 Americas 124 Sudan 37,138 0 2,776 0 30,867 EMRO 175 Liberia 5,396 0 148 0 2,715 Africa 191 Saint Martin 2,481 0 38 0 1,399 Non 198 St. Barth 1,005 0 1 0 462 Non 200 Diamond Princess 712 0 13 0 699 NA 203 Wallis and Futuna 445 0 7 0 438 Non 206 Grenada 164 0 1 0 161 Americas 209 Anguilla 113 0 0 0 111 Non 210 Falkland Islands 63 0 0 0 63 Non 213 Vatican City 27 0 0 0 27 Non 214 Montserrat 21 0 1 0 19 Non 215 Solomon Islands 20 0 0 0 20 WPRO 216 Western Sahara 10 0 1 0 8 Non 217 MS Zaandam 9 0 2 0 7 NA 218 Vanuatu 4 0 1 0 3 WPRO 219 Marshall Islands 4 0 0 0 4 WPRO 220 Samoa 3 0 0 0 3 WPRO 221 Saint Helena 2 0 0 0 2 Non

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 474. 30 July 2021

222 Micronesia 1 0 0 0 1 WPRO Total 197,381,922 +3957949 4,214,877 +63178 176,813,076

Figure 4. Areas with reported confirmed cases of COVID-19 (19 – 25 July 2021)

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

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

For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 474. 30 July 2021

Table 5. COVID-19 cases and deaths reported by states/UT in India between 24-30 July, 2021 (Updated as of 30 July 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 7534 +9 10 -9 7395 +18 129 0 Nicobar Islands Andhra 1962049 +13457 21279 -2292 1927438 +15626 13332 +123 Pradesh Arunachal 47477 +2769 4252 -146 43000 +2898 225 +17 Pradesh Assam 564030 +9809 14114 -2091 544695 +11755 5221 +145 Bihar 724719 +489 481 -116 714596 +598 9642 +7 Chandigarh 61948 +32 37 +3 61102 +29 809 0 Chhattisgarh 1001781 +1018 2086 -1155 986175 +2160 13520 +13 Dadra and 10643 +19 36 0 10603 +19 4 0 Nagar Haveli and Daman and Diu Delhi 1436144 +424 554 -31 1410541 +446 25049 +9 Goa 170900 +701 1077 -299 166679 +979 3144 +21 Gujarat 824829 +221 268 -102 814485 +323 10076 0 Haryana 769858 +193 712 -53 759516 +229 9630 +17 Himachal 205728 +928 1098 +163 201110 +754 3520 +11 Pradesh Jammu and 321207 +867 1144 -369 315686 +1232 4377 +4 Kashmir Jharkhand 347105 +259 259 -46 341720 +301 5126 +4 Karnataka 2901247 +11253 23277 -1441 2841479 +12496 36491 +198 Kerala 3349365 +131350 155327 +25946 3177453 +104558 16585 +846 Ladakh 20324 +40 60 -23 20057 +62 207 +1 Lakshadweep 10162 +62 70 +3 10042 +58 50 +1 Madhya 791796 +75 130 -55 781153 +129 10513 +1 Pradesh Maharashtra 6290156 +45099 81933 -15580 6075888 +59382 132335 +1297 Manipur 96824 +7846 10895 +500 84408 +7261 1521 +85 Meghalaya 63745 +4399 5750 +1337 56933 +2988 1062 +74 Mizoram 37171 +6679 11862 +4118 25168 +2551 141 +10 Nagaland 27653 +629 1299 +62 25798 +547 556 +20 Odisha 974132 +12198 15276 -2190 953088 +13928 5768 +460 Puducherry 120725 +722 972 +17 117961 +696 1792 +9 Punjab 599005 +415 553 -258 582162 +633 16290 +40 Rajasthan 953622 +160 259 -101 944410 +260 8953 +1 Sikkim 26132 +1791 3297 +578 22498 +1204 337 +9 Tamil Nadu 2555664 +12624 21207 -4319 2500434 +16758 34023 +185

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 474. 30 July 2021

Telangana 643716 +4347 9188 -669 630732 +4994 3796 +22 Tripura 78059 +2451 3640 -611 73665 +3042 754 +20 Uttarakhand 341982 +353 669 +20 333952 +331 7361 +2 Uttar Pradesh 1708373 +316 784 -244 1684834 +548 22755 +12 West Bengal 1526539 +5278 11300 -905 1497116 +6100 18123 +83 Total 31572344 +31529240 405155 +401274 30743972 +30705232 423217 +422734 Source: https://www.mohfw.gov.in/

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

For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 474. 30 July 2021

iv. Travel Bans/Advisories & Quarantine Orders

[1] Austria – The country announced on 27 July 2021 that all arrivals, including returning citizens, from Spain, the Netherlands and Cyprus are to present a negative PCR test to enter the country. [2] Belgium – From 29 July 2021, all citizens arriving from a very high-risk area are no longer exemptef from quarantine upon arrival, regardless of their vaccination status and occupation. Exceptions to the quarantine rule for citizens returning from these areas will only apply to those travelling for an essential or professional reason. [3] Cambodia – Land borders with Thailand will be closed from 29 July until 12 August 2021, except for transporting goods and emergencies. [4] Czech Republic – From 26 July 2021, travellers arriving from Ireland, Monaco, Greece, Netherlands and Spain (including the Balearic Islands) will have to undego testing and quarantine upon arriving in the country, unless they have proof of full vaccination or recovery from a recent infection. [5] Denmark – Non-fully vaccinated arrivals from Belgium, France and certain areas of Greece have been moved into the yellow category of countries from 26 July 2021, and hence are to follow entry rules, such as testing requirements to enter the country. Denmark has also advised citizens against non-essential travel to Finland despite quarantine-free arrival for fully vaccinated citizens. [6] France – Fully vaccinated travelers arriving from India will be allowed to enter the country from 28 July 2021, so long they fulfil the requirements such as being vaccinated with one of the approved or yet to be approved vaccines for at least 7 days, or holding on to a ‘talent passport’ or is a student or researcher. [7] Germany – From 28 July 2021, travelers vaccinated with a vaccine listed as “effective” by the Rober Koch Institute will be exempted from quarantine upon arrival, if they are able to submit their proof of vaccination. However, all travelers, regardless of arriving via land or air, are still required to produce a negative test result to enter the country; the latest quarantine regulations will last until at least 10 September 2021. [8] Iceland – From 27 July 2021, all arriving travelers aged above 16 years old are to present a negative PCR or rapid antigen test result taken within 72 hours from arrival to enter the country, even if they are vaccinated or recovered from a recent infection. [9] Japan – Fully vaccinated travelers who departing from Japan for Italy, Austria, Turkey, Bulgaria, Poland and South Korea will be exempted from quarantine upon arrival if they are holding on the the Japanese COVID-19 vaccine certificate. [10] Kuwait – Unvaccinated or not fully vaccinated citizens, except those under 16 years old, are pregnant or have prior approval will be banned from outbound travel from 1 August 2021. [11,12] Netherlands – Outbound travel to all European Union countries will be allowed from 27 July 2021, with a negative advice only issued to countries with new virus variants not yet widespread in the Netherlands. Inbound travel from citizens from countries in the EEA and Schengen Zone, who are fully vaccinated for at least 14 days will also be allowed from 27 July 2021, except those from very high-risk areas. Travellers aged above 12 years old will have to provide a negative test result from 8 August 2021, when returning from an EU country deemed to have a higher risk of infection.

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

For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 474. 30 July 2021

[13] Norway – Eased travel restrictions from 26 July 2021 to allow entry of children travelling with parents who are holders of the EU digital COVID-19 Vaccination Certificate, and family members of Norwegian citizens. [14] Saudi Arabia – Citizens were warned from travelling to areas on Saudi Arabia’s list of blacklisted COVID-19 countries, as they will face a 3-year travel ban upon return. [15] Slovenia – Cross border workers not holding on to a EU Digital COVID-19 Passport, but are employed in an EU Member State ot Schengen Area country, reside within 10km from the shared border of Slovenia and another neighbouring country, and return to Slovenia within 5 days of crossing the border, will be allowed to enter the country freely without restrictions from 23 July 2021, until 15 August 2021 (or latest until 1 September 2021). [16] South Korea – The quarantine-free travel bubble with Saipan commenced on 24 July 2021. [17] United Arab Emirates – Extension of travel ban for inbound flights from 16 countries, including Afghanistan, Bangladesh, the Democratic Republic of Congo, Indonesia, India, Liberia, Namibia, Nepal, Nigeria, Pakistan, Uganda, Sierra Leone, South Africa, Sri Lanka, Vietnam, and Zambia, with no end date for the travel ban specified. [18] United Kingdom – From 2 August 2021, travelers arriving from the United States and Europe, except for France, who were fully vaccinated with an approved vaccine by the US FDA or the European Medicines Agency will be able to enter England, Northern Ireland and Scotland with pre and post-arrival coronavirus test results, without quarantine requirements. [19, 20] United States – Travel alert for Israel was raised to Level 3 on 26 July 2021, due to concerns about high COVID-19 infection rates in the country. Travel advisories against Spain, Portugal, Cyprus and Kyrgyzstan were also released on 27 July 2021. As of 26 July 2021, United States will keep existing travel restrictions on international travel in place.

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 474. 30 July 2021 v. Lockdowns

[1-3] Australia – Lockdown in Victoria and South Australia ended on 28 July 2021, reinstating all travel and retail businesses within the state but household visits in Victoria remained banned for another 14 days, until 10 August 2021. Masking remains mandatory in all settings outside the home, unless an exemption applies. However, the lockdown in Sydney was extended for 4 weeks, until 28 August 2021. [4] Cambodia – A lockdown of the 8 provinces bordering Thailand will commence from 29 July 2021 until 12 August 2021. The 8 provinces involved are Koh Kong, Pursat, Battambang, Pailin, Banteay Meanchey, Oddar Meanchey, Preah Vihear and Siem Reap. The lockdown will ban business operations, except those involved in operating airlines, and ban people from leaving their homes or gathering in groups. [5] Cambodia – From 29 July to 12 August 2021, a daily 9pm to 3 am cufew will be reimposed in Phnom Penh and all provincial capitals. [6] Canada – Enhanced restrictions in Central Okanagan from 29 July 2021 include travel advisories against non-essential travel to Kelowna, West Kelowna, Peachland and Lake County for individuals not fully vaccinated, mandatory masking in indoor spaces and enforcement of safety guidelines in workplaces and retail spaces. [7] China – Schools, businesses and all travel into and out of Jiangcheng County in Yunnan province will be suspended from 26 to 27 July as nuclic acid testing are being performed through the county. [8] China – Nanjing has restricted travel into and out of the city as entry and exit restrictions on residents were strengthened, land chekcpoints have been set-up and the airport suspended all flights until mid-August. Some public transport has been suspended and all taxis and rideshare drivers have been instructed to stay within the city. [9] India (Goa) – Statewide curfew extended until 7am, 2 August 2021. [10] India (Manipur) – The lockdown will be extended until 3 August 2021, but with relaxations including the opening of insurance offices such as banks for 3 days from 10 am to 2.30 pm, and the delivery of cooked food and grocery items to homes. [11] India (Kerala) – A 2-day weekend lockdown will be imposed statewide from 21 July 2021 to 1 August 2021. [12] Netherlands – Large scale or multiple-day festivals will be banned for the entire August 2021. [13] Oman – The daily curfew of 10 pm to 4 am, where movement and commercial activities have to be restricted, will be extended until further notice. [14] Pakistan – From 1 August 2021, a vaccination certificate will be required for domestic air travel within Pakistan. In addition, unvaccinated citizens will be not allowed to enter government offices, schools, restaurants and shopping malls from 1 August 2021. [15] Portugal – From 31 July 2021, eased restrictions will lift the daily 11pm to 5am curfew, restrictions on operating hours of retail shops and restaurants, and allow on-site working although remote working is still recommended. Fans can also attend sporting events under certain conditions. The next wave of eased restrictions to allow non-mandatory masking in small- to medium-sized gatherings held outdoors is expected to be released in September, when 70% of the population is fully to vaccinated.

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

For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 474. 30 July 2021

[16] Rwanda – Lockdown for the capital Kigali, and eight other districts extended for five days from 27 July 2021. [17] South Africa – Eased restrictions on gatherings, school reopenings, domestic travel and alcohol sales will come into effect from 26 July 2021, but nighttime curfew and mandatory masking regulations remains active. [18] South Korea – From 27 July 2021, social distancing rules will be increased to Level 3 for 2 weeks across most non-capital areas nationwide, except in some small counties. The tightened rules include a 10 pm dining curfew and limiting social gatherings at 4 people. [19] United States (Chicago) – Alabama, Alaska, Arizona, Kansas, Mississippi, Oklahoma, Tennessee, Texas, and Wyoming were all added to the city's "orange" list on 28 July 2021. This brings the total areas included in the list to 14 states and 1 territory. All unvaccinated arrivals from these areas are "advised" to either get tested for COVID-19 within 72 hours or quarantine for 10 days upon arrival. [20] Vietnam – Daily overnight curfew from 6pm to 6am will be imposed in Ho Chi Minh city from 26 July 2021 until 1 August 2021. [21] Vietnam - A 15-day lockdown has been imposed in Hanoi from 24 July 2021 will limit all public gatherings at 2 people and allow government offices, hospitals and essential businesses to stat open.

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

For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 474. 30 July 2021

vi. Military Surveillance

[1-8] South Korea – A total of 17 new cases were reported between 24 to 30 July 2021, of which one case was linked to the Cheonghae unit cluster. This brings the total caseload in the unit to 272 out of the 301 members in the unit, of which 261 cases have recovered as of 29 July 2021. Remaining 29 members of the unit who tested negative have been quarantined and a Navy facility and will undergo another round of testing before exiting quarantine on 3 August 2021.

Remaining cases unlinked to the cluster were reported from 11 service members and 5 employees from various bases. This includes trainees from an Army boot camp (3 cases) and a soldier in Nonsan, an Army officer and an soldier from Paju, a draftee of an Bupyeong Army unit (after returning from vacation to Cheongju), a conscript of a Jinhae Navy unit, a soldier from Siheung , a Navy officer from Changwon and four civilian officers respectively in Daegu (Air Force), Seoul, Yangju and Hongcheon. This brings the total number of cases in military personnel to 1,498 cases, as of 30 July 2021. The defense ministry has extended the strictest social distancing rules for military personnel, restricting service members’ vacations and off-installation activities from 26 July to 8 August 2021 to control the infections.

[9, 10] United States Forces Korea – A total of 17 cases, including 9 service members from Camp Casey (2 cases), Osan Air Base (3 cases) and new arrivals from US (4 cases), were reported between 14 July and 29 July 2021. Remaining cases were family members of a Department of Defense employee (4 cases), dependents of service members in Osan and Camp Carroll (2 cases), and a DoD civilian at K-16 Air Base in Seongnam who were all infected following contact with previous cases locally, except for a family member of a USFK contractor who just arrived from the US (1 case). This brings the total number of infections reported among the USFK-affiliated population to 1,136 as of 29 July 2021.

[11, 12] United States Forces Japan – A total of 23 cases were reported across bases in Japan from 26 July to 27 July 2021. Cases were reported from Naval Air Facility Atsugi (2 cases), Yokosuka Naval Base (9 cases), Marine Corps Air Station Iwakuni (1 case), Sasebo Naval Base (1 case) and the Marine Corps on Okinawa (10 cases). As of 23 July 2021, a total of 103 active COVID-19 cases were reported, of which 32 cases were from Kadena Air Base, 46 cases from 5 bases on Okinawa and 12 cases from Marine Corps Air Station Iwakuni.

[13-16] United States – A outbreak involving at least 115 cases was reported from Fort Polk, Louisiana on 28 July 2021. The outbreak originated from an ongoing National Guard training exercise, from early July 2021, which will last for approximately another week. Most cases involve soldiers from the Arkansas Guard's 39th Infantry Brigade Combat Team, but a personnel at Fort Polk and other units facilitating the training have also reported cases. There are currently no hospitalisations from the cases, and at least 9 building have been set aside for quarantining the cases and those awaiting test results from th lab on base.

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 474. 30 July 2021

Overall, a total of 312,892 cases and 373 associated deaths were reported across the entire Defense Department, of which most cases were reported from the military (208,603 cases) and most deaths were from civilians (244 deaths), as of 28 July 2021. The latest deaths were respectively reported from 2 Navy sailors on 23 July and 26 July 2021, whose deaths were attributed to COVID-19 associated complications. The number of active infections (21 cases) as of 26 July 2021, has declined from the peak of 240 active infections on 8 January 2021, to its lowest since the earliest days of the pandemic.

vii. WHO Guidance & Other Protocols

There are no updates published by the WHO from 24 July – 30 July:

• Guidance on conducting vaccine effectiveness evaluations in the setting of new SARS-CoV-2 variants: Interim guidance, 22 July 2021. Addendum to Evaluation of COVID-19 vaccine effectiveness Available at: https://www.who.int/publications/i/item/WHO-2019-nCoV-vaccine_effectiveness- variants-2021.1

viii. CDC Guidance & Protocols

US CDC

The following updates were published by the US CDC from 24 July – 30 July:

• Guidance for Implementing COVID-19 Prevention Strategies in the Context of Varying Community Transmission Levels and Vaccination Coverage Available at: https://www.cdc.gov/mmwr/volumes/70/wr/mm7030e2.htm • Science Brief: COVID-19 Vaccines and Vaccination Available at: https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/fully- vaccinated-people.html

EU CDC

The following updates were published by the EU CDC from 24 July – 30 July:

• Rapid Risk Assessment: COVID-19 outbreaks in long-term care facilities in the EU/EEA in the context of current vaccination coverage Available at: https://www.ecdc.europa.eu/en/publications-data/rapid-risk-assessment-covid-19- outbreaks-long-term-care-facilities-eueea

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 474. 30 July 2021

ix. Vaccines/Therapeutics Development

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

Vaccines

[1] Global – The European Medicines Agency authorized the Moderna’s COVID-19 vaccine for use in childred aged 12 years and older on 23 July 2021. The European Commission’s approval for vaccine use in this age group is currently pending approval, following the EMA’s recommendation. [2] Global – The ongoing, placebo-controlled, observer-blinded, multinational, pivotal efficacy study of the Pfizer BNT162b2 vaccine involving 44,165 ≥16-year-old participants and 2,264 12 to 15- year-old participants. Most of the 152 recruitment sites were in the United States (130), followed by Turkey (9), Germany (6), and South Africa (4). At up to 6-months follow-up, the study demonstrated a overall vaccine efficacy of 91% (95% CI: 89-93.2%), regardless of previous COVID- 19 infection, and 97% efficacy (95% CI 80.3‒99.9) against severe disease. Vaccine efficacy of 86%‒ 100% was seen across countries and in populations with diverse characteristics of age, sex, race/ethnicity, and COVID-19 risk factors in participants without evidence of previous SARS-CoV- 2 infection. [3] Russia – A trial of a combined Astrazeneca/Sputnik V vaccine was approved on 27 July 2021. The trial will combine the first shot of the Sputnik Light vaccine with a shot each from the Astrazeneca vaccine. [4] Tanzania – Mass vaccination drive with the single-shot Johnson and Johnson COVID-19 vaccine has commenced on 28 July 2021. [5] Zimbabwe – Zimbabwe approved the Johnson and Johnson COVID-19 vaccine for emergency use in the country on 28 July 2021.

Therapeutics

[6] Japan – Phase 1 trials for S-217622, an orally administered 3CL protease inhibitor for treating COVID-19 by Shionogi & Co. Ltd. commenced on 27 July 2021.

Vaccine Approval Status

Table 6: Number of approving countries per vaccine as of 26 July 2021 Number of countries Developer Vaccine approving Anhui Zhifei Longcom RBD-Dimer 2 Bharat Biotech Covaxin 9 CanSino Ad5-nCoV 8

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 474. 30 July 2021

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 56 Kazakhstan RIBSP QazVac 1 Medigen MVC-COV1901 1 Minhai Biotechnology Co SARS-CoV-2 Vaccine (Vero Cells) 1 Moderna mRNA-1273 64 Oxford/AstraZeneca AZD1222 119 BioNTech/Pfizer BNT162b2 97 Serum Institute of India Covishield 46 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] China – A total of 623 AEFIs were reported from the 7.12 million doses (87.5 events per million doses) of Sinovac vaccine administered in Dalian from 27 November 2020 to 8 June 2021. Among the 623 reported AEFIs, 544 reports were minor and 7 reports were classified as serious AEFIs. Of the serious AEFIs, only 5 cases were anaphylaxis reactions (0.7 per 1 million doses) and none were associated with COVID-19 vaccination. Age-specific rates of AEFIs ranged from 74.0 per million doses among persons aged 45 to 59 years, to 102.0 per million doses among persons aged 18 to 44 years. [2] Taiwan – A total of 23 very serious AEFIs and 95 serious AEFIs were reported from the 282,991 people vaccinated between 23 and 25 July 2021. Fifteen of the fatalities (6 males and 9 females aged between 26 to 95 years old) had received the Astrazeneca vaccine and died 1 to 45 days after vaccination. The remaining 8 fatalities died between 2 and 21 days after receiving the Moderna vaccine, and were 4 males and 4 females aged between 64 and 89 years old. As of 26 July 2021, a total of 507 deaths involving 241 females and 266 males following vaccination were reported in Taiwan, of which 444 received the Atrazeneca vaccine and the remaining received the Moderna vaccine. [3] United States – A total of 699 reports of myocarditis or pericarditis were confirmed to be related to COVID-19 vaccination, of 1,194 reports received among people ages 30 and younger who received a COVID-19 vaccine between 14 December 2020 and 26 July 2021.. Most cases have been reported after mRNA COVID-19 vaccination (Pfizer-BioNTech or Moderna), particularly in male adolescents and young adults.

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

For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 474. 30 July 2021

x. Scientific Publications with Epidemiology and Clinical Focus

Impact of tiered restrictions on human activities and the epidemiology of the second wave of COVID-19 in Italy [1]

To counter the second COVID-19 wave in autumn 2020, the Italian government introduced a system of physical distancing measures organized in progressively restrictive tiers (coded as yellow, orange, and red) imposed on a regional basis according to real-time epidemiological risk assessments. We leverage the data from the Italian COVID-19 integrated surveillance system and publicly available mobility data to evaluate the impact of the three-tiered regional restriction system on human activities, SARS-CoV-2 transmissibility and hospitalization burden in Italy. The individuals' attendance to locations outside the residential settings was progressively reduced with tiers, but less than during the national lockdown against the first COVID-19 wave in the spring. The reproduction number R(t) decreased below the epidemic threshold in 85 out of 107 provinces after the introduction of the tier system, reaching average values of about 0.95-1.02 in the yellow tier, 0.80-0.93 in the orange tier and 0.74-0.83 in the red tier. We estimate that the reduced transmissibility resulted in averting about 36% of the hospitalizations between November 6 and November 25, 2020. These results are instrumental to inform public health efforts aimed at preventing future resurgence of cases.

Infant outcomes and maternal COVID-19 status at delivery [2]

Objectives: To compare clinical characteristics and outcomes of infants born to COVID-19 to non COVID- 19 mothers at delivery in a community hospital in Queens, New York.

Methods: Case-control study conducted March 15 to June 15, 2020. Cases were infants born to mothers with laboratory-confirmed COVID-19 infection at delivery. The infant of non COVID-19 mother born before and after each case were selected as controls.

Results: Of 695 deliveries, 62 (8.9%) infants were born to COVID-19 mothers; 124 controls were selected. Among cases, 18.3% were preterm compared to 8.1% in controls (p=0.04). In preterm cases, birth weight was not significantly different between groups. However, there was a significantly higher proportion of neonatal intensive care unit (NICU) admissions, need for respiratory support, suspected sepsis, hyperbilirubinemia, feeding intolerance and longer length of stay (LOS) in preterm cases. Among term cases, birth weight and adverse outcomes were not significantly different between cases and controls except for more feeding intolerance in cases. All infants born to COVID-19 mothers were COVID-19 negative at 24 and 48 h of life. No infants expired during birth hospitalization.

Conclusions: Significantly, more infants of COVID-19 mothers were premature compared to controls. Preterm cases were more likely to have adverse outcomes despite having similar birth weight and gestational age. These differences were not seen among full term infants. Health care providers should anticipate the need for NICU care when a COVID-19 mother presents in labor.

25 | 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 474. 30 July 2021

COVID-19 false dichotomies and a comprehensive review of the evidence regarding public health, COVID-19 symptomatology, SARS-CoV-2 transmission, mask wearing, and reinfection [3]

Scientists across disciplines, policymakers, and journalists have voiced frustration at the unprecedented polarization and misinformation around coronavirus disease 2019 (COVID-19) pandemic. Several false dichotomies have been used to polarize debates while oversimplifying complex issues. In this comprehensive narrative review, we deconstruct six common COVID-19 false dichotomies, address the evidence on these topics, identify insights relevant to effective pandemic responses, and highlight knowledge gaps and uncertainties. The topics of this review are: 1) Health and lives vs. economy and livelihoods, 2) Indefinite lockdown vs. unlimited reopening, 3) Symptomatic vs. asymptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, 4) Droplet vs. aerosol transmission of SARS-CoV-2, 5) Masks for all vs. no masking, and 6) SARS-CoV-2 reinfection vs. no reinfection. We discuss the importance of multidisciplinary integration (health, social, and physical sciences), multilayered approaches to reducing risk ("Emmentaler cheese model"), harm reduction, smart masking, relaxation of interventions, and context-sensitive policymaking for COVID-19 response plans. We also address the challenges in understanding the broad clinical presentation of COVID-19, SARS-CoV-2 transmission, and SARS-CoV-2 reinfection. These key issues of science and public health policy have been presented as false dichotomies during the pandemic. However, they are hardly binary, simple, or uniform, and therefore should not be framed as polar extremes. We urge a nuanced understanding of the science and caution against black-or-white messaging, all-or-nothing guidance, and one-size-fits-all approaches. There is a need for meaningful public health communication and science-informed policies that recognize shades of gray, uncertainties, local context, and social determinants of health.

Integrative genomic analyses identify susceptibility genes underlying COVID-19 hospitalization [4]

Despite rapid progress in characterizing the role of host genetics in SARS-Cov-2 infection, there is limited understanding of genes and pathways that contribute to COVID-19. Here, we integrate a genome-wide association study of COVID-19 hospitalization (7,885 cases and 961,804 controls from COVID-19 Host Genetics Initiative) with mRNA expression, splicing, and protein levels (n = 18,502). We identify 27 genes related to inflammation and coagulation pathways whose genetically predicted expression was associated with COVID-19 hospitalization. We functionally characterize the 27 genes using phenome- and laboratory-wide association scans in Vanderbilt Biobank (n = 85,460) and identified coagulation- related clinical symptoms, immunologic, and blood-cell-related biomarkers. We replicate these findings across trans-ethnic studies and observed consistent effects in individuals of diverse ancestral backgrounds in Vanderbilt Biobank, pan-UK Biobank, and Biobank Japan. Our study highlights and reconfirms putative causal genes impacting COVID-19 severity and symptomology through the host inflammatory response.

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 474. 30 July 2021

xi. Sources

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 474. 30 July 2021

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Lockdowns Refer to Situation Report 91 for all updates before 1st May 2020 1. https://www.abc.net.au/news/2021-07-27/victoria-new-local-covid-cases-lockdown-restrictions- ease/100325504 2. https://www.abc.net.au/news/2021-07-26/what-restrictions-will-remain-when-sa-covid-19- lockdown-ends/100323482

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 474. 30 July 2021

3. https://www.channelnewsasia.com/news/world/australia-new-south-wales-sydney-covid-19- lockdown-extended-15313964 4. https://www.channelnewsasia.com/news/asia/cambodia-to-impose-covid-19-lockdowns-in-areas- bordering-thailand-15325332 5. https://www.khmertimeskh.com/50904327/damage-control-curfews-reimposed-to-stem-delta- variant-spread/ 6. https://thetyee.ca/News/2021/07/28/Mask-Rules-Travel-Restrictions-Return-Central-Okanagan/ 7. https://qconline.com/news/local/govt-and-politics/the-latest-vietnam-virus-surge-leads-to-hanoi- lockdown/article_c809657c-59ea-54b6-9e6a-55092b038094.html 8. https://www.theguardian.com/world/2021/jul/29/city-of-nanjing-isolated-as-china-fights-worst- covid-outbreak-in-months 9. https://www.hindustantimes.com/india-news/breaking-news-updates-july-25-2021- 101627172892457.html 10. https://www.financialexpress.com/lifestyle/health/coronavirus-in-india-latest-update-live-kerala- covid-19-surge-ignites-fear-of-third-wave/2297582/ 11. https://www.ndtv.com/india-news/coronavirus-complete-lockdown-in-kerala-on-saturday-sunday- amid-rising-cases-of-covid-19-2497435 12. https://www.reuters.com/article/health-coronavirus-netherlands-idUSL8N2P246Z 13. https://www.khaleejtimes.com/coronavirus-pandemic/covid-19-oman-extends-night-curfew-to- curb-virus-spread 14. https://www.business-standard.com/article/current-affairs/covid-19-pakistan-to-ban-education- malls-air-travel-for-unvaccinated-121073000040_1.html 15. https://www.channelnewsasia.com/news/world/portugal-lifts-night-time-curfew-as-covid-19- vaccination-speeds-up-15331210 16. https://africa.cgtn.com/2021/07/25/rwandas-government-announces-five-day-extension-of-covid- 19-lockdown/ 17. https://www.straitstimes.com/world/safrica-has-largely-passed-peak-of-third-virus-wave-president 18. https://www.reuters.com/world/asia-pacific/south-korea-steps-up-covid-19-curbs-ahead-peak- holiday-season-2021-07-25/ 19. https://cbs12.com/news/local/unvaccinated-florida-travelers-to-chicago-urged-to-test-negative-or- quarantine 20. https://sg.news.yahoo.com/vietnams-economic-hub-imposes-night-061653511.html 21. https://qconline.com/news/local/govt-and-politics/the-latest-vietnam-virus-surge-leads-to-hanoi- lockdown/article_c809657c-59ea-54b6-9e6a-55092b038094.html

Military Surveillance 1. https://en.yna.co.kr/view/AEN20210725003251325 2. https://en.yna.co.kr/view/AEN20210726005300315?section=national/politics 3. https://en.yna.co.kr/view/AEN20210726004851325?section=search 4. https://en.yna.co.kr/view/AEN20210724001800325?section=search 5. https://en.yna.co.kr/view/AEN20210728005500325 6. https://www.koreatimes.co.kr/www/nation/2021/07/205_313046.html 7. https://en.yna.co.kr/view/AEN20210730003900325?section=search 8. https://en.yna.co.kr/view/AEN20210729004200325?section=search 9. https://en.yna.co.kr/view/AEN20210727004100325?section=search 10. https://www.stripes.com/theaters/asia_pacific/2021-07-29/south-korea-coronavirus-covid-19-us- military-2356295.html

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 474. 30 July 2021

11. https://www.stripes.com/theaters/asia_pacific/2021-07-26/tokyo-coronavirus-us-military- restrictions-covid-19-2312437.html 12. https://www.stripes.com/theaters/asia_pacific/2021-07-27/tokyo-pandemic-record-coronavirus- cases-covid-19-2326137.html 13. https://www.fortcarsonmountaineer.com/2021/07/pandemic-not-over-delta-variant-concerns- growing/ 14. https://www.defense.gov/Explore/Spotlight/Coronavirus/DOD-Response-Ti-/ 15. https://www.military.com/daily-news/2021/07/28/us-navy-loses-two-more-sailors-covid-19.html 16. https://www.military.com/daily-news/2021/07/28/surge-of-covid-19-infections-fort-polk-national- guard-training-continues.html

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Scientific Reports 1. Manica M, Guzzetta G, Riccardo F, Valenti A, Poletti P, Marziano V, Trentini F, Andrianou X, Mateo- Urdiales A, Del Manso M, Fabiani M, Vescio MF, Spuri M, Petrone D, Bella A, Iavicoli S, Ajelli M, Brusaferro S, Pezzotti P, Merler S. Impact of tiered restrictions on human activities and the epidemiology of the second wave of COVID-19 in Italy. Nat Commun. 2021 Jul 27;12(1):4570. doi: 10.1038/s41467-021-24832-z. PMID: 34315899. 2. Zgutka K, Prasanth K, Pinero-Bernardo S, Lew LQ, Cervellione K, Rhythm R, Rahman L, Dolmaian G, Cohen L. Infant outcomes and maternal COVID-19 status at delivery. J Perinat Med. 2021 Mar 15;49(6):691-696. doi: 10.1515/jpm-2020-0481. PMID: 33713593. 3. Escandón K, Rasmussen AL, Bogoch II, Murray EJ, Escandón K, Popescu SV, Kindrachuk J. COVID-19 false dichotomies and a comprehensive review of the evidence regarding public health, COVID-19 symptomatology, SARS-CoV-2 transmission, mask wearing, and reinfection. BMC Infect Dis. 2021 Jul 27;21(1):710. doi: 10.1186/s12879-021-06357-4. PMID: 34315427. 4. Pathak GA, Singh K, Miller-Fleming TW, Wendt FR, Ehsan N, Hou K, Johnson R, Lu Z, Gopalan S, Yengo L, Mohammadi P, Pasaniuc B, Polimanti R, Davis LK, Mancuso N. Integrative genomic analyses identify susceptibility genes underlying COVID-19 hospitalization. Nat Commun. 2021 Jul 27;12(1):4569. doi: 10.1038/s41467-021-24824-z. PMID: 34315903.

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For citation: Centre for Infectious Disease Epidemiology and Research-NUS. COVID-19 Situation Report 474. 30 July 2021

Acknowledgement:

Dr. Pang Junxiong, Vincent

Ms Chua Ee Yong Pearleen

Ms Chua Hui Lan

Ms Gwee Xiao Wei Sylvia

Ms Koh Jiayun

Ms Shah Shimoni Urvish

Ms Wang Min Xian

Mr Lau Wai Hong Nicholas

Any queries? Email Sylvia Gwee @ [email protected]

Centre for Infectious Disease Epidemiology and Research

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

For more information, please visit:

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

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